Tobacco Use Among U.S. Racial/Ethnic Minority Groups African Americans American Indians and Alaska Natives Asian Americans and Pacific Islanders Hispanics A Report of the Surgeon General DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promo tion Office on Smoking and Health Suggested Citation U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smok- ing and Health, 1998. For sale by the Superintendent of Documents, U.S. Government Printing Office, Washing- ton, D.C., 20402, S/N 017-001-00527-4. Use of trade names is for identification only and does not constitute endorsement by the U.S. Department of Health and Human Services. THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON, O.C. 2020} The Honorable Newt Gingrich Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: I am pleased to transmit to the Congress the Surgeon General’s report on the health consequences of smoking, entitled Tobacco Use Among U.S. Racial/Ethnic Minority Groups. This report is mandated by Section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law 91-222) and includes the health effects of smokeless tobacco products, as mandated by Section 8(a) of the Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99-252). The report was prepared by the Centers for Disease Control and Prevention. This is the first Surgeon General’s report to focus on tobacco use among four U.S. racial/ethnic minority groups: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. It provides a single, comprehensive source of data on each racial/ethnic group’s patterns of tobacco use, physical effects related to tobacco smoking and chewing, societal and psychosocial factors associated with tobacco use, and a selection of specific tobacco control programs. Armed with accurate data, health professionals can plan appropriate programs to address more effectively the health needs of these groups. Smoking is the leading cause of preventable death in the United States. Certain racial/ethnic minority populations remain at high risk for using tobacco and often bear a disproportionate share of the human and economic cost of tobacco use. For instance, African Americans suffer the highest death rates from several diseases caused by smoking. Although some recent declines in lung cancer trends are encouraging, we have reason for great concern about recently reported increases in rates of smoking among African-American and Hispanic high school students. According to estimates from the U.S. Bureau of the Census, over the next 50 years, the size of these four racial/ethnic minority groups is expected to increase dramatically, becoming almost half of the U.S. population by the year 2050. This projection clearly indicates the need to develop effective strategies to prevent tobacco-related disease and death in these four minority population groups. Enclosure THE SECRETARY OF HEALTH ANDO HUMAN SERVICES WASHINGTON, D.C. 2020) The Honorable Albert Gore, Jr. President of the Senate Washington, D.C. 20510 Dear Mr. President: I am pleased to transmit to the Congress the Surgeon General’s report on the health consequences of smoking, entitled Tobacco Use Among U.S. Racial/Ethnic Minority Groups. This report is mandated by Section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law 91-222) and includes the health effects of smokeless tobacco products, as mandated by Section 8({a) of the Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99-252). The report was prepared by the Centers for Disease Control and Prevention. This is the first Surgeon General’s report to focus on tobacco use among four U.S. racial/ethnic minority groups: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. It provides a single, comprehensive source of data on each racial/ethnic group’s patterns of tobacco use, physical effects related to tobacco smoking and chewing, societal and psychosocial factors associated with tobacco use, and a selection of specific tobacco control programs. Armed with accurate data, health professionals can plan appropriate programs to address more effectively the health needs of these groups. Smoking is the leading cause of preventable death in the United States. Certain racial/ethnic minority populations remain at high risk for using tobacco and often bear a disproportionate share of the human and economic cost of tobacco use. For instance, African Americans suffer the highest death rates from several diseases caused by smoking. Although some recent declines in lung cancer trends are encouraging, we have reason for great concern about recently reported increases in rates of smoking among African-American and Hispanic high school students. According to estimates from the U.S. Bureau of the Census, over the next 50 years, the size of these four racial/ethnic minority groups is expected to increase dramatically, becoming almost half of the U.S. population by the year 2050. This projection clearly indicates the need to develop effective strategies to prevent tobacco-related disease and death in these four minority population groups. C Me Enclosure Foreword The United States of America is a rich blend of cultures. This diversity demands close attention from the agencies and individuals responsible for pro- tecting the public’s health. For too long in tobacco control, attention to diversity has been less consistent than is necessary for planning and developing effective health programs. As a result, we sometimes lack sufficient information on which to base tobacco control interventions. With this report, we begin to address such problems and point the way to filling these gaps in knowledge. Tobacco use causes devastating disease and premature death in every population in the United States. For four major U.S. racial/ethnic minority groups— African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics—patterns of tobacco use, adverse health effects, and the effectiveness of interventions need to be understood in terms of tobacco’s cultural and socioeconomic effects on the members of these groups. This report describes the complex factors that play a part in the growing epidemic of diseases caused by tobacco use in these four groups. Since 1964 when the first Surgeon General’s report on smoking and health was released, this report is the first to focus exclusively on tobacco use among members of these four racial/ethnic groups. Together these groups constitute about 25 percent of the U.S. population, and that proportion 1s growing rapidly. Public health programs must effectively address the health needs of this significant pro- portion of people. Such action is of paramount importance to reducing tobacco use in the United States and meeting national health objectives for the year 2000. We hope that this report will provide the basis for renewing our commitment to develop more effective tobacco control programs and policies for people of every racial and ethnic background. In addition, the report can be used by parents and communities as a tool to develop their own solutions. With continued diligence, we shall strive to reach and exceed whenever possible our stated health goals by the year 2000 and reduce the enormous health burden caused by tobacco products. Claire V. Broome, M.D. Acting Director Centers for Disease Control and Prevention and Acting Administrator Agency for Toxic Substances and Disease Registry Preface from the Surgeon General, U.S. Department of Health and Human Services Effective strategies are needed to reduce tobacco use among members of U.S. racial/ethnic groups and thus diminish their burden of tobacco-related diseases and deaths. Cigarette smoking is the leading cause of preventable disease and death in the United States. There is enormous potential to reduce heart disease, cancer, stroke, and respiratory disease among members of racial and ethnic groups, who make up the most rapidly growing segment of the U.S. population. This Surgeon General's report is the first to address the diverse tobacco control needs of the four major U.S. racial/ethnic minority groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. This report is also the only single, comprehensive source of data on each group’s patterns of tobacco use, physical effects related to tobacco smoking and chewing, and societal and psychosocial factors associated with tobacco use. The findings detailed in this report indicate that if tobacco use is not reduced among members of these four racial/ethnic groups, they will experience increas- ing morbidity and mortality from tobacco use. The toll is currently highest for African American adults. Findings also suggest that some close, long-term rela- tionships between tobacco companies and various racial/ethnic communities could hamper U.S. efforts to lower rates of tobacco use by the year 2000. Also notable is the support that members of racial/ethnic groups have shown for legislative efforts to control tobacco use, sales, advertising, and promotion. As this report goes to press, discouraging news comes from a report published by the Centers for Disease Control and Prevention on the Youth Risk Behavior Survey about tobacco use among African American and Hispanic high school students. Past-month smoking increased among African American students by 80 percent and among Hispanic students by 34 percent from 1991 through 1997. The consistent decline once seen among young African Americans has sharply reversed in recent years. Past-month smoking prevalence increased from 13 per- cent to 23 percent among African Americans and from 25 percent to 34 percent among Hispanics. Although cancer remains common in Americans of all racial and ethnic groups, the pattern of increasing lung cancer deaths in the 1970s and 1980s among African American, Hispanic, and some American Indian and Alaska Native subgroups has been halted or reversed for some groups from 1990 through 1995. Some en- couraging news from Cancer Incidence and Mortality, 1973-1995: A Report Card for the U.S. was just published by the American Cancer Society, the National Cancer Institute, and the Centers for Disease Control and Prevention. The report described lung cancer trend data from 1990 through 1995 for African Americans, Asian Ameri- cans and Pacific Islanders, and Hispanics. Lung cancer death rates declined significantly for African American men and for Hispanic men and women from ut 1990 through 1995; death rates did not change significantly for African American women or for Asian American and Pacific Islander men or women. Although lung cancer trends may continue to decline among some racial/ethnic groups for sev- eral more years, recent increases in smoking prevalence among adolescent African Americans and Hispanics and among Asian American and Pacific Islander adoles- cent males, coupled with the lack of decline among American Indian and Alaska Native adults, do not bode well for long-term trends in lung cancer. One purpose of this report is to guide researchers in their future efforts to garner more information needed to develop effective prevention and control pro- grams. Several significant research questions need to be addressed. For example, why are African American youths smoking cigarettes in lower proportions than youths in other racial/ethnic groups? How does acculturation affect patterns of tobacco use among immigrants to the United States? What are the differential effects of gender on tobacco use among members of certain racial/ethnic groups? What racial- and ethnic-specific protective factors and risk factors will promote the development of culturally appropriate interventions to prevent and control tobacco use? And to what extent are culturally specific tobacco control programs necessary to curb tobacco use among racial/ethnic populations? While research- ers are redirecting their focus, federal, state, and private tobacco control partners need to address program issues, such as how to develop and evaluate culturally appropriate prevention and cessation interventions. This report includes examples of numerous racial- and ethnic-specific tobacco control programs used in communities across the country. These and other racial/ethnic group-specific programs must be disseminated to all areas of the country, where program planners can develop their own strategies, taking into consideration the cultural attitudes, norms, expectations, and values of the targeted cultural groups. In each of these endeavors, we will succeed only if we are sensitive to our cultural differences and similarities. | challenge federal and state agencies as well as researchers and practitioners in the social, behavioral, public health, clinical, and biomedical sciences to join me in the pursuit of effective strategies to prevent and control tobacco use among racial/ethnic groups. By meeting this challenge, we will progress toward achieving the nation’s year 2000 tobacco-related health objectives and will help to prevent the unnecessary disability, disease, and deaths that result from tobacco use. David Satcher, M.D., Ph.D. Surgeon General and Assistant Secretary for Health iv Acknowledgments This report was prepared by the U.S. Department of Health and Human Services under the general direc- tion of the Centers for Disease Control and Preven- tion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Claire V. Broome, M.D., Acting Director, Centers for Disease Control and Prevention, Atlanta, Georgia. James S. Marks, M.D., M.P.H., Director, National Center for Chronic Disease Prevention and Health Pro- motion, Centers for Disease Control and Prevention, Atlanta, Georgia. Virginia 5. Bales, M.P.H., Deputy Director, National Center for Chronic Disease Prevention and Health Pro- motion, Centers for Disease Control and Prevention, Atlanta, Georgia. Michael P. Eriksen, Sc.D., Director, Office on Smoking and Health, National Center for Chronic Disease Pre- vention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. The editors of the report were Gerardo Marin, Ph.D., Senior Scientific Editor, Profes- sor, Department of Psychology, University of San Fran- cisco, San Francisco, California. Gayle Lloyd, M.A., Managing Editor, Office on Smok- ing and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Valerie R. Johnson, Senior Editor, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Anne M. Pritchett, Technical Editor, Cygnus Corpora- tion, Rockville, Maryland. Contributing authors were Neal L. Benowitz, M.D., Professor and Chief, Division of Clinical Pharmacology, Departments of Medicine, Pharmacy, and Psychiatry, School of Medicine, Uni- versity of California, San Francisco, California. Alan Blum, M.D., Associate Professor, Baylor College of Medicine, Houston, Texas. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Ronald L. Braithwaite, Ph.D., Associate Professor, Di- vision of Behavioral Sciences and Health Education, Emory University School of Public Health, Atlanta, Georgia. Felipe G. Castro, M.S.W., Ph.D., Director, Hispanic Research Center, and Associate Professor, Department of Psychology, Arizona State University, Tempe, Arizona. Moon §. Chen, Jr, Ph.D., M.P.H., Professor, Depart- ment of Preventive Medicine, Ohio State University, Columbus, Ohio. David B. Coultas, M.D., Associate Professor of Medi- cine, School of Medicine, University of New Mexico, Albuquerque, New Mexico. Luis G. Escobedo, M.D., M.P.H., Medical Epidemiolo- gist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Dorothy L. Faulkner, Ph.D., M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Larri L. Fredericks, Ph.D., M.P.H., Associate Scientist, American Indian Cancer Control Project, Medical Re- search Institute, Berkeley, California. Gary A. Giovino, Ph.D., Chief, Epidemiology Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Sandra W. Headen, Ph.D., Assistant Professor, Depart- ment of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, North Carolina. Felicia Schanche Hodge, Dr.P.H., Principal Investiga- tor and Director, Center for American Indian Research and Education, Berkeley, California. Nancy J. Kaufman, R.N., M.S., Vice President, Robert Wood Johnson Foundation, Princeton, New Jersey. Surgeon General’s Report Juliette S. Kendrick, M.D., Medical Epidemiologist, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Gary King, Ph.D., Assistant Professor and Coordina- tor, Urban Health Research Program, School of Medi- cine, University of Connecticut Health Center, Farmington, Connecticut. Beverly S. Kingsley, Ph.D., M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Rod Lew, M.PH., Health Education Director, Asian Health Services, Oakland, California. Ann M. Malarcher, Ph.D., Epidemiologist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Robert K. Merritt, M.A., Health Scientist, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Michael D. Newcomb, Ph.D., Professor, Department of Psychology, University of California, Los Angeles, California. John P. Peddicord, M.S., Computer Scientist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Richard Pollay, Ph.D., Professor of Marketing, and Curator, History of Advertising Archives, University of British Columbia, Vancouver, British Columbia, Canada. Amelie G. Ramirez, Dr.P.H., Associate Professor, De- partment of Family Practice, University of Texas, and Director, South Texas Health Research Center, San Antonio, Texas. Patricia A. Richter, Ph.D., M.P.H., Toxicologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. vi Robert G. Robinson, Dr.P.H., Associate Director for Program Development, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Richard B. Rothenberg, M.D., M.P.A., Professor, De- partment of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia. Jonathan M. Samet, M.D., Chairman, Department of Epidemiology, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland. Michael W. Schooley, M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Dana Shelton, M.P.H., Epidemiologist, Office on Smok- ing and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Michael B. Siegel, M.D., M.P.H., Assistant Professor, Boston University School of Public Health, Boston, Massachusetts. Charyn D. Sutton, President, The Onyx Group, Bala Cynwyd, Pennsylvania. Scott L. Tomar, D.M.D., Dr.P.H., Assistant Professor, Department of Dental Public Health and Hygiene, School of Dentistry, University of California, San Fran- cisco, California. Bao-Ping Zhu, M.S., M.B.B.S., Ph.D., Visiting Scientist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Reviewers were Jasjit S. Ahluwalia, M.D., M.P.H., M.S., Assistant Pro- fessor of Medicine, Emory University School of Medi- cine, Atlanta, Georgia. David G. Altman, Ph.D., Associate Professor, Depart- ment of Public Health Sciences, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina. Glen Bennett, M.P.H., Coordinator, Office of Preven- tion, Education, and Control, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Gilbert J. Botvin, Ph.D., Director, Institute for Preven- tion Research, Department of Public Health, Cornell University Medical College, New York, New York. L. Jackson Brown, Director, Epidemiology and Oral Disease Prevention Program, National Institute of Dental Research, National Institutes of Health, Bethesda, Maryland. Linda Burhansstipanoy, Dr.P.H., Director, Native American Cancer Research Program, American Medi- cal Center Cancer Research Center, Denver, Colorado. David Burns, M.D., Professor of Medicine, University of California at San Diego Medical Center, San Diego, California. W. Michael Byrd, M.D., M.P.H., Visiting Research Fel- low, Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts. Portia S. Choi, M.D., M.P.H., District Health Officer, Dr. Ruth Temple Health Center, Los Angeles, California. Nathaniel Cobb, M.D., Director, Cancer Prevention and Control Program, Indian Health Service Headquarters West, Albuquerque, New Mexico. Janet L. Collins, Ph.D., Director, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control] and Prevention, Atlanta, Georgia. Robert J. Collins, D.M.D., Chief Dental Officer, U.S. Public Health Service, Rockville, Maryland. Linda S. Crossett, R.D.H., Research Scientist, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. K. Michael Cummings, Ph.D., Director, Smoking Con- trol Program, Roswell Park Cancer Institute, New York State Department of Health, Buffalo, New York. Dorynne J. Czechowicz, M.D., Associate Director for Medical and Professional Affairs, Division of Clinical Research, National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland. vil Tobacco Use Among U.S. Racial/Ethnic Minority Groups Ronald M. Davis, M.D., Director, Center for Health Promotion and Disease Prevention, Henry Ford Health System, Detroit, Michigan. Richard A. Daynard, Ph.D., J.D., Chairman, Tobacco Products Liability Project, Northeastern University School of Law, Boston, Massachusetts. Jane L. Delgado, Ph.D., President and Chief Executive Officer, National Coalition of Hispanic Health and Human Services Organization, Washington, D.C. John Elder, Ph.D., M.P.H., Professor, Graduate School of Public Health, San Diego State University, San Di- ego, California. Harmon Eyre, M.D., Deputy Executive Vice President for Medical Affairs and Research, American Cancer Society, Atlanta, Georgia. Michael C. Fiore, M.D., M.P.H., Director, Center for Tobacco Research and Intervention, University of Wis- consin Medical School, Madison, Wisconsin. Adele M. Franks, M.D., Assistant Director for Science, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Harold P. Freeman, M.D., Director of Surgery, Harlem Hospital Center, New York, New York. Thomas J. Glynn, Ph.D., Chief, Prevention Control Extramural Research Branch, National Cancer Insti- tute, National Institutes of Health, Rockville, Mary- land. Michael G. Goldstein, M.D., Associate Professor of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, Rhode Island. Robert A. Hahn, Ph.D., M.P.H., Epidemiologist, Epi- demiology Program Office, Centers for Disease Con- trol and Prevention, Atlanta, Georgia. Betty Lee Hawks, M.A., Special Assistant to the Direc- tor, Office of Minority Health, U.S. Department of Health and Human Services, Rockville, Maryland. Clark W. Heath, Jr., M.D., Vice President for Epidemi- ology and Surveillance Research, American Cancer Society, Atlanta, Georgia. Jack E. Henningfield, Ph.D., Vice President, Pinney Associates, Bethesda, Maryland. Surgeon General’s Report John H. Holbrook, M.D., Director of Internal Medicine, University of Utah Hospital, Salt Lake City, Utah. Thomas Houston, M.D., Director, Department of Pre- ventive Medicine and Public Health, American Medi- cal Association, Chicago, IHinois. Rudolph S. Jackson, Dr.P.H., Professor, Department of Health Education, North Carolina Central University, Durham, North Carolina. Elaine M. Johnson, Ph.D., Director, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Nora L. Keenan, Ph.D., Epidemiologist, Office of Sur- veillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Monina Klevens, D.D.S., M.P.H., Medical Officer, Di- vision of HIV/AIDS, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia. Norman A. Krasnegor, Ph.D., Chief, Human Learning and Behavior Branch, Center for Research for Moth- ers and Children, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland. Leonard E. Lawrence, M.D., President, National Medi- cal Association, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas. Edward Lichtenstein, Ph.D., Research Scientist, Oregon Research Institute, Eugene, Oregon. Douglas S. Lloyd, M.D., M.P.H., Associate Adminis- trator for Public Health Practice, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland. Judith Mackay, M.B.E., J.P., FR.C.P., Director, Asian Consultancy on Tobacco Control, Kowloon, Hong Kong. Audrey F. Manley, M.D., M.P.H., President, Spelman College, Atlanta, Georgia. Alfred McAlister, Ph.D., Associate Professor and As- sociate Director, Center for Health Promotion Research and Development, The University of Texas at Austin, Austin, Texas. vit J. Michael McGinnis, M.D., Scholar-in-Residence, National Academy of Sciences, Washington, D.C. Bertha Mo, Ph.D., M.P.H., Senior Program Officer, In- ternational Development Research Centre, Ottawa, Ontario, Canada. C. Tracy Orleans, Ph.D., Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, New Jersey. Terry F. Pechacek, Ph.D., Visiting Scientist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Cheryl L. Perry, Ph.D., Professor, Division of Epi- demiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. John P. Pierce, Ph.D., Sam M. Walton Professor for Cancer Research, Department of Family and Preven- tive Medicine, University of California, San Diego, California. Donald H. Reece, Tobacco Control Coordinator, Indian Health Service, Albuquerque, New Mexico. Patrick Remington, M.D., M.P.H., Chief Medical Officer, Wisconsin Division of Health, Madison, Wisconsin. Irene Reveles-Chase, M.P.H., Health Education Con- sultant, Tobacco Control Section, California Depart- ment of Public Health, Sacramento, California. Nancy A. Rigotti, M.D., Director, Quit Smoking Ser- vice, General Internal Medicine Unit, Massachusetts General Hospital, Boston, Massachusetts. Donald J. Sharp, M.D., Medical Epidemiologist, Of- fice on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Donald R. Shopland, Coordinator, Smoking and To- bacco Control Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland. Beverly R. Singer, M.A., Research Staff Associate, School of Social Work, Columbia University, New York, New York. Jesse L. Steinfeld, M.D., Surgeon General, U.S. Public Health Service, 1969-1973, San Diego, California. Jonathan R. Sugarman, M.D., M.P.H., Medical Epide- miologist, Portland Area Indian Health Service, Seattle, Washington. Michael J. Thun, M.D., Director, Analytic Epidemiol- ogy, American Cancer Society, Atlanta, Georgia. Michael H. Trujillo, M.D., M.P.H., Director, Indian Health Service, Rockville, Marvland. Kenneth E. Warner, Ph.D., Richard D. Remington Col- legiate Professor of Public Health, Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan. Raymond Weston, Ph.D., Postdoctoral Fellow, Memo- rial Sloan-Kettering Cancer Center, Division of Psychia- try, New York, New York. Judith Wilkenfeld, J.D., Assistant Director, Division of Advertising Practices, Federal Trade Commission, Washington, D.C. Jerome Williams, Ph.D., Professor of Marketing, Penn- sylvania State University, University Park, Pennsylvania. Ernst L. Wynder, M.D., President, American Health Foundation, New York, New York. Other contributors were Marco Andujar, Telecommunications Specialist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Ruth Atchison, Proofreader, Cygnus Corporation, Rockville, Maryland. Cheryl Baldwin, Graphic Artist/Desktop Publishing Specialist, High 5 Design, Gaithersburg, Maryland. Mary Bedford, Proofreader, Cygnus Corporation, Rockville, Maryland. Christine V. Bellantoni, Graduate Student, University of Connecticut Health Center, Farmington, Connecticut. Maureen Berg, Desktop Publishing Specialist, Market Experts, Silver Spring, Maryland. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Marissa Bernstein, Indexer, Cygnus Corporation, Rockville, Maryland. Nowell D. Berreth, Writer-Editor, Office on Smoking and Health, National Center for Chronic Disease Pre- vention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Joyce Buchanan, Administrative Assistant, Institute for Social Research, Survey Research Center, University of Michigan, Ann Arbor, Michigan. Janine E. Bullard, Proofreader, Cygnus Corporation, Rockville, Maryland. Ralph S. Carabello, Ph.D., Epidemiologist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Jeffrey H. Chrismon, Systems Analyst, TRW Inc., Atlanta, Georgia. Paulette Clark McGee, Proofreader, Cygnus Corpora- tion, Rockville, Maryland. Coreen A. Colovos, Copy Editor, Cygnus Corporation, Rockville, Maryland. David F. Coole, M.S., Statistical Programmer, TRW Inc., Atlanta, Georgia. Karen M. Deasy, Associate Director, Office on Smok- ing and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Washington, D.C. Susan R. Derrick, Program Analyst, Office on Smok- ing and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Ellen C. Dreyer, R.N., M.S., Project Director, Cygnus Corporation, Rockville, Maryland. Rita Elliott, M.A., Editorial Consultant, University of New Mexico, School of Medicine, Albuquerque, New Mexico. Raymond J. Gamba, M.S., Graduate Student, The Claremont Graduate School, Claremont, California. Maritta Perry Grau, M.A., Copy Editor, The Write Touch: Editorial Services, Frederick, Maryland. Surgeon General's Report Sarah Gregory, Acting Managing Editor, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Lillian E. Hatch, M.S.L.S., Information Specialist, Cyg- nus Corporation, Rockville, Maryland. Elizabeth L. Hess, Copy Editor, Cygnus Corporation, Rockville, Maryland. Thomya Hogan, Proofreader, Cygnus Corporation, Rockville, Maryland. Reta N. Horton, M.A., Secretary, Office on Smoking and Health, National Center for Chronic Disease Pre- vention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Frederick L. Hull, Ph.D., Writer-Editor, Technical In- formation and Editorial Services Branch, National Center for Chronic Disease Prevention and Health Pro- motion, Centers for Disease Control] and Prevention, Atlanta, Georgia. Mescal J. Knighton, Writer-Editor, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Anh Lé, Project Coordinator, Vietnamese Community Health Promotion Project, University of California, San Francisco, California. Yun Chen W. Lin, M.P.H., Technical Information Spe- cialist, TRW Inc., Atlanta, Georgia. William T. Marx, M.L.LS., Technical Information Spe- cialist, Office on Smoking and Health, National Cen- ter for Chronic Disease Prevention and Health Promo- tion, Centers for Disease Control and Prevention, At- lanta, Georgia. Maribet McCarty, R.N., M.P.H., Technical Information Specialist, The Orkand Corporation, Atlanta, Georgia. Margie McDonald, Word Processing Specialist, Cyg- nus Corporation, Rockville, Maryland. Linda A. McLaughlin, Word Processing Specialist, Cygnus Corporation, Rockville, Maryland. Jennifer A. Michaels, M.L.S., Technical Information Specialist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Pro- motion, Centers for Disease Control and Prevention, Atlanta, Georgia. Barbara A. Mills, Secretary, Office on Smoking and Health, National Center for Chronic Disease Preven- tion and Health Promotion, Centers for Disease Con- trol and Prevention, Atlanta, Georgia. Paul D. Mowery, M.S., Senior Research Scientist, Battelle Memorial Institute, Atlanta, Georgia. Leslie A. Norman, Public Affairs Specialist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Ward C. Nyholm, Desktop Publishing Specialist, Cygnus Corporation, Rockville, Maryland. Patrick O'Malley, Ph.D., Research Scientist, Institute for Social Research, Survey Research Center, Univer- sity of Michigan, Ann Arbor, Michigan. Anniette Ponce de Leon, Student, University of San Francisco, San Francisco, California. Felicia A. Powell, M.S., Statistical Programmer, TRW Inc., Atlanta, Georgia. Christopher Rigaux, Project Director, Cygnus Corpo- ration, Rockville, Maryland. Patricia L. Schwartz, Graphic Artist/ Desktop Publish- ing Specialist, Cygnus Corporation, Rockville, Maryland. Matthew B. Spangler, Proofreader, Cygnus Corpora- tion, Rockville, Maryland. Catherine T. Timmerman, Chief Operating Officer, Cygnus Corporation, Rockville, Maryland. Peggy E. Williams, M.S., Proofreader, Marietta, Georgia. Eve J. Wilson, Ph.D., Project Manager, Cygnus Corpo- ration, Rockville, Maryland. Beatrice K. Wolman, MS., Project Manager, Cygnus Corporation, Rockville, Maryland. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Chapter 1. Introduction and Summary of Conclusions 3 Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups 19 Introduction 21 Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups 22 Retrospective Analyses of Smoking Prevalence Among African Americans and Hispanics 74 Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior 83 Exposure to Environmental Tobacco Smoke 86 Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use 87 Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic Minority Groups 135 Introduction 137 Lung Cancer 137 Other Cancers 149 Chronic Obstructive Pulmonary Disease 158 Coronary Heart Disease 160 Cerebrovascular Disease 164 Smoking and Pregnancy 166 Summary of Health Consequences from Active Cigarette Smoking 172 Effects of Exposure to Environmental Tobacco Smoke 172 Effects of Smokeless Tobacco Use 174 Nicotine Addiction and Racial/Ethnic Differences 175 Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups 205 Introduction 207 Historical Context of Tobacco 208 Economic Influences 213 Advertising and Promotion 2 Psychosocial Determinants 2 Chapter 5. Tobacco Control and Education Efforts Among Members of Four Racial/Ethnic Minority Groups 257 Introduction 259 Primary Prevention Efforts 266 Smoking Cessation Programs 2/74 Environmental Tobacco Smoke and Clean Indoor Air Policies 287 Economic Efforts to Reduce Tobacco Use 292 Efforts to Control Tobacco Advertising and Promotion 293 Tobacco Product Regulations 298 List of Tables and Figures 311 Glossary 319 Index 321 Chapter 1 Introduction and Summary of Conclusions Introduction 5 Major Conclusions 6 Preparation of This Report 7 Terms Related to Race and Ethnicity 7 Terms Related to Tobacco Use 8 Demographic Characteristics of the Four Racial/Ethnic Minority Groups 8 Effects of Racial/Ethnic Background on Health 11 Chapter Conclusions 12 Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups 12 Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic Minority Groups 12 Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups 13 Chapter 5. Tobacco Control and Education Efforts Among Members of Four Racial/Ethnic Minority Groups 14 References 15 Introduction Tobacco Use Among U.S. Racial/Ethnic Minority Groups This Surgeon General’s report on tobacco use summarizes current information on risk factors and patterns related to tobacco use among members of four major racial and ethnic minority groups in the United States: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Island- ers, and Hispanics. In addition, this report presents information on national and regional efforts to curtail consumption of tobacco products among members of these four groups. Previous Surgeon General's reports on smoking and health have briefly summarized find- ings related to one or more of the racial/ethnic groups covered in this report, but this is the first Surgeon General's report to concentrate specifically on the four major racial/ethnic groups in the United States. Several factors prompted the development of this report. First, the information in this report has never before been compiled in one source. Consequently, policymakers, community leaders, researchers, and public health workers have had difficulty determin- ing the extent of the problem, identifying gaps in in- formation regarding tobacco use among members of the four groups, or being aware of existing tobacco con- trol programs that have demonstrated effectiveness. Thus, incorporating such information into the design and implementation of culturally appropriate services has been difficult. Second, the four racial/ethnic groups currently constitute about one-fourth of the population of this country, and the Bureau of the Census projects that by 2050 the non-Hispanic white population in the United States will total only 53 percent (Day 1996). Prevent- ing health problems related to tobacco use among the individuals in racial and ethnic groups will be inte- gral to achieving U.S. public health objectives, such as those proposed in Healthy People 2000: National Health Promotion and Disease Prevention Objectives (U.S. Depart- ment of Health and Human Services [USDHHS] 1991, 1995; National Center for Health Statistics [NCHS] 1994). This report contributes essential knowledge that must be incorporated into efforts to accomplish the Healthy People 2000 objectives, particularly these six goals: © Objective 3.1. Reduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age- adjusted baseline: 135 deaths per 100,000 people in 1987.) Among African Americans, reduce the number from 168 to 115 deaths per 100,000 people between 1987 and the year 2000 (Objective 3.1a). Objective 3.2. Slow the rise in lung cancer deaths to achieve a rate of no more than 42 per 100,000 people. (Age-adjusted baseline: 38.5 deaths per 100,000 people in 1987.) Among African Ameri- can males, slow the rise from 86.1 to 91 deaths per 100,000 people between 1990 and the year 2000 (Objective 3.2b). Objective 3.4. Reduce the prevalence of cigarette smoking to no more than 15 percent among people aged 18 years and older. (Baseline: 29 percent in 1987 [31 percent for men and 27 percent for women].) Particular year 2000 objectives include lowering the prevalence of smoking to 18 percent among African Americans (Objective 3.4d), 15 per- cent among Hispanics (Objective 3.4e), and 20 per- cent among American Indians and Alaska Natives (Objective 3.4f) and Southeast Asian men (Objec- tive 3.4g). Objective 3.5. Reduce the initiation of cigarette smoking by children and youths so that no more than 15 percent have become regular cigarette smokers by the age of 20 years. (Baseline: 30 per- cent of youths had become regular cigarette smok- ers by the ages of 20-24 years in 1987.) Objective 3.9. Reduce the prevalence of smokeless tobacco use among males aged 12-24 years to no more than 4 percent. (Baseline: 6.6 percent among males aged 12-17 years in 1988; 8.9 percent among males aged 18-24 years in 1987.) A specific objec- tive is to lower the prevalence of smokeless tobacco use among American Indian and Alaska Native young adults to 10 percent by the year 2000 (Ob- jective 3.9a). Objective 3.18. Reduce stroke deaths to no more than 20 per 100,000 people. (Age-adjusted baseline: 30.4 deaths per 100,000 people in 1987.) Among African Americans, reduce the number from 52.5 to 27.0 deaths per 100,000 people between 1987 and the year 2000 (Objective 3.18a). Introduction and Summary 5 Surgeon General's Report This report of the Surgeon General also responds to the need to thoroughly analyze the smoking-related health status of racial/ethnic groups and to determine if there is a differential risk for tobacco addiction (Chen 1993), High risk might derive from personal charac- teristics but also from social factors, such as migratory patterns, acculturation, and the tobacco industry’s his- torical involvement in the racial/ethnic communities and targeted advertising and promotion of tobacco products (see Chapter 4). In addition, this report is needed to document how patterns of health, disease, and illness among people in the various racial/ethnic minority groups differ from patterns in the rest of the U.S. population. These differences reflect the groups’ exposure to to- bacco products, as well as the heterogeneity of the groups’ lifestyles, cultural beliefs and practices, genetic backgrounds, and environmental exposures. This re- port illustrates how patterns of tobacco use differ among and within the four racial/ethnic groups (Chapter 2). It compares the groups in terms of the incidence and the prevalence of death rates for diseases commonly associated with tobacco use and presents data from case-control and cohort studies whenever possible (Chapter 3). The health status of members of racial and eth- nic groups in this country has also been the focus of previous federal reports, such as the Health Status of Minorities and Low-Income Groups (Health Resources and Services Administration [HRSA] 1985), the Report of the Secretary's Task Force on Black and Minority Health (USDHHS 1985), and Chronic Disease in Minority Popu- lations (Centers for Disease Control and Prevention [CDC] 1994). This Surgeon General’s report supports initiatives such as the Hispanic Health and Nutrition Examination Survey in the early 1980s; the Surgeon General’s National Hispanic/Latino Health Initiative (Novello and Soto-Torres 1993); special funding ini- tiatives from federal agencies such as the CDC, the National Cancer Institute, the Nationa] Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, the National Heart, Lung, and Blood Institute (1994), and the National Institute of Mental Health (National Institutes of Health 1993); the Department of Health and Human Services's 1996 Hispanic Agenda for Action: Improving Services to Hispanic Americans, and the 1998 President’s Race Ini- tiative, which includes special funding initiatives for the CDC, the Indian Health Service, and the Health Resources and Services Administration. 6 Chapter 1 Major Conclusions 1. Cigarette smoking is a major cause of disease and death in each of the four population groups stud- ied in this report. African Americans currently bear the greatest health burden. Differences in the magnitude of disease risk are directly related to differences in patterns of smoking. Tobacco use varies within and among racial/ ethnic minority groups; among adults, American Indians and Alaska Natives have the highest prevalence of tobacco use, and African American and Southeast Asian men also have a high preva- lence of smoking. Asian American and Hispanic women have the lowest prevalence. Among adolescents, cigarette smoking prevalence increased in the 1990s among African Americans and Hispanics after several years of substantial de- cline among adolescents of all four racial/ethnic minority groups. This increase is particularly strik- ing among African American youths, who had the greatest decline of the four groups during the 1970s and 1980s. No single factor determines patterns of tobacco use among racial/ethnic minority groups; these pat- terns are the result of complex interactions of mul- tiple factors, such as socioeconomic status, cultural characteristics, acculturation, stress, biological el- ements, targeted advertising, price of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives. Rigorous surveillance and prevention research are needed on the changing cultural, psychosocial, and environmental factors that influence tobacco use to improve our understanding of racial/ethnic smoking patterns and identify strategic tobacco control opportunities. The capacity of tobacco control efforts to keep pace with patterns of to- bacco use and cessation depends on timely recog- nition of emerging prevalence and cessation patterns and the resulting development of appro- priate community-based programs to address the factors involved. Preparation of This Report This report of the Surgeon General was prepared by the Office on Smoking and Health, National Cen- ter for Chronic Disease Prevention and Health Promo- tion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, as part of the Department's mandate, under Public Laws 91-222 and 99-252, to report to the U.S. Congress current in- formation about the health effects of tobacco use. The report was produced with the assistance of experts in the behavioral, epidemiological, medical, and public health fields. Initial background papers were produced by more than 25 scientists who were selected because of their expertise and familiarity with the topics covered in this report. Their various contri- butions were summarized into five major chapters that were reviewed by 28 peer reviewers. The entire manu- script was then sent to 43 scientists and experts, who reviewed it for its scientific integritv. Subsequently, the report was reviewed by various institutes and agencies within the Department of Health and Human Services. Terms Related to Race and Ethnicity Race and ethnicity are classifications currently used for various purposes, such as tracking morbidity and mortality statistics, defining group characteristics (as is done in many studies and by most federal and state agencies, including the U.S. Bureau of the Cen- sus), and exploring the health characteristics of indi- viduals and groups. Most extant data consider four racial groups in the United States (African American or black, American Indian and Alaska Native, Asian American and Pacific Islander, and white) as well as two ethnic categories (Hispanic and non-Hispanic). Specific choices have been made in selecting the labels used to identify individuals who share a given race, tradition, culture, or ethnicity. These labels dif- fer somewhat from those published in the Race and Ethnic Standards for Federal Statistics and Adminis- trative Reporting, more commonly known as Direc- tive 15 (U.S. Department of Commerce 1978). This di- rective presents rules for classifying persons into four racial groups (American Indian or Alaskan Native, Asian or Pacific Islander, black, and white) and two ethnic categories (Hispanic origin and not of Hispanic origin). The labels in this report were chosen to reflect current preferred use by many members of each group and researchers as well as to more clearly identify Tobacca Use Among U.S. Racial/Ethnic Minority Groups members of a given group. Nevertheless, because of differences in the way in which ethnicity has been as- certained in the various studies, some overlap and misclassification may exist, particularly with regard to Hispanic origin (for example, Hispanics of African background may be classified as African Americans, or Hispanics may be classified as non-Hispanic whites). In addition, the terms used in this report do not always precisely depict the racial/ethnic group studied (for instance, this report consistently uses the term American Indian and Alaska Native, even when de- scribing studies of Native Americans—a category that in some cases excludes Alaska Natives). Moreover, the terms used here do not reflect the fact that some studies were conducted in the 48 contiguous states and may exclude a substantial number of Alaska Natives and Native Hawaiians. Throughout this report, the following labels and definitions are used, with the ref- erents basically agreeing with those of Directive 15: e African American. Individuals who trace their an- cestry of origin to Sub-Saharan Africa. e = American Indian and Alaska Native. Persons who have origins in any of the original peoples of North America and who maintain that cultural identifi- cation through self-identification, tribal affiliation, or community recognition. © Asian American and Pacific Islander. Individuals who trace their background to the Far East, South- east Asia, the Indian subcontinent, or the Pacific Islands. ¢ Hispanic. Persons who trace their background to one of the Spanish-speaking countries in the Americas or to other Spanish cultures or origins. e White. Persons who have origins in any of the original peoples of Europe, North Africa, or the Middle East. Throughout most of this report, white refers to non-Hispanic whites. Finally, this report avoids using such labels as people of color, special populations, multicultural popula- tions, or diverse populations because some people con- sider them inaccurate, improper, or pejorative. With- out question, not everyone will agree with the terms used in this report because no universally accepted labels exist. These terms will continue to evolve with time. Introduction and Summary = 7 Surgeon General’s Report Terms Related to Tobacco Use Throughout this report, prevalence of smoking ces- sation is used to describe the proportion of persons who had ever smoked and who were former smokers at the time of survey (this term is used instead of quit ratio or quit rate). Definitions related to smoking status—ever smokers, never smokers, current smok- ers, and former smokers—are presented later in this report (see Chapter 2). Demographic Characteristics of the Four Racial/Ethnic Minority Groups In the 1990 U.S. Census, the four racial and eth- nic groups that are the focus of this report accounted for 24 percent of the population, or more than 60 mil- lion people (Table 1). African Americans were the larg- est group, followed by Hispanics, Asian Americans and Pacific Islanders, and American Indians and Alaska Natives. Although these groups constitute a minority of the total population, their overall growth of 32 percent between 1980 and 1990 far exceeds the 4- percent increase among whites (Table 1). Asian Ameri- cans and Pacific Islanders had the largest growth during that period, followed by Hispanics, American Indians and Alaska Natives, and African Americans. Because of this rapid growth, racial and ethnic popu- lations tend to be younger than the white majority. Demographic characteristics vary significantly when the four racial and ethnic groups are compared with whites, according to 1990 census data (Table 2; within-group variability is masked because all sub- groups that make up a given racial or ethnic group are considered together) (U.S. Bureau of the Census 1993c). The median ages of Hispanics (25.6 years), as well as American Indians and Alaska Natives (26.9 years), are lower than those of the other racial/ethnic group mem- bers. Hispanics have the lowest proportion of high school graduates (49.8 percent) of all groups and the highest proportion of people who speak a language other than English (77.8 percent). Asian Americans and Pacific Islanders (38.4 percent) as well as Hispan- ics (39.4 percent) have the largest proportions of indi- viduals who feel they do not speak English “very well.” They also have the highest proportions of foreign-born persons, American Indians and Alaska Natives, Afri- can Americans, and Hispanics have significantly higher levels of unemployment and poverty as well as substantially lower household incomes than Asian Americans, Pacific Islanders, or whites. In all four groups, a majority of members live in urban environ- ments; however, American Indians and Alaska Natives have the lowest proportion of urban residents. Differences in the demographic characteristics of each of the various racial and ethnic groups are related to variations in national background and immigration history. Asian Americans and Pacific Islanders, for example, include approximately 32 different ethnic and Table 1. U.S. population distribution, by race/ethnicity and Hispanic origin and percentage change, 1980-1990 : 1980 (in millions) White* 180.26 African American* 26.10 Hispanic 14.61 Asian American and Pacific Islander 3.50 American Indian and Alaska Nativet 1.42 *Excludes persons of Hispanic origin. +Excludes 3.5 million Hispanics in Puerto Rico. tIncludes Eskimos and Aleuts. Source: U.S. Bureau of the Census 1983, 1993c. 8 Chapter 1 1990 (in millions) % Change age 29.28 12 21.90" 50 7.23 107 2.02 42 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 2. Selected demographic characteristics for the U.S. population, by race/ethnicity, 1990 African American Indians/ Asian Americans/ Characteristic Americans Alaska Natives Pacific Islanders Hispanics Whites* Population 29,930,524 2,015,143 7,226,986 21,900,089 188,424,773 Women (percentage) 52.8 50.4 51.2 49.2 51.3 Median age (years) 28.2 26.9 30.1 25.6 34.9 Foreign born (percentage) 4.9 2.3 63.1 35.8 3.3 Education (percentage of persons aged 225 years) High school education 63.1 65.5 77.5 49.8 79.1 Bachelor’s degree or higher 114 9.3 36.6 9.2 22.1 English-language ability (percentage of persons aged 25 years) Speak a language other than English 6.3 23.8 73.3 77.8 5.7 Do not speak English “very well” 2.4 9.2 38.4 39.4 1.8 Number of persons per family 3.5 3.6 3.7 3.8 3.0 Percentage of families with own children aged <18 years 56.5 60.7 59.5 64.5 45.2 Employment status’ (percentage of persons aged 216 years) Employed 62.7 62.1 67.5 67.5 65.3 Unemployed 12.9 14.4 5.3 10.4 5.0 Percentage of employed persons aged 216 years in a managerial / professional occupation 18.1 18.3 30.6 14.1 28.5 Household income in 1989 ($) Median 19,758 20,025 36,784 24,156 31,672 Mean 25,872 26,602 46,695 30,301 40,646 Per capita income in 1989 ($) 8,859 8,328 13,638 8,400 16,074 Poverty rate (percentage) Families 26.3 27.0 11.6 22.3 7.0 Persons 29.5 30.9 14.1 25.3 9.2 Urban residents (percentage) 87.2 56.0 95.4 91.4 70.9 *Excludes persons of Hispanic origin. The population figures for African Americans in Tables 1 and 2 are different because the population cited in Table 2 includes African Americans of Hispanic origin, while the African American population cited in Table 1 excludes persons of Hispanic origin. tThese figures do not include several categories of people who were not in the civilian labor force for various reasons, such as students, housewives, retired workers, seasonal workers in an off season who were not looking for work, institutionalized persons, and persons doing only incidental unpaid family work (less than 15 hours during the reference week). Source: U.S, Bureau of the Census 1993a,c. Introduction and Summary = 9 Surgeon General’s Report national groups and speak nearly 500 languages and dialects (Chen 1993). They trace their background to areas as diverse as Mongolia to the north, Indonesia and the South Pacific Islands to the south, India to the west, and Japan to the east. Hispanics include indi- viduals who trace their background to the original set- tlers of large areas in what is now the Southwest United States as well as recent immigrants from any of the 18 Spanish-speaking countries in Latin America. The American Indian and Alaska Native population in the United States is likewise composed of a richly diverse group of indigenous cultures of indigenous cultures, over half of whom do not live on a reservation (U.S. Bureau of the Census 1993c). More than 500 federally recognized tribes and an additional 100 nonfederally recognized tribes are concentrated primarily in 25 res- ervation states (U.S. Bureau of the Census 1992a). American Indians and Alaska Natives continue to speak more than 150 languages. (For additional infor- mation, see U.S. Bureau of the Census reports on Asian Americans and Pacific Islanders [1993a], Hispanics [1993b], and American Indians and Alaska Natives [1993c].) Most African Americans in the United States can trace their ancestry to territories that include the modern states of Benin, Burkina Faso (formerly Upper Volta), Cameroon, the Congo Republic, Cote d'Ivoire (Ivory Coast), the Democratic Republic of the Congo (formerly Zaire), Gabon, Gambia, Ghana, Guinea, Liberia, Nigeria, Senegal, Sierra Leone, and Togo (Ploski and Williams 1989). The mode of entry for practically all Africans who entered the United States in the seventeenth, eighteenth, and nineteenth centuries (until 1865) was as slaves (see Chapter 4 for further historical discussion). Many recent immigrants came from the Caribbean islands and Sub-Saharan Africa. This report excludes data on the 3.5 million residents of Puerto Rico as well as data on residents of other territories and associated states of the United States; however, many of the issues discussed in this report are relevant to these individuals because they have been influenced by the events taking place in the 50 states. Over the next 50 years, the population of the four groups is expected to increase dramatically, reaching close to one-half of the country’s population by the year 2050 (Table 3), according to estimates from the USS. Bureau of the Census (1992b). These estimates underscore the need to develop appropriate interven- tions to avert disturbing tobacco addiction patterns in this large segment of the population. Table 3. Estimated percentage distribution of the U.S. population, by race/ethnicity and Hispanic origin, 1990-2050 Non-Hispanic African Asian American/ American Year American Pacific Islander Indian* White Hispanic 1990 11.8 2.8 0.7 75.7 9.0 1995 12.1 3.5 0.7 73.6 10.1 2000 12.3 4.2 0.8 71.6 11.1 2005 12.6 4.9 0.8 69.6 12.2 2010 12.8 5.5 0.8 67.6 13.2 2020 13.3 6.8 0.9 63.9 15.2 2050 15.0 10.1 1.1 52.7 21.1 *Includes Eskimos and Aleuts. Source: U.S. Bureau of the Census 1992b. 10. Chapter 1 Effects of Racial/Ethnic Background on Health Extensive research has been conducted on the relationship between health and race/ethnicity (see, for example, Harwood 1981; Polednak 1989; Braithwaite and Taylor 1992; Young 1994). Published reports of these studies tend to show different rates of illness across racial/ethnic groups. Some of these dif- ferences may be explained by variations in each group's beliefs and attitudes, traditional health-related practices, normative behaviors, social conditions, lev- els of access to high-quality health care, experiences with discrimination and racism, living environments, competing causes of death, and genetic backgrounds. Genetic factors may contribute to certain differences among groups of people; however, culture, degree of acculturation, and socioeconomic factors are probably far more significant determinants of health status in the United States (Freeman 1993; Adler et al. 1994). Culture is a broad concept (Kroeber and Kluckhohn 1963)—its influence encompasses all as- pects of daily life, including beliefs and practices about health and illness as well as norms that dictate behav- iors. Most contemporary societies include many dif- ferent cultures, which may be defined by historical, geographic, economic, social, and political elements (Helman 1985). The United States has always been a nation of immigrants and coexisting cultures. Acculturation—the process of learning the val- ues, beliefs, norms, and traditions of a new culture (Marin 1992)—allows individuals to make choices and to learn of new worldviews, while keeping their origi- nal views (biculturalism) or modifying their initial perspectives to be more consonant with those of the new culture (assimilation). In multicultural societies such as the United States, acculturation occurs among immigrants (as they learn the host culture) as well as among individuals born in the United States (as they learn the culture of immigrants). Despite the signifi- cance of acculturation’s link with human behavior, few studies have focused on how acculturation might affect the health status and behavior of ethnic groups in the United States. Part of the problem has been the difficulty in designing appropriate measuring instru- ments (Marin 1992), although recent research has begun to assess the role that acculturation plays in Tobacco Use Among U.S. Racial/Ethnic Minority Groups determining the health status of members of U.S. racial/ethnic groups (Pérez-Stable 1994; Vega and Amaro 1994; Williams and Collins 1995). Socioeconomic characteristics, which are power- ful determinants of health and disease (USDHHS 1985, 1991; Liberatos et al. 1988; HRSA 1991; Williams and Collins 1995), differ markedly among the racial and ethnic groups of the United States (Table 2). Levels of income and education may directly and indirectly af- fect the health status of individuals (Council on Ethi- cal and Judicial Affairs 1990; Weissman et al. 1991). Income, for example, often is a determinant of access to health care as well as of the quantity and quality of health care available. Persons with low incomes, re- gardless of race or ethnicity, are more likely to be uninsured (American College of Physicians 1990), to encounter delays in seeking or receiving care or to be denied care (Tallon 1989), to rely on hospital clinics and emergency rooms for health services (NCHS 1985), and to receive substandard care (Burstin et al. 1992). Level of education may influence health beliefs and behaviors, which determine whether and how indi- viduals seek health care, make treatment choices, and comply with treatment suggestions. Because the lit- erature reviewed in this report has often failed to con- sider the role of socioeconomic factors in the health status of members of racial/ethnic groups, under- standing the significance of the results is difficult. Nevertheless, these published reports indicate that access to health care and the type of care received are partly determined by the race and ethnicity of the pa- tient and that members of minority groups are less likely than whites to receive adequate care (e.g., Blendon et al. 1989; CDC 1989; Todd et al. 1993; Wil- liams and Collins 1995). The information summarized in this report re- flects the role of race, ethnicity, and culture in shaping tobacco use among members of the four population groups. Unfortunately, currently available methods do not help delineate the role of acculturation, socio- economic conditions, and societal problems such as racism, prejudice, and discrimination (e.g., Osborne and Feit 1992; Freeman 1993; Pappas 1994). Never- theless, efforts were made here to discern the possible role of these variables in explaining tobacco use among racial/ethnic minority group members. Introduction and Summary 11 Surgeon General's Report Chapter Conclusions Following are the specific conclusions for each chapter in this report. Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups 1. In 1978-1995, the prevalence of cigarette smoking declined among African American, Asian Ameri- can and Pacific Islander, and Hispanic adults. However, among American Indians and Alaska Natives, current smoking prevalence did not change for men from 1983 to 1995 or for women from 1978 to 1995. Tobacco use varies within and among racial/ ethnic groups; among adults, American Indians and Alaska Natives have the highest prevalence of tobacco use; African American and Southeast Asian men also have a high prevalence of smok- ing. Asian American and Hispanic women have the lowest prevalence. In all racial/ethnic groups discussed in this report except American Indians and Alaska Natives, men have a higher prevalence of cigarette smoking than women. In all racial/ethnic groups except African Ameri- cans, men are more likely than women to use smokeless tobacco. Cigarette smoking prevalence increased in the 1990s among African American and Hispanic ado- lescents after several years of substantial decline among adolescents of all four racial/ethnic minor- ity groups. This increase is particularly striking among African American youths, who had the greatest decline of the four groups during the 1970s and 1980s. Since 1978, the prevalence of cigarette smoking has remained strikingly high among American Indian and Alaska Native women of reproductive age and has not declined as it has among African Ameri- can, Asian American and Pacific Islander, and Hispanic women of reproductive age. Declines in smoking prevalence were greater among African American, Hispanic, and white men who were high school graduates than they 12. Chapter 1 were among those with less formal education. Among women in these three groups, education- related declines in cigarette smoking were less pronounced. 8. Educational attainment accounts for only some of the differences in smoking behaviors (current smoking, heavy smoking, ever smoking, and smoking cessation) between whites and the racial/ ethnic minority groups discussed in this report. Other biological, social, and cultural factors are likely to further account for these differences. 9. Compared with whites who smoke, smokers in each of the four racial/ethnic minority groups smoke fewer cigarettes each day. Among smok- ers, African Americans, Asian Americans and Pa- cific Islanders, and Hispanics are more likely than whites to smoke occasionally (less than daily). 10. The data in general suggest that acculturation in- fluences smoking patterns in that individuals tend to adopt the smoking behavior of the current broader community; however, the exact effects of acculturation on smoking behavior are difficult to quantify because of limitations on most available measures of this cultural learning process. Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic Minority Groups 1. Cigarette smoking is a major cause of disease and death in each of the four racial/ethnic groups stud- ied in this report. African Americans currently bear the greatest health burden. Differences in the magnitude of disease risk are directly related to differences in patterns of smoking. 2. Although lung cancer incidence and death rates vary widely among the nation’s racial/ethnic groups, lung cancer is the leading cause of cancer death for each of the racial/ethnic groups studied in this report. Before 1990, death rates from malig- nant neoplasms of the respiratory system increased among African American, Hispanic, and American Indian and Alaska Native men and women. From 1990 through 1995 death rates from respiratory can- cers decreased substantially among African Ameri- can men, leveled off among African American women, decreased slightly among Hispanic men and women, and increased among American Indian and Alaska Native men and women. Rates of tobacco-related cancers (other than lung cancer) vary widely among members of racial / ethnic groups, and they are particularly high among African American men. The effect of cigarette smoking (as reflected by biomarkers of tobacco exposure) on infant birth weight appears to be the same in African American and white women. As reported in previous Sur- geon General’s reports, cigarette smoking increases the risk of delivering a low-birth-weight infant. No significant racial /ethnic group differences have been consistently demonstrated in the relationship between smoking and infant mortality or sudden infant death syndrome (SIDS); cigarette smoking has been associated with increased risk of SIDS and remains a probable cause of infant mortality. Future research is needed and should focus on how tobacco use affects coronary heart disease, stroke, cancer, chronic obstructive pulmonary disease, and other respiratory diseases among members of racial/ethnic groups. Studies also are needed to determine how the health effects of smokeless to- bacco use and exposure to environmental tobacco smoke vary across racial/ethnic minority groups. Persons of all racial/ethnic backgrounds are vul- nerable to becoming addicted to nicotine, and no consistent differences exist in the overall severity of addiction or symptoms of addiction across racial/ethnic groups. Levels of serum cotinine (a biomarker of tobacco exposure) are higher in African American smok- ers than in white smokers for similar levels of daily cigarette consumption. Further research is needed to clarify the relationship between smoking prac- tices and serum cotinine levels in U.S. racial/ ethnic groups. Variables such as group-specific patterns of smoking behavior (e.g., number of puffs per cigarette, retention time of tobacco smoke in the lungs), rates of nicotine metabolism, and brand mentholation could be explored. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups 1. The close association of tobacco with significant events and rituals in the history of many racial/ ethnic communities and the tobacco industry’s long history of providing economic support to some racial/ethnic groups—including employ- ment opportunities and contributions to commu- nity groups and leaders—may undermine prevention and control efforts. The tobacco industry’s targeted advertising and promotion of tobacco products among members of these four U.S. racial/ethnic groups may un- dermine prevention and control efforts and thus lead to serious health consequences. The high level of tobacco product advertising in racial/ethnic publications is problematic be- cause the editors and publishers of these publica- tions may omit stories dealing with the damaging effects of tobacco or limit the level of tobacco-use prevention and health promotion information in- cluded in their publications. Although much of the original research on psy- chosocial factors that influence tobacco use reflects general processes that may apply to racial/ethnic populations, documenting such generalizability requires further research. The initiation of tobacco use and early tobacco use among members of the various racial/ethnic mi- nority groups seem to be related to numerous cat- egories of variables—such as sociodemographic, environmental, historical, behavioral, personal, and psychological—although the predictive power of these categories or of specific risk factors is not known with certainty because of the paucity of research. Cigarette smoking among members of the four racial/ethnic groups is associated with depression, psychological stress, and environmental factors such as advertising and promotion and peers who smoke, as is also the case in the general popula- tion. The role of these factors in tobacco use among members of these racial/ethnic groups deserves attention by researchers and persons who develop smoking prevention and cessation programs. Introduction and Summary = 13 Surgeon General's Report Chapter 5. Tobacco Control and Education Efforts Among Members of Four Racial/ Ethnic Minority Groups 1. More research is needed on the effect of culturally appropriate programs to reduce tobacco use among racial/ethnic minority groups. Interven- tions should be language appropriate; addressing psychosocial characteristics such as depression, stress, and acculturation may increase the accep- tance of programs by members of racial/ethnic groups. To be culturally appropriate, tobacco control pro- grams must reflect the targeted racial/ethnic group’s cultural values, consider the group’s psychosocial correlates of tobacco use, and use strategies that are acceptable and credible to mem- bers of the group. Culturally competent program staff must be aware and accepting of cultural dif- ferences, be able to assess their own cultural val- ues, be conscious of intercultural dynamics when persons of different cultures interact, be aware of a racial/ethnic group’s relevant cultural charac- teristics, and have the skills to adapt to cultural diversity. Numerous strategies are needed to control tobacco use among racial/ethnic youths: restricting mi- nors’ access to tobacco products, establishing cul- turally appropriate school-based programs, and designing mass media efforts geared to young people’s interests, attitudes, expectations, and norms. Recent provisions of the Synar Amend- ment, designed to prevent minors’ access to to- bacco products, and the FDA regulations aimed at reducing the access to and appeal of tobacco products to young people are intended to reduce tobacco use among all youth, including members of racial/ethnic minority groups. 14 Chapter 1 4, Members of racial/ethnic groups are less likely than the general population to participate in smok- ing cessation groups and to receive cessation ad- vice from health care providers. Barriers to ethnic group participation include limited cultural com- petence of health care providers and a lack of trans- portation, money, and access to health care. Available data indicate that racial/ethnic groups support smoking restrictions, such as increasing cigarette excise taxes, banning cigarette advertise- ments, restricting access to cigarette vending ma- chines, raising the legal age of purchase, prohibiting sponsorship of events by tobacco com- panies, and establishing clean indoor air regula- tions. Additional research is needed to evaluate how best to build on this base of public opinion support to strengthen existing tobacco prevention and control programs within racial/ethnic communities. Prevention and cessation efforts in racial/ethnic communities are limited by underdeveloped to- bacco control infrastructures and low levels of re- sources for research, program development, and program dissemination. Greater resources are needed in racial/ethnic minority communities to build tobacco control infrastructures and to develop initiatives. 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Issues in the measurement of acculturation among Hispanics. In: Geisinger KF, editor. Psychologi- cal Testing of Hispanics. Washington (DC): American Psychological Association, 1992:235-51. National Center for Health Statistics. Persons With and Without a Regular Source of Medical Care: United States. Data from the National Health Survey. Vital and Health Statistics. Series 10, No. 151. Hyattsville (MD): US Department of Health and Human Services, Pub- lic Health Service, National Center for Health Statis- tics. DHHS Publication No. (PHS) 85-1579, 1985. National Center for Health Statistics. Healthy People 2000 Review, 1993. Hyattsville (MD): US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics. DHHS Publication No. (PHS) 94-1232-1, 1994. Introduction and Summary = 15 Surgeon General's Report National Heart, Lung, and Blood Institute. 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Latino Health in the US: A Grow- ing Challenge. Washington (DC): American Public Health Association, 1994:247-78. Ploski HA, Williams J, editors. The Negro Almanac: A Reference Work on the African American. Detroit: Gale Research Inc, 1989. Polednak AP. Racial and Ethnic Differences in Disease. New York: Oxford University Press, 1989. Tallon JR Jr. A health policy agenda proposal for in- cluding the poor. Journal of the American Medical Asso- ciation 1989;261(7):1044. Todd KH, Samaroo N, Hoffman JR. Ethnicity asa risk factor for inadequate emergency department analge- sia. Journal of the American Medical Association 1993;269(12):1537-9. US Bureau of the Census. Chapter C, General Social and Economic Characteristics. Part 1, United States Summary. 1980 Census of Population, Volume 1, Charac- teristics of the Population. Washington (DC): US Gov- ernment Printing Office. 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Introduction and Summary = 17 Chapter 2 Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups Introduction 21 Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups 22 African Americans 22 Prevalence of Cigarette Smoking 22 Number of Cigarettes Smoked Daily 23 Quitting Behavior 25 Women of Reproductive Age 26 Young People 28 American Indians and Alaska Natives 44 Prevalence of Cigarette Smoking 44 Number of Cigarettes Smoked Daily 45 Quitting Behavior 46 Women of Reproductive Age 48 Young People 49 Regional and Tribal Tobacco Use 50 Asian Americans and Pacific Islanders 56 Prevalence of Cigarette Smoking 56 Number of Cigarettes Smoked Daily 56 Quitting Behavior 57 Women of Reproductive Age 57 Young People 59 State and Local Smoking Estimates 60 Cigarette Smoking in Asian Countries 65 Hispanics 66 Prevalence of Cigarette Smoking 66 Number of Cigarettes Smoked Daily 69 Quitting Behavior 70 Women of Reproductive Age 71 Young People 72 Retrospective Analyses of Smoking Prevalence Among African Americans and Hispanics 74 Prevalence of Cigarette Smoking Among Successive Birth Cohorts 74 African Americans 74 Hispanics 75 Long-Term Trends in Cigarette-Smoking Initiation 78 African Americans 78 Hispanics 78 Cigarette Brand Preferences 79 Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior 83 Current Smoking 85 Smoking Cessation 85 Heavy Smoking 85 Ever Smoking 85 Occasional Smoking 86 Exposure to Environmental Tobacco Smoke 86 Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use 87 Cigarette Smoking 87 Pipe and Cigar Use 91 Use of Smokeless Tobacco 94 Conclusions 94 Appendix 1. Sources of Data 95 National Health Interview Survey (NHIS) 95 Hispanic Health and Nutrition Examination Survey (HHANES) 95 Behavioral Risk Factor Surveillance System (BRFSS) 95 Adult Use of Tobacco Survey (ALTS) 96 Monitoring the Future (MTF) Surveys 96 Youth Risk Behavior Survey (YRBS) 96 Teenage Attitudes and Practices Survey (TAPS) 96 Appendix 2. Measures of Tobacco Use 97 Cigarette Smoking and Cessation 97 Number of Cigarettes Smoked Daily 97 Use of Cigars, Pipes, and Smokeless Tobacco 97 Appendix 3. Patterns of Cigarette Use Among Whites 98 Appendix 4. Patterns of Cigarette Use Among African Americans 112 Appendix 5. Validation of the Retrospective Assessment of Smoking Prevalence 122 References 125 Introduction Tobacco Use Among U.S. Racial/Ethnic Minority Groups Over the past 15 years, the prevalence of ciga- rette smoking has generally declined among adult African Americans, Asian Americans and Pacific Islanders, and Hispanics. Nevertheless, rates of ciga- rette smoking and other tobacco use are still high among certain racial/ethnic minority groups compared with among the overall population, particularly American Indians and Alaska Natives. Designing more successful public health efforts to reduce tobacco-related diseases and deaths in racial / ethnic populations requires greater understanding of these racial/ethnic patterns of tobacco use. This chapter summarizes how smoking behaviors such as current tobacco use, cigarette consumption, and quit- ting behavior among adults vary within and among racial/ethnic groups. In addition, for all racial/ ethnic groups, the prevalence of cigarette smoking is examined for two groups of special interest, women of reproductive age and adolescents. The purpose of this chapter is to summarize in one source the reported trends and patterns of tobacco use among members of the four racial/ethnic minor- ity groups, by gender, age, and level of education. In addition, newly compiled information is presented on smoking patterns by birth cohort (based on year of birth) for African Americans and Hispanics. The rela- tionship between racial/ethnic group and education as predictors of cigarette smoking is explored, and data on cigarette brand preference and exposure to environmental tobacco smoke are presented. The in- fluence of acculturation on smoking behavior is ex- amined among the two fastest growing immigrant groups to the United States—Asian Americans and Pacific Islanders and Hispanics. Although reports of the effects of acculturation vary widely in the litera- ture, it is an important correlate of behavior despite limitations in conceptualization, operationalization, and measurement. The analyses presented in this chapter incorpo- rate data from national and state-specific population- based surveys of adults, national population-based surveys of adolescents, and local and international surveys of various adult and adolescent populations. The national studies cited in this chapter include the National Health Interview Survey (NHIS) (1978-1995), which garners yearly data on cigarette smoking; the Behavioral Risk Factor Surveillance System (BRFSS) (1987-1992), which collects information on behavioral risks among adults in the United States; the Adult Use of Tobacco Survey, which has been conducted periodi- cally since 1964; the Hispanic Health and Nutrition Examination Survey (HHANES), which gathered de- mographic and cigarette-smoking information from Hispanics between 1982 and 1984; the Monitoring the Future (MTF) surveys, which have been conducted in high schools annually since 1975; and the Teenage Attitudes and Practices Survey (TAPS), conducted in 1989 and 1993. Appendix 1 describes these major data sources, and Appendix 2 details the various measures of tobacco use. Appendix 3 presents data on patterns of cigarette use among whites that can be compared with the racial/ethnic group data presented in the chapter. Appendix 4 presents supplementary data on patterns of tobacco use among African Americans, and Appendix 5 describes how the authors validated one of the analytic techniques used to retro- spectively estimate smoking prevalence. The analyses in this chapter update and expand on previous Surgeon General’s reports that describe tobacco use among racial/ethnic groups; most of these previous reports have focused on cigarette smoking only among African Americans (U.S. Department of Health, Education, and Welfare [USDHEW] 1979; U.S. Department of Health and Human Services [USDHHS] 1983, 1988, 1989, 1990a). For some analyses reported here, small sample sizes limit the precision of the estimates. The patterns described in the text generally use point estimates, but confi- dence intervals presented in most tables can be referred to when the precision of the estimates needs to be defined. Patterns of Tobacco Use 21 Surgeon General’s Report Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups African Americans Prevalence of Cigarette Smoking The overall prevalence of cigarette smoking among African Americans declined from 37.3 percent in 1978-1980 to 26.5 percent in 1994-1995, according to data from the NHIS (Table 1) (National Center for Health Statistics [NCHS], public use data tapes, 1978- 1995). Between 1978 and 1995, the prevalence of cur- rent smoking among African American men fell from 45.0 to 31.4 percent, whereas the prevalence among African American women fell from 31.4 to 22.7 per- cent. Although the prevalence of smoking among African American men remained consistently higher than that among African American women, the gen- der differential in smoking prevalence narrowed over the 18-year period. Similar patterns have been observed since 1965 among both African Americans and whites (Figure 1) (Centers for Disease Control and Prevention [CDC] 1994c). Magnitudes of decline in smoking prevalence also differed by age (Table 1). Between 1978 and 1995, Table 1. Percentage of adult African Americans who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985 1987-1988t 1990-1991t 1992-1993t 1994-1995 Characteristic % +cit % +Cl % +Cl % +CI Fo +Cl % +CI Total 373 1.7 353 14 323 111 27.9 1.1 270 15 265 1.7 Gender Men 45.0 25 40.2 22 376 18 341 18 324 25 314 2.7 Women 314 18 314 17 280 14 229 13 226 16 22.7 19 Age (years) 18-34 38.7 2.8 34.7 2.) 32.0 1.7 26.0 1.7 22.1 2.2 21.0 2.4 35-54 43.9 24 422 27 372 19 356 19 35.9 2.7 34.2 3.0 >55 26.5 24 278 24 261 20 200 20 223 28 235 28 Education’ Less than high school 364 25 387 21 363 20 33.1 22 342 34 348 33 High school 42.1 26 394 28 388 2.1 33.5 19 319 2.7 313 31 Some college 36.7 55 348 34 330 2.7 289 28 275 32 264 37 College 34.6 67 284 43 197 32 178 2.9 182 42 16.7 3.8 “Excludes African Americans who reported they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 11978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. “Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 22. Chapter 2 African Americans 18-34 years of age experienced the largest decline in smoking prevalence, from 38.7 to 21 0 percent, whereas African Americans aged 55 years and older experienced the smallest decline, from 26.5 to 23.5 percent. In the years 1978-1980, persons 18-34 years of age were nearly 1.5 times more likely to smoke than those 55 years of age or older. By 1994 and 1995, however, because of the differential decline in smok- ing prevalence, the prevalence of smoking among younger adults was as low as that among their older counterparts. The prevalence of cigarette smoking among Af- rican Americans decreased most among college gradu- ates (Table 1)—a pattern that has been found in the nation as a whole (Pierce et al. 1989). Among African American college graduates, the smoking prevalence fell from 34.6 percent in 1978-1980 to 16.7 percent in 1994-1995. In comparison, smoking prevalence among African Americans with less than 12 years of educa- tion was 36.4 percent in 1978-1980 and 34.8 percent in 1994-1995. In the years 1978-1980, the prevalence of Tobacco Use Among ULS. Racial/Ethnic Minority Groups smoking varied little by level of education. However, by 1994 and 1995, an inverse relationship had emerged. As the level of education increased, the prevalence of cigarette smoking decreased. Number of Cigarettes Smoked Daily The percentage of African American smokers who reported that they were light smokers (smoking fewer than 15 cigarettes per day) increased from 56.0 percent in 1978-1980 to 63.9 percent in 1994-1995, ac- cording to the NHIS data (Table 2) (NCHS, public use data tapes, 1978-1993). This upward trend was found across all sociodemographic groups, with men, per- sons less than 55 years of age, and college graduates experiencing the largest increases in light smoking. Throughout the 18-year period, African Ameri- can women who smoked were consistently more likely than their male counterparts to smoke fewer than 15 cigarettes per day (Table 2), African American smok- ers 18-34 vears of age were slightly more likely than Figure 1. Trends in the prevalence of cigarette smoking among African American and white men and women, National Health Interview Surveys, United States, 1965-1995 70- 607 African ame American 50-4 men African y —— American & 40 women < Vv Y er ee LT White & 30> men — White 20-4 women 10-5 0 | | 1965 1970 1975 1980 1985 1990 1995 Year Source: National Center for Health Statistics, public use data tapes, 1965, 1966, 1970, 1974, 1976, 1977, 1978, 1979, 1980, 1983, 1985, 1987, 1988, 1990, 1991, 1992, 1993, 1994, and 1995. Patteris of Tobacco Use = 23 Surgeon General's Report Table 2. Percentage of adult African American smokers” who reported smoking <15, 15-24, or >25 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985* 1987-1988 1990-1991' 1992-1993* 1994~-1995* % +CI % +CT % +I % +xtClI Characteristic % +ClH % 4+CI Total <15 cigarettes 56.0 2.2 554 2.5 15-24 cigarettes 33.6 2.2 35.2 2.4 >25 cigarettes 10.4 1.7 94 1.6 Gender Men <15 cigarettes 50.4 3.2 523 3.8 15-24 cigarettes 37.1 36 363 3.4 >25 cigarettes 12.5 2.3 114 2.6 Women <15 cigarettes 62.2 3.2 586 3.1 15-24 cigarettes 298 28 34.1 28 >25 cigarettes 8.1 23 7.3 1.5. Age (years) 18-34 <15 cigarettes 59.8 3.6 56.9 3,7 15-24 cigarettes 31.7 3.3 34.4 3.3 >25 cigarettes 8.5 2.3 8.7 2.3 33-54 <15 cigarettes 51.2 34 351.0 4.1 15-24 cigarettes 35.6 3.7 37.7 39 >25 cigarettes 13.20 2.7 13 25 >55 <15 cigarettes 55.3 5.4 60.4 5.6 15-24 cigarettes 34.8 5.6 32.3 5.9 >25 cigarettes 99 4.8 74° 3.) 58.8 2.0 60.6 2.2 63.3 3.0 63.9 3.5 32.8 1.9 31.9 21 31.1 2.8 28.4 3.2 84 1.2 7.9 1.2 5.6 1.3 76 2.1 53.2 3.1 55.2 3.1 59.3 4.5 61.1 5.1 37.0 3.1 35.6 3.1 344 42 28.6 4.7 98 1.7 9.2 19 6.3 2.0 10.3 3.7 65.0 2.7 67.1 2.6 67.9 3.8 67.1 4.2 28.2 2.4 27.5 2.5 27.4 3.6 28.3 4.0 68 13 54. 13 4,7 1.5 46 1.7 64.1 2.9 67.2 3.4 69.5 5.1 70.0 5.5 28.5 2.7 26.6 3.2 25.5 4.8 23.3 5.3 74 1,7 6.2 1.8 5.1 2.1 6.7 2.7 52.1 3.1 54.6 3.4 60.4 4.3 58.9 5.2 37.7 3.1 36.9 3.2 33.20 4.1 32.2 4.8 10.2 17 8.5 1.9 63 2.1 8.9 3.6 59.1 5.2 60.4 4.8 59.0 6.5 66.7 6.6 33.6 5.0 31.9 4.7 36.3 6.4 27.3 6.0 7.3 2.5 7.7 2.7 4.7 2.7 6.0 3.8 “Excludes African Americans who reported they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 11978, 1979, and 1980 data were combined; 1983-and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 195% confidence interval. their older counterparts to be light smokers (except for the years 1983-1985). An association between edu- cation and light smoking became apparent in 1990-1991. In 1990 and beyond, among smokers, education was directly related to the proportion of 24 Chapter 2 smokers who smoked fewer than 15 cigarettes per day. As the level of education increased, the proportion smoking lightly also increased. Throughout the 18-year period, the prevalence of heavy smoking (smoking 25 or more cigarettes per Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 2. Continued 1978-1980' 1983-1985' 1987-1988' 1990-1991" 1992-1993* 1994-1995" Characteristic % +cr % +CI G% +Cl % +Cl % +Cl % +Cl Education Less than high school <15 cigarettes 53.1 40 560 4.1 57.3 3.1 573 34 57.7 55 561 6.0 15-24 cigarettes 33.5 3.6 32.7 40 327 33 335 3.3 33.9 54 325 5.6 >25 cigarettes 134 3.1 14 3.1 10.0 2.2 9.2 2.3 8.4 3.0 W5 4.5 High school <15 cigarettes 539 47 524 44 583 36 59.0 3.7 62.7 46 64.0 5.7 15-24 cigarettes 34.9 48 406 41 33.2 35 348 3.6 33.4 44 292 4.9 >25 cigarettes 11.2 3.6 6.9 2.1 8.5 19 6.2 1.6 3.9 1.8 6.8 3.9 Some college <15 cigarettes 4o7 75 486 66 563 47 60.9 56 634 7.0 63.0 8.4 15-24 cigarettes 37.6 6.1 37.4 68 347 47 32.2 5.5 31.0 68 322 8.2 >25 cigarettes 12.7 5.9 14.1 5.1 9.0 3.1 6.9 2.9 5.6 3.1 49 2.5 College <15 cigarettes 57.1 10.2 50.9 97 55.2 96 65.0 9.3 74.7 10.0 79.0 9.9 15-24 cigarettes 341 9.0 356 109 382 96 249 7.9 206 95 18.1 9.5 > 25 cigarettes 8.8 5.5 13.5 94 6.7 3.4 10.1 6.7 4.7 4.0 29 3.5 SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. day) was higher among African American men than among women, and it was higher among respondents 35-54 years of age than among their younger and older counterparts (Table 2). No clear patterns emerged in the relationship between education and the prevalence of heavy smoking. Quitting Behavior Between 1978 and 1995, the overall prevalence of smoking cessation (the percentage of persons who have ever smoked 100 cigarettes and who have quit smoking) among African Americans increased from 26.8 to 35.4 percent, according to data from the NHIS (Table 3) (NCHS, public use data tapes, 1978-1995). The prevalence of cessation generally increased over time across all gender, age, and education categories. The largest increases were among persons 55 years of age or older and college graduates. Throughout the 18-year period, the prevalence of smoking cessation remained higher among persons 55 years of age or older than among their younger counterparts (Table 3). Since 1983, college graduates have been generally more likely to quit smoking than persons with less than 16 years of education. Attempts to quit smoking during the previous year and short-term success at quitting were measured ina multivariate analysis of the 1991 NHIS data (CDC 1993). After statistical control was made for gender, age, education, and poverty status, African Americans were more likely than whites to stop smoking for at jeast one day during the previous year. However, Af- rican Americans who had stopped smoking for at least one day were less likely than whites to have quit for at least one month. Data from the National Cancer Institute (NCD Supplement of the 1992-1993 Current Population Sur- vey (CPS) indicate that among adults who were daily smokers one year before being surveyed, African Americans who had tried to quit for at least one day were slightly more likely than whites to have relapsed to daily smoking. African Americans were also slightly more likely than whites to have become occasional smokers (i.e., to be smoking on only some days) and slightly less likely to have quit smoking (Table 4) (US. Bureau of the Census, public use data tapes, Patterns of Tobacco Use 25 Surgeon General’s Report Table 3. Percentage of adult African American ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985t 1987-1988' 1990-1991 1992-1993 1994-1995" Characteristic % +CIh % +CI % +CI % +CI % +Cl % +CI Total 268 1.7 300 18 318 16 361 18 370 24 354 26 Gender Men 28.7 20 335 26 339 23 368 25 391 35 349 37 Women 2745 25 262 25 294 21 352 24 345 31 359 34 Age (years) 18-34 17.9 28 202 28 188 23 210 26 23.7 46 196 41 35-54 277 26 295 29 33.1 26 35.2 26 332 34 33.1 4.0 >55 423 40 470 36 492 30 573 36 568 44 547 44 Education$ Less than high school 32.6 2.7 327 25 350 25 380 33 40.0 42 368 4.0 High school 244 34 288 36 273 27 £324 26 334 38 316 43 Some college 32.4 59 350 47 366 40 381 44 390 53 373 63 College 298 86 370 69 50.2 61 £513 61 48.7 87 51.1 85 *Excludes African Americans who reported they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever smokers include current and former smokers. 11978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 195% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 1992-1993). Some data suggest that African Ameri- cans may be more likely than whites to be dependent on nicotine (see Chapter 3, Table 18, in the section Racial/Ethnic Differences in Self-Reported Nicotine Dependence; Royce et al. 1993), although a report by Andreski and Breslau (1993) suggests the opposite. African Americans appear to have comparatively lim- ited access to preventive health services, including smoking cessation services (USDHHS 1988; Hymowitz et al. 1991). Women of Reproductive Age Between 1978 and 1995, the prevalence of cur- rent smoking among African American women of re- productive age (18-44 years) declined from 35.4 to 23.4 percent, according to data from the NHIS (Table 5) 26 Chapter 2 (NCHS, public use data tapes, 1978-1995). Women who were college graduates experienced an over- whelming decline in smoking prevalence, from 37.0 to 10.8 percent, whereas women with less than a high school education (<12 years) experienced a slight in- crease in the prevalence of current smoking, from 41.1 to 46.3 percent. In the years 1978-1980, the prevalence of smok- ing varied little by level of education. However, by 1994 and 1995, a marked inverse relationship between smoking and educational level had emerged. As the level of education increased, the prevalence of smok- ing decreased. This inverse relationship has also been found in other studies of women of reproductive age (CDC 1991a, 1994b). National data on tobacco use and pregnancy are available from the 1967 and 1980 National Natality Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 4. Current cigarette smoking status among persons* who reported that they were daily smokers 1 year before being surveyed, Current Population Survey National Cancer Institute Supplement, 1992-1993 American Asian Indians/ Americans/ African Alaska Pacific Currrent Americans Natives Islanders Hispanics Whites Total smoking status g x+cr % +Cl % +CJ % +ClI % +Cl % +CI Smoke every day; did not 598 1.5 62.8 5.5 57.8 44 59.8 2.3 63.1 0.5 62.5 0.5 try to quit for at least one day during the previous vear Smoke every day; didtry 29.7. 14 28.9 5.1 32.0 4.2 28.5 2.1 26.0 O05 266 O04 to quit for at least one day during the previous year Smoke on some days 5.6 0.7 3.7 2.1 48 19 5.6 1.1 3.7 0.2 40 0.2 Do not smoke cigarettes; 22 0.5 1.8 1.5 2.5 1.4 2.5 0.7 3.4 0.2 3.2 0.2 abstinent for 1-90 days Do not smoke cigarettes; 27 0.5 28 19 2.9 1.5 36 09 3.8 0.2 3.7 0.2 abstinent for 91-364 days *Aged 18 years and older; N = 44,272. t95% confidence interval. Source: U.S. Bureau of the Census, public use data tapes, 1992-1993, Surveys, the 1982 and 1988 National Surveys of Fam- ily Growth, the 1985 and 1990 NHI5s, the 1988 Na- tional Maternal and Infant Health Survey (NMIHS), and the 1992-1993 National Pregnancy and Health Survey. Furthermore, since 1989, national trend data on smoking and pregnancy have become readily avail- able from information collected on the revised U.S. Standard Certificate of Live Birth, which is included as part of U.S. final natality statistics compiled each calendar year (NCHS 1992, 1993, 1994; Ventura et al. 1994). Among the earliest sources of national trend data on smoking during pregnancy were the National Na- tality Surveys, which were administered to a national sample of married mothers of live infants born in 1967 and 1980 (Kleinman and Kopstein 1987; USDHHS 1989). Among African American mothers <20 years of age, smoking rates remained virtually constant over time at about 27 percent. The smoking prevalence among African American mothers aged >20 years de- clined from 33 percent in 1967 to 23 percent in 1980. The National Survey of Family Growth collected data in 1982 and 1988 on the smoking behavior of females 15-44 years of age during their most recent pregnancy. In 1982, 29.2 percent of African American women re- ported smoking during their most recent pregnancy, compared with 23.4 percent in 1988 (Pamuk and Mosher 1992; Chandra 1995). More recent data from US. final natality statistics indicate that smoking rates for African Americans during pregnancy declined from 17.1 percent in 1989 to 10.6 percent in 1995 (Table 6). Smoking rates declined for African American teen- aged mothers from 1989 through 1995 but remained virtually unchanged for African American adult moth- ers aged 20-49 years during those years (NCHS 1992, 1993, 1994; Ventura et al. 1994, 1995, 1996). In general, African American adolescent mothers were less likely to have smoked than mothers 20-49 years Patterns of Tobacco Use 27 Surgeon General's Report Table 5. Percentage of African American women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988t 1990-1991* 1992-1993" 1994-1995" Characteristic % +crHt % +CI % +CI] % +ClI % +Cl % +Cl Total 354 23 341 20 306 18 254 16 238 21 234 24 Education$ Less than high school 41.1 56 524 57 482 42 445 47 457 69 463 78 High school 363 40 368 38 345 30 316 30 300 38 284 43 Some college 371 68 323 50 306 38 264 34 262 47 26.1 5.6 College 370 10.2 218 65 200 43 173 43 131 50 108 49 “Excludes African American women who reported they were of Hispanic origin. For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. old—a finding that is consistent with previously published data (USDHHS 1994). Data from the 1988 NMIHS indicate that 27 per- cent of African American mothers sampled reported smoking cigarettes in the 12 months before delivery (Sugarman et al. 1994). The National Pregnancy and Health Survey, conducted between October 1992 and August 1993 and sponsored by the National Institute on Drug Abuse (NIDA), provides nationally represen- tative data on the prevalence of prenatal drug use among females of reproductive age (15-44 years). Ac- cording to the National Pregnancy and Health Survey, 19.8 percent of African American women reported us- ing cigarettes during their pregnancies (NIDA 1994). In the 1985 and 1990 NHISs, questions related to smok- ing were asked of women aged 18-44 years who had given birth within the past five years. In 1985, 27.5 percent of African American women smoked during the 12 months before the birth and 22.6 percent smoked after learning of their pregnancy; in 1990, 19 percent smoked during the year before the birth and 14.1 per- cent after learning of their pregnancy (Floyd et al. 1993). 28 Chapter 2 Young People Cigarette Smoking In the 1970s and 1980s, the prevalence of ciga- rette smoking declined among both male and female African American high school seniors, according to data from the MTF surveys (Figure 2) (Bachman et al. 1991b). The prevalence of daily cigarette smoking, based on two-year rolling averages (percentages cal- culated by averaging the data for the specified year and the previous year to increase racial subgroup sample sizes and stabilize estimates), among African American high school seniors was 24.9 percent in 1977, 4.1 percent in 1993, and 7.0 percent in 1996 (Figure 3) (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). Between 1974 and 1991, signifi- cant declines in the prevalence of cigarette smoking also were observed among African American adoles- cents participating in the National Household Surveys on Drug Abuse (NHSDAs) as well as among African Americans 18 and 19 years of age who participated in the NHISs (Nelson et al. 1995). Tobacco Use Among ULS. Racial/Ethnic Minority Groups Table 6. Percentage of live-born infants’ mothers who reported smoking during pregnancy, by year and race/ ethnicity, U.S. final natality statistics, 1989-1995 1989 1990 1991 1992 1993 1994 1995 Race of mother* African American 17.1 15.9 14.6 13.8 12.7 114 10.6 American Indian and Alaska Native 23.0 224 226 225 216 210 209 Asian American and Pacific Islander’ 5.7 5.5 5.2 4.8 4.3 3.6 3.4 Chinese 2.7 2.0 1.9 1.7 1.1 0.9 0.8 Filipino 5.1 5.3 5.3 4.8 4.3 3.7 3.4 Hawaiian and part Hawaiian 193° 210 194 185 17.2 160 15.9 Japanese 8.2 8.0 7.5 6.6 6.7 5.4 5.2 Other Asian American or 4.2 3.8 3.8 3.6 3.2 2.9 2.9 Pacific Islander White 204 194 188 179 168 15.6 15.0 Hispanic origin of mother! Hispanic origin 8.0 6.7 6.3 5.8 5.0 4.6 4.3 Cuban 6.9 6.4 6.2 3.9 5.0 4.8 4.1 Central and South American 3.6 3.0 2.8 2.6 2.3 1.8 1.8 Mexican American 6.3 5.3 4.8 4.3 3.7 3.4 3.1 Other and unknown Hispanic 12.1 10.8 10.7 10.1 9.3 8.1 8.2 Puerto Rican 14.5 13.6 13.2 12.7 11.2 10.9 10.4 African American, non-Hispanic 17.2 15.9 14.6 13.8 12.7 11.5 10.6 White, non-Hispanic 21.7 21.0 205 19.7 186 17.7 17.1 Total 195 184 178 169 158 146 13.9 *Includes data for 43 states and the District of Columbia (DC) in 1989, 45 states and DC in 1990, and 46 states and DC in 1991-1995, Excludes data for California, Indiana, New York (but includes New York City), and South Dakota in 1994 and 1995; Oklahoma in 1989-1990; and Louisiana and Nebraska in 1989, which did not require the reporting of mother’s tobacco use during pregnancy on the birth certificate. White and African American racial groups include persons of Hispanic and non-Hispanic origin. Maternal tobacco use during pregnancy was not reported on the birth certificates in California and New York, which together accounted for 43-66 percent of the births in each Asian subgroup (except Hawaiian) during 1989-1991. *Includes data for 42 states and DC in 1989, 44 states and DC in 1990, 45 states and DC in 1991-1992, and 46 states and DC in 1993-1995. Excludes data for California, Indiana, New York (but includes New York City), and South Dakota in 1994 and 1995; Oklahoma in 1989-1990; and Louisiana and Nebraska in 1989, which did not require the reporting of either Hispanic origin of mother or tobacco use during pregnancy on the birth certificate. Persons of Hispanic origin may be of any race. Sources: National Center for Health Statistics 1996; Ventura et al. 1996, 1997. The prevalence of cigarette smoking among Af- rican American adolescents has been substantially lower than the prevalence among white and Hispanic adolescents (Figures 2 and 3) (Bachman et al. 1991b; USDHHS 1994; CDC 1996; Johnston et al. 1996). Lo- cal, more limited surveys have also shown similar differences in cigarette smoking prevalence between African American and white youths (for example, Sheridan et al. 1993; Greenlund et al. 1996). In addition to the slight increases in the 1990s in smoking prevalence among African American high school seniors (Figures 2 and 3), CDC’s Youth Risk Behavior Survey (YRBS) detected an increase in the prevalence of cigarette smoking from 1991 to 1995 Patterns of Tobacco Use 29 Surgeon General's Report Figure 2. Trends in daily smoking* among African American and white high school seniors, by gender, United States, 1977-1996 35 3040 TtTTt ve, 25 5 20-4 157 Percentage 10- 0 tT oT To 1977 1979 1981 1983 1985 Year wees =A fricam American males African American females eeee T | T | T | I q | ] 1987 1989 1991 1993 1995 White males ----- White females Note: To increase racial subgroup sample sizes and stabilize estimates, the percentages were calculated by averaging the data for the specified year and the previous year. *Daily smoking is defined as smoking one or more cigarettes per day during the previous 30 days. Source: Institute for Social Research, University of Michigan, unpublished data from the Monitoring the Future surveys, 1976-1996. among male African American high school students (CDC 1996). The prevalence of previous-month smoking among African American male high school students increased from 14.1 percent in 1991 to 27.8 percent in 1995. Among female African American high school students, prevalence was 11.3 percent in 1991 and 12.2 percent in 1995 (CDC 1996). Data from the MTF surveys indicate that the prevalence of daily smoking increased more rapidly from 1993 to 1996 for male than for female African American high school seniors (Figure 2) (Institute for Social Research, University of Michigan, unpublished data from the MTF surveys, 1976-1996). Yet even with this increase, the prevalence of smoking among African American high school seniors was still lower than that for members of other racial/ethnic groups during 1990- 1994 (Table 7). 30 Chapter 2 The trend of lower smoking prevalences among African American adolescents observed in recent years has continued as these individuals age and become young adults, according to the NHIS data. From 1978 through 1995, the prevalence of current smoking de- clined more among African Americans aged 20-24 years than among whites of the same ages, regardless of gen- der (Table 8) or level of forma] education (Table 9) (NCHS, public use data tapes, 1978-1995). In addition, among persons 25-29 and 30-34 years of age, recent declines in smoking prevalence were greater for Afri- can Americans than for whites (Table 8) (Figure 4). In addition to the recent increases seen among African American high school seniors (Figures 2 and 3), the MTF surveys indicate that previous-month smoking prevalence (based on two-year rolling aver- ages) among eighth-grade African American students Tobacco Use Among U.S. Racial/Ethnic Minority Groups Figure 3. Trends in daily smoking* among African American, Hispanic, and white high school seniors, United States, 1977-1996 35 — ao | Percentage —_ T on | 0 TT OT OT TT TS 1977 1979 1981 1983 1985 1987 Year T T 1989 1991 1993 1995 mums §=African Americans ——- Hispanics seco Whites Note: To increase racial subgroup sample sizes and stabilize estimates, the percentages were calculated by averaging the data for the specified year and the previous year. *Daily smoking is defined as smoking one or more cigarettes per day during the previous 30 days. Sources: Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data, 1996. increased from 5.3 percent in 1992 to 9.6 percent in 1996; among ninth-grade African American students, the prevalence increased from 6.6 percent in 1992 to 12.2 percent in 1996 (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). These recent pat- terns among African American adolescents suggest that the progress seen among young adults (Table 8) may reverse itself in the future. Possible biases. The accuracy of the finding that African American youths have been smoking less than white youths has been called into question. For ex- ample, trends observed may have resulted from arti- factual phenomena such as differential dropout rates or misclassification bias. Differential dropout rates. Some investigators have hypothesized that the data may be biased for two rea- sons. First, the data from school-based surveys exclude youths who are school dropouts. Second, because African American youths have a higher dropout rate than do white youths, the smoking prevalence rates may be more biased for African American youths than for white youths. However, this bias should only be apparent in the school surveys. The proportion of young adults (aged 25-29 years) who have completed at least four years of high school increased from 74 percent in 1976 to 83 percent in 1993 for African Ameri- cans; for whites, this proportion was 86 percent in 1976 and 87 percent in 1993 (Kominski and Adams 1994). The increasing rate of completing at least four years of high school among African American young adults, relative to whites, is not consistent with the hypoth- esis that the trend in smoking prevalence observed in school surveys is related to the dropout rate. Further- more, in household surveys, the trends in smok- ing prevalence among African Americans have also Patterns of Tobacco Use 31 Surgeon General's Report Table 7. Trends in the percentage of high school seniors who were previous-month smokers, by race/ ethnicity and gender, Monitoring the Future surveys, United States, 1976-1979, 1980-1984, 1985-1989, 1990-1994 1976-1979 1980-1984 1985-1989 1990-1994 Males African American 33.1 19.4 15.6 11.6 American Indian and Alaska Native 50.3 39.6 36.8 41.1 Asian American and Pacific Islander 20.7 21.5 16.8 20.6 Hispanic 30.3 23.8 23.3 28.5 White 35.0 27.5 29.8 33.4 Females African American 33.6 22.8 13.3 8.6 American Indian and Alaska Native 55.3 50.0 43.6 39.4 Asian American and Pacific Islander 24.4 16.0 14.3 13.8 Hispanic 31.4 25.1 20.6 19.2 White 39.1 34.2 34.0 33.1 Note: The Institute for Social Research usually reports the N (weighted), which is approximately equal to the sample size. Cases are weighted to account for differential probability of selection and then normalized to average 1.0. For males, the ranges of the N (weighted) for each of the cells in this table are 2,916 4,393 for African Americans, 342-587 for American Indians and Alaska Natives, 242-1,166 for Asian Americans and Pacific Islanders, 893-2,808 for Hispanics, and 24,931-31,954 for whites. For females, the ranges of the N (weighted) for each of the cells in this table are 3,982-5,716 for African Americans, 299-586 for American Indians and Alaska Natives, 223-1,143 for Asian Americans and Pacific Islanders, 940--2,723 for Hispanics, and 25,627—31,933 for whites. Sources: Bachman et al. 1991a; Institute for Social Research, University of Michigan, unpublished data. become lower than those for whites (Nelson et al. 1995). Finally, data from the 1989 TAPS have shown that Af- rican American youths—both active students and dropouts—are significantly less likely than white youths to have smoked recently. Among students 17 and 18 years of age who remained in school, African Americans (5.7 percent) were less likely than whites (19.3 percent) to have smoked in the previous week (CDC 1991b). Among youths who left school, 17.1 percent of African Americans and 46.1 percent of whites had smoked in the previous week. Similarly, 1991 NHSDA data show that among youths 16-18 years old, 7.2 percent of African American high school seniors and 27.7 percent of white high school seniors had smoked in the previous month, compared with 30.4 percent of African American dropouts and 72.2 percent of white dropouts (Kopstein and Roth 1993). Thus, dropout status does not account for the lower smoking prevalence among African American youths. Differential misclassification bias. Other research- ers have proposed that in recent years, African Ameri- can youths may have been more likely to misclassify 32. Chapter 2 their smoking status when questioned. No trend data are available on differences in misclassification of smoking status over time between African Americans and whites. However, data from the 1976-1992 MTF surveys have been used to compare the trends of high school seniors’ reports of smoking by their friends—a measure for which they would have little reason to underreport Johnston et al. 1993b; USDHHS 1994). Until 1993, the percentage of African American seniors who reported that most or all of their friends smoke declined substantially more than that of white seniors. Since 1993, an increase in this measure has been ob- served for African Americans, but not for whites (Bachman et al. 1980a, 1980b, 1981, 1984, 1985, 1987, 1991a, 1993a, 1993b, 1997; Johnston et al. 1980a, 1980b, 1982, 1984, 1986, 1991, 1992, 1993a, 1995b, 1997). This observation may be limited by the fact that African American and white youths have friends from several ethnic groups. Bauman and Ennett (1994) recently assessed misclassification bias in a household survey of ado- lescents 12-14 years of age, using carbon monoxide and salivary cotinine (a nicotine metabolite) as biological Table 8. Percentage of African Americans and whites cigarette smokers,” by age group and gender, 1978-1995 aggregate data Tobacco Use Among U.S. Racial/Ethnic Minority Groups 20-34 years of age who reported being current National Health Interview Surveys, United States, 1978-1980' 1983-1985' 1987-1988" 1990-1991" 1992-1993t 1994-1995" Characteristic % +Ch &% +Cl % +Cl % +CI % +Cl % +I Aged 20-24 years African Americans Total 37.3 43 32.0 3.6 24.7 2.9 16.8 2.7 15.0 4.1 13.7 39 Men 44.8 68 31.6 6.2 25.4 5.0 213 48 20.3 7.6 19.6 7.3 Women 31.8 44 32.3 3.8 24.1 3.3 13.1 2.5 10.7 3.4 89 33 Whites Total 35.6 1.6 35.5 1.6 304 1.5 28.4 1.5 32.0 2.3 33.3 2.5 Men 37.2 2.2 34.1 2.3 30.5 2.3 28.0 2.3 32.2 3.1 34.9 3.6 Women 34.0 2.0 36.8 2.2 30.3 18 28.8 2.0 32.4 3.1 31.6 3.3 Aged 25-29 years African Americans Total 41.5 3.9 39.0 3.9 38.3 3.4 30.5 3.3 21.7 3.6 21.0 43 Men 47.6 49 41.6 6.2 43.1 5.5 35.9 5.7 21.3 5.9 22.6 7.6 Women 36.5 5.8 36.8 4.6 34.3 3.7 26.1 3.6 221 4.5 19.6 5.3 Whites Total 38.4 1.4 36.2 1.5 34.7 1.3 30.8 13 31.2 1.9 32.2 2.1 Men 42.3 2.0 38.3 2.2 34.5 1.8 31.2 1.9 31.9 2.7 32.6 3.1 Women 34.7 2.0 34.1 19 35.0 1.7 30.5 1.7 30.6 2.5 31.9 2.8 Aged 30-34 years African Americans Total 43.0 5.1 40.8 4.5 41.0 3.1 36.5 3.0 34.2 4.2 31.9 43 Men 50.2 8.2 45.5 7.1 43.6 5.1 38.9 4.8 38.3 6.9 31.2 68 Women 37.55 6.0 37.1 4.6 38.9 3.6 34.5 3.6 30.8 4.9 32.5 5.7 Whites Total 38.6 1.8 344 1.5 33.1 13 31.1 1.2 32.9 1.7 30.7 1.8 Men 43.1 2.5 37.3 2.2 35.9 1.8 32.7 1.7 33.1 2.4 31.3 2.6 Women 34.2 2.3 315 1.9 30.4 1.6 29.6 1.5 32.7 2.2 30.2 2.6 *For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of surv include persons who reported smoking at survey that they currently smoked every day or on some days. 11978, 1979, and 1980 data were combined; 1983 and 19 combined; 1990 and 1991 data were combined; 1992 an were combined. t95% confidence interval. ey that they currently smoked. For 1992-1995, current smokers least 100 cigarettes in their lives and who reported at the time of 85 data were combined; 1987 and 1988 data were d 1993 data were combined; and 1994 and 1995 data Source: National Center for Health Statistics, public use data tapes, 1978-1995. markers for tobacco use. Among adolescents who re- ported that they did not smoke, African Americans were more likely than whites to test positive for car- bon monoxide and for cotinine. Overall, however, white adolescents were three times more likely than African American adolescents to test positive for car- bon monoxide, suggesting that whites in this study were substantially more likely to smoke, regardless of Patterns of Tobacco Use 33 Surgeon General’s Report Table 9. Percentage of African Americans and whites 20-24 years of age who reported being current cigarette smokers,* by education and gender, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988t 1990-1991' 1992-1993" 1994-1995 Characteristic % +c % +CI % +CI] % +CI % +CI % +CI >12 years’ education African Americans Total 41.9 5.2 38.6 4.5 30.4 3.7 22.8 3.9 18.5 5.4 16.7 54 Men 49.1 7.9 38.2 7.7 29.6 6.3 28.9 69 21.9 94 22.2 10.1 Women 35.9 63 38.9 4.9 31.0 4.5 17.8 3.5 15.2 5.1 12.5 5.0 Whites Total 45.2 18 48.3 2.3 44.2 214 40.5 24 46.9 3.2 454 4.2 Men 47.8 2.8 47.8 3.5 46.2 3.2 40.5 3.4 475 48 47.1 58 Women 42.7 2.6 48.7 2.9 42.3 2.8 40.5 3.1 46.4 4.5 43.6 5.6 >13 years’ education African Americans Total 26.4 64 17.3 44 12.4 3.7 7.2 2.9 90 53 93 5.6 Men 32.0 11.3 156 7.9 13.3 7.0 9.2 5.3 16.6 12.4 15.9 10.6 Women 23.5 6.7 18.5 6.6 11.9 4.0 55 3.0 46 4.0 3.1 3.0 Whites Total 21.6 2.0 18.2 1.8 15.4 1.5 16.0 1.5 19.0 2.6 23.6 2.8 Men 22.0 2.5 15.8 24 14.0 2.0 145 24 17.6 3.5 24.6 4.2 Women 21.2 2.5 20.5 2.6 16.7. 2.1 17.3 2.1 20.3 3.5 22.7 3.8 “For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 11978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. Source: National Center for Health Statistics, public use data tapes, 1978-1995. differential misclassification. In a study of young adults 18-30 years old, Wagenknecht and colleagues (1992) also found differential misclassification, with African Americans (5.7 percent) more likely than whites (2.8 percent) to misclassify themselves as non- smokers. However, these researchers suggested that their results may have been influenced by differential exposure to environmental tobacco smoke and by dif- ferences in nicotine metabolism. Using a sample of seventh- through tenth-grade New York State public school students, Wills and Cleary (1997) compared self- 34 Chapter 2 reports of cigarette smoking with measured carbon monoxide from expired air. The investigators found that the sensitivity for self-reports was slightly lower for African Americans than for whites, but the magni- tude of the effect was small. When self-reported smok- ing rates were adjusted for carbon monoxide values, at every grade level African American students had significantly lower smoking prevalences than whites. Although the phenomenon of differential mis- classification may need further investigation, no evi- dence indicates that misclassification bias explains the Tobacco Use Among U.S. Racial/Ethnic Minority Groups Figure 4. Trends in smoking* among African Americans and whites aged 20-34 years, United States, Percentage Percentage 1978-1995 African Americans oF 40 - 30- 20- 10-4 0+ 4 TT TT tt rt rt rr 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year 505 Whites 40-4 Peep ueeaeuaegedn Treas 394 "Te eunaeeaasanag ath?” 20-4 10-4 0+ TT TT 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year asta Aged 20-24 m——— Aged 25-29 — Aged 30-34 *For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. Source: National Health Interview Surveys, National Center for Health Statistics, public use data tapes, 1978-1995; see Table 8 for corresponding data. Patterns of Tobacco Use 35 Surgeon General's Report substantial decline in smoking prevalence reported by African American youths. Possible behavioral, sociodemographic, and attitudinal explanations. Exploring possible interac- tions between the use of alcohol or other drugs and changes in cigarette smoking among African American and white adolescents may yield important scientific data. Understanding the trends of smoking behavior in the context of factors such as the age when youths start smoking, background and lifestyle factors, and attitudes about smoking may help program develop- ers design better smoking prevention and control in- terventions for these and other population subgroups. Differential use of other drugs. MTF data were ana- lyzed to explore possible interactions between the use of alcohol or other drugs and changes in cigarette smoking among African American and white adoles- cents (Table 10) (Figures 5 and 6) (Institute for Social Research, University of Michigan, public use data tapes, 1976-1994). Between 1976 and 1994, the per- centage of African American adolescents who were abstinent from (i.e., did not use in the previous month) both cigarettes and other substances (Table 10) was higher than for whites and tended to increase more rapidly for African Americans than for whites in ev- ery category of drug use. For example, 41.7 percent of African American high school seniors surveyed in 1976-1979 were abstinent from cigarettes and alcohol, compared with 64.1 percent in 1990-1994. Among white seniors, 22.4 percent were abstinent from both cigarettes and alcohol in 1976-1979, compared with 37.1 percent in 1990-1994. Concurrent use (i.e., use of both substances in the past month) was lower and tended to decrease more rapidly among African Ameri- can seniors than among white seniors between 1976 and 1994. In addition, trends in the use of cigarettes, alcohol, and other substances among high school se- niors indicate that among both smokers and nonsmok- ers, African Americans were generally less likely than whites to use substances other than tobacco (Table 10). Age of smoking initiation. African American smok- ers initiate smoking at slightly later ages than white smokers, according to the findings of two national studies (Escobedo et al. 1990; CDC 1991c). In addi- tion, data from the 1994-1995 (combined) NHSDAs indicate that among U.S. adults aged 30-39 years who had ever smoked daily, the average ages for first try- ing a cigarette and for becoming a daily smoker were about one year higher for African American males than for white males and about two years higher for African American females than for white females (Table 11) (USDHHS, Substance Abuse and Mental Health Services Administration, public use data tapes, 1994-1995). 36 Chapter 2 These differences in the age of smoking initia- tion are not large enough to suggest that the differ- ences in smoking prevalence currently observed among African American and white adolescents will disappear as these populations age (CDC 1991c). The data presented in Table 11 and by Escobedo and col- leagues (1990) indicate that although African Ameri- cans are more likely than whites to begin smoking in their early 20s, virtually all smokers in both groups have begun by age 25. Furthermore, the prevalence of cigarette smoking has decreased more rapidly for African Americans than for whites among those persons aged 20-24 years, 25-29 years, and 30-34 years (Table 8), suggesting that a birth cohort effect has occurred. Background and lifestyle factors. Investigations of background and lifestyle factors have not identified characteristics that might account for the greater de- cline in smoking among African American youths. Wallace and Bachman (1991) analyzed the MTF data and found that the difference was not explained by factors such as parents’ education, presence of two parents in the household, location of residence, college plans, academic performance, employment status, religiousness, or political views. To assess the incidence of cigarette smoking among African Ameri- can and white adolescents, Faulkner and colleagues (1996) analyzed longitudinal data from the 1989-1993 TAPS. The analyses were restricted to 3,531 African Americans and whites aged 11-17 years who reported in 1989 that they had never tried cigarettes. After controlling statistically for variables that were sociodemographic (sex, age, and parental education), environmental (household smoking and number of same-sex friends who smoke), personal (beliefs about the perceived benefits of smoking), and behavioral (in- tention to smoke, participation in organized physical activity, and academic performance), the study found that African Americans were significantly less likely than whites to have tried cigarette smoking four years later. Lowry and colleagues (1996) analyzed cross- sectional data on 6,321 adolescents (aged 12-17 years) from the YRBS supplement to the 1992 NHIS. African Americans were significantly less likely than whites to have smoked in the previous 30 days. This analysis controlled statistically for the educational level of the responsible adult, for family income, for the age and sex of the adolescent, and for whether the adolescent was in or out of school. Furthermore, the major declines in smoking reported for African American high school seniors have occurred regardless of parents’ education; the Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 10. Percentage of African American and white high school seniors who reported recently using or not using cigarettes and other selected substances,* Monitoring the Future surveys, United States, 1976-1994 aggregate data Cigarette use among African Americans* 1976-1979 1980-1984 1985-1989 1990-1994 Characteristic Yes No Yes No Yes No Yes No Alcohol use Yes 22.7 25.9 15.2 31.2 11.0 29.5 7.2 26.2 No 9.7 41.7 5.3 48.4 3.1 56.4 2.6 64.1 Marijuana use Yes 17.2 11.9 11.2 14.2 6.4 7.8 3.1 5.8 No 15.0 55.9 9.3 65.3 7.6 78.2 6.6 84.5 Cocaine use Yes 1.4 0.6 1.4 1.3 1.0 1.0 0.3 0.2 No 31.7 66.3 19.7 77.6 13.3 84.8 9.6 89.8 Any illicit drug uset Yes 17.6 12.9 11.4 15.2 6.6 9.3 3.3 6.8 No 14.0 55.5 8.8 64.6 7.0 77.1 6.2 83.7 Cigarette use among whites? 1976-1979 1980-1984 1985-1989 1990-1994 Characteristic Yes No Yes No Yes No Yes No Alcohol use Yes 33.7 40.5 28.2 46.0 28.6 40.9 27.5 29.7 No 3.3 22.4 2.7 23.1 3.6 26.8 5.7 37.1 Marijuana use Yes 22.4 13.7 16.9 12.8 14.4 8.1 11.8 44 No 14.3 49.6 13.8 56.5 17.5 60.0 21.3 62.5 Cocaine use Yes 2.6 1.1 3.5 2.0 3.4 1.4 1.2 0.2 No 34.3 62.0 27.3 67.2 28.5 66.6 31.9 66.7 Any illicit drug uset Yes 23.3 14.8 18.9 15.5 16.1 10.0 13.3 5.9 No 13.3 48.6 11.7 53.9 15.7 58.3 19.6 61.2 *Refers to use of these substances in the last 30 days. *Entries are percentages of the entire African Am tAny illicit drug use includes any use of marijuan opiates, stimulants, barbiturates, methaqualone, lone is excluded from the definition of illicit drugs for the 1990-1994 survey data. tire white high school senior population. SEntries are percentages of the en Institute for Social Research, University of Michigan, public use data tapes, Source: Survey Research Center, 1976-1994. erican high school senior population. a, hallucinogens, cocaine, or heroin or any use of other or tranquilizers not under a physician’s orders. Methaqua- Patterns of Tobacco Use 37 Surgeon General’s Report Figure 5. United States, 1976-1979 and 1990-1994 1976-1979 O, 3% 7% African Americans Whites 3% *In the previous month. Use of cigarettes and alcohol* among African American and white high school seniors, 1990-1994 Cigarettes and alcohol Cigarettes but no alcohol No cigarettes but alcohol Neither Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data tapes, 1976-1994; see Table 10 for corresponding data. respondent's personal income; school performance; the importance of religion to the respondent; geographic region of residence; and, except for those who were raised on a farm, the locale in which the respondent grew up (Table 12) (Institute for Social Research, Uni- versity of Michigan, public use data tapes, 1976-1994). Attitudes about smoking. One possible explana- tion is that the attractiveness (or functional value) of cigarette smoking has decreased more rapidly among African American high school seniors than among white seniors. For example, African American seniors have, over time, become increasingly more likely than 38 Chapter 2 white seniors to acknowledge the health risks of ciga- rette smoking, to claim that smoking is a dirty habit, and to claim that they prefer to date nonsmokers. From 1976 through 1989, African Americans were more likely than whites to disagree with the statement, “I person- ally don’t mind being around people who are smok- ing” (USDHHS 1994). African American youths also have been less likely than white youths to believe that cigarette smok- ing helps control weight. In anonymous surveys of 659 students (with an average age of 16 years) from two racially integrated high schools in the area Figure 6. United States, 1976-1979 and 1990-1994 1976-1979 African Americans Whites *In the previous month. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Use of cigarettes and illicit drugs* among African American and white high school seniors, 1990-1994 Cigarettes and illicit drugs Cigarettes but no illicit drugs No cigarettes but illicit drugs Neither Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data tapes, 1976-1994; see Table 10 for corresponding data. of Memphis, Tennessee, 46 percent of white females, 30 percent of white males, 10 percent of African Ameri- can females, and 14 percent of African American males endorsed the statement, “Smoking cigarettes can help you control your weight /appetite” (Camp et al. 1993). When respondents who smoked at least once a week were asked whether they had smoked to control their weight, 61 percent of the white girls and 16 percent of the white boys said that they had smoked to control their weight, whereas none of the African American smokers reported that they smoked to control their weight. Further research is needed to delineate the role of weight control concerns in patterns of cigarette smoking initiation among adolescents of ethnic groups. One recent study suggests that African American ado- lescent females prefer a significantly heavier ideal body size than white adolescent females (Parnell et al. 1996), a finding consistent with the notion that the potential weight-controlling effects of cigarettes have less func- tional utility among young African American females than among white females. A previous Surgeon General’s report indica- ted that parental concern about whether an adoles- cent smoked appeared to decrease the risk of that Patterns of Tobacco Use 39 Surgeon General's Report Table 11. Cumulative percentages of recalled age at which a respondent first tried a cigarette and began smoking daily, among African American, Hispanic, and white men and women aged 30-39, National Household Surveys on Drug Abuse, United States, 1994-1995 All men* First tried a cigarette Began smoking daily Age African African (years) American Hispanic White American Hispanic White y P P <12 7.0 9.2 14.9 1.4 14 13 <14 17.1 20.6 32.2 3.7 4.6 4.6 <16 34.8 39.0 51.0 10.9 11.2 11.8 <18 55.1 54.7 68.7 20.3 19.6 26.4 <19 59.9 62.7 74.0 25.5 26.3 34.3 <20 64.6 65.5 76.1 28.6 28.4 38.5 <25 71.5 72.9 80.9 40.5 37.2 47 4 <30 74.3 76.4 81.7 44.6 42.5 48.8 <39 75.1 76.7 82.5 45.1 43.4 49.9 Mean age NA NA NA NA NA NA All women’ First tried a cigarette Began smoking daily Age African African (years) American Hispanic White American Hispanic White <12 4.6 3.5 7.8 0.6 0.2 0.8 <14 13.3 11.3 27.7 2.5 2.0 5.3 <16 25.7 22.5 49.4 5.9 5.6 15.8 <18 43.9 33.9 67.5 15.9 9.5 30.0 <19 52.3 40.7 73.2 21.7 14.3 38.6 <20 55.8 43.0 75.7 24.0 15.5 41.6 <25 66.1 51.4 80.3 33.7 21.8 49.2 <30 68.3 55.8 81.4 37.0 25.7 51.0 <39 69.3 57.4 82.0 38.1 26.7 51.4 Mean age NA NA NA NA NA NA *N = 3,536 'N = 5,143 NA = data not available. adolescent becoming a cigarette smoker (USDHHS 1994). In a study conducted in Los Angeles and San Diego in 1986, African American parents placed a higher value than white parents on becoming involved in preventing their children from beginning to smoke (Flay et al. 1988; Koepke et al. 1990). Data from two surveys conducted in eight U.S. communities in 1988 and 1989 indicate that African American adults were more likely than white adults to perceive cigarette 40 Chapter 2 smoking as a very serious health problem in their com- munity, to favor eliminating vending machines from places where teenagers gather, and to prohibit smok- ing in their car (Royce et al. 1993). More recent findings from focus groups con- ducted at several U.S. sites suggest that African Ameri- can parents may be more likely than white parents to express clear antismoking messages (McIntosh 1995; Mermelstein et al. 1996). Findings from these focus Tobacco Use Among U.S. Racial/Ethnic Minority Groups Men who had ever smoked daily First tried a cigarette Began smoking daily African African American Hispanic White American Hispanic White 8.9 13.6 15.7 3.0 3.2 2.7 22.7 29.7 36.7 8.3 10.6 9.2 45.7 55.4 61.0 24,2 25.7 23.7 73.7 74.1 83.9 45.0 45.1 52.9 81.1 83.4 90.5 56.4 60.7 68.8 87.0 86.9 93.0 63.5 65.4 77.1 96.1 97.0 98.4 89.7 85.7 95.1 99.9 99.6 98.9 98.9 97.9 97.7 100.0 100.0 100.0 100.0 100.0 100.0 15.9 15.3 14.6 18.4 18.6 17.6 Women who had ever smoked daily First tried a cigarette Began smoking daily African African American Hispanic White American Hispanic White 5.9 6.9 8.9 1.6 0.7 1.6 20.1 25.4 37.8 6.7 7.6 10.3 38.6 48.7 66.1 15.5 21.1 30.7 66.8 68.6 85.9 41.8 35.4 58.3 77.2 78.2 92.0 57.0 53.4 75.0 81.4 80.8 94.4 62.9 58.0 80.8 96.0 94.5 99.2 88.4 81.8 95.6 99.6 99.2 99.9 97.2 96.4 99.2 100.0 100.0 100.0 100.0 100.0 100.0 16.6 16.2 14.6 18.9 19.5 17.1 Source: Substance Abuse and Mental Health Services Administration, public use data tapes, 1994-1 995. groups also suggest that smoking by African Ameri- can adolescents may be a sign of disrespect toward parents (USDHHS 1994). Additionally, African Ameri- can adolescent females appear to perceive that absti- nence from smoking enhances their image, whereas white girls are more likely to perceive that smoking empowers them (perhaps because of themes expressed in cigarette advertising) (Mermelstein et al. 1996). The responses of African American community leaders, including that of former USDHHS Secretary Louis Sullivan, against cigarette marketing campaigns that appear to target African Americans may have influ- enced young people's attitudes and behaviors about smoking (McIntosh 1995). Further research is needed to better under- stand the large decreases in smoking prevalence that occurred among African American youth in the 1970s and 1980s. Research is also needed to better Patterns of Tobacco Use 41 Surgeon General's Report Table 12. Percentage of African American and white high school seniors who reported previous-month and heavy* smoking, by selected variables, Monitoring the Future surveys, United States, 1976-1994 Previous-month smoking (%) 1976-1979 1980-1984 1985-1989 1990-1994 African African African African Characteristic Americans Whites Americans Whites Americans Whites Americans Whites Parental education Less than high school 34.0 42.0 23.2 36.8 13.9 37.6 11.8 37.6 High school 35.3 39.5 21.2 34.1 14.1 34.8 10.7 34.8 Some college 30.9 35.0 20.7 29.2 16.0 31.3 9.4 32.5 College 29.4 32.4 18.3 26.7 13.3 29.1 9.3 32.4 Some postgraduate 30.1 31.2 21.9 23.7 14.7 28.3 9.8 31.7 study Personal income’ Low NA NA 16.4 24.5 12.6 24.6 7.5 24.6 Medium NA NA 19.4 30.5 14.9 28.8 9.4 29.7 High NA NA 22.8 33.3 14.1 34.5 9.8 35.5 Very high NA NA 23.4 37.8 16.5 39.8 12.4 41.3 School performance Far above average 25.9 25.8 16.2 21.0 11.4 23.0 8.0 24.6 Slightly above average 31.2 35.8 20.2 29.6 12.7 30.7 8.4 32.2 Average 34.4 45.3 22.5 38.5 15.3 38.9 10.6 39.4 Below average 40.0 52.4 28.0 44.1 20.5 46.7 17.6 48.3 Importance of religion Very important 29.3 25.0 19.1 21.9 11.4 21.9 8.2 22.1 Important 34.1 38.9 23.4 32.4 16.7 32.0 11.5 33.7 Not/somewhat 40.0 43.0 23.5 35.2 18.3 36.8 12.4 38.5 important Region Northeast 37.1 40.4 25.7 33.5 18.1 34.9 10.9 34.9 North Central 34.8 38.9 20.3 - 32.8 16.0 34.6 10.1 35.5 South 32.6 37.7 20.6 31.7 12.7 31.1 10.1 33.6 West 29.1 25.8 20.2 21.3 17.8 26.0 8.0 26.6 Locale in which respondent grew up Farm 33.6 37.9 24.9 31.6 26.7 33.0 22.3 31.9 Country 35.5 38.3 23.3 30.7 14.6 33.1 12.2 32.2 Small city 28.5 37.4 20.0 30.1 14.1 31.1 12.1 32.6 Medium-sized city 31.5 37.4 20.1 31.2 14.5 32.3 8.7 34.7 Suburb of medium- 34.5 36.9 18.5 32.0 16.5 32.0 6.8 34.7 sized city Large or very large city 36.2 38.5 22.3 32.0 13.9 33.4 8.5 33.6 Suburb of large or 34.1 32.7 20.0 29.1 14.0 30.2 9.0 33.8 very large city *Heavy cigarette smoking is 10 or more cigarettes smoked per day reported at time of survey. tPersonal income is the sum of income from employment, allowance, and other sources. Trend data are available for 1982-1994 only. NA = data not available. 42. Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Heavy cigarette smoking (%) 1976-1979 1980-1984 1985-1989 1990-1994 African African African African Americans Whites Americans Whites Americans Whites Americans Whites 9.3 24.0 6.2 21.5 3.0 21.3 2.7 19.1 10.8 21.6 4.6 17.4 2.4 15.7 1.6 15.9 9.1 17.4 4.8 13.1 3.3 12.3 1.4 12.6 7.2 14.9 3.5 10.3 2.4 9.5 1.6 11.6 9.1 14.8 5.3 9.0 4.1 8.3 1.2 9.8 NA NA 3.1 10.1 2.2 8.7 1.1 8.0 NA NA 3.4 12.5 3.0 9.2 1.7 9.1 NA NA 6.1 16.3 2.4 14.2 1.2 13.5 NA NA 6.9 20.7 3.3 19.8 2.3 20.1 7.6 10.6 3.7 8.1 3.0 7.1 1.5 7.1 8.4 17.7 4.1 12.8 2.0 11.2 1.2 11.3 10.2 25.9 5.2 20.2 2.7 17.5 1.5 17.3 11.7 33.5 7.2 26.1 5.1 25.4 4.4 26.0 8.5 10.4 4.0 8.7 2.1 7.3 1.2 7.5 9.4 19.1 5.7 14.5 3.1 12.0 1.9 11.9 12.8 25.0 6.0 18.6 3.9 16.3 24 16.5 12.2 23.2 6.3 17.4 4,7 16.6 2.1 14.4 11.1 19.3 5.3 16.0 3.0 13.8 1.9 13.9 9.2 19.5 4.7 14.8 2.1 12.4 1.6 13.8 7.4 12.5 4.2 7.9 3.3 8.4 1.1 8.8 9.9 16.4 5.4 12.3 8.1 12.2 5.1 12.2 10.0 20.2 5.1 14.9 2.9 13.7 1.5 13.1 8.7 19.0 4.5 13.7 2.7 12.2 2.8 12.5 9.4 20.2 4.9 15.4 2.2 13.1 1.3 13.4 9.0 20.6 4.0 15.2 2.8 12.6 1.1 12.7 10.8 22.9 5.4 16.5 2.3 14.9 1.2 14.0 9.3 16.4 3.8 14.0 3.7 11.0 1.2 12.2 Source: Institute for Social Research, University of Michigan, public use data tapes, 1976-1994. Patterns of Tobacco Use 43 Surgeon General’s Report understand the reasons for the increase in prevalence that occurred in the early 1990s (Figures 2 and 3) (CDC 1996). Other risk behaviors. The Surgeon General's re- port Preventing Tobacco Use Among Young People (USDHHS 1994) has concluded that “Tobacco use in adolescence is associated with a range of health- compromising behaviors, including being involved in fights, carrying weapons, engaging in higher-risk sexual behavior, and using alcohol and other drugs” (p. 9). Escobedo and colleagues (1997) have observed these associations for African American adolescent males and females. Using data from the YRBS supple- ment of the 1992 NHIS, the researchers found that af- ter their analysis controlled statistically for age, ethnicity, sex, parental educational level, region of the country, and other risk behaviors, marijuana use, binge drinking, and physical fighting were significantly as- sociated with cigarette smoking among African Ameri- can adolescent males and females. Focus group data suggest that African American youths are more likely than white youths to pair cigarette smoking with mari- juana use as a way to maintain and enhance the drug effects of each (Mermelstein et al. 1996). Smokeless Tobacco Use The prevalence of smokeless tobacco use among African American adolescents has remained fairly constant in recent years. According to the MTF sur- veys, previous-month smokeless tobacco use (based on two-year rolling averages) was reported by 1.8 percent of eighth-grade African American students in 1992 and 2.2 percent in 1996, among tenth-grade students, the prevalence was 2.9 percent in 1992 and 2.5 percent in 1996; and among high school seniors, the prevalence was 2.1 percent in 1987 and 2.7 per- cent in 1996 (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). Similarly, the YRBS data indicate that 2.1 percent of African American high school students were current smokeless tobacco us- ers in 1991 (USDHHS 1994), and 2.2 percent were so in 1995 (CDC 1996). African American adolescent males are substan- tially less likely than white adolescent males to use smokeless tobacco. Among male high school students participating in the 1995 YRBS, for example, 3.5 percent of African Americans and 25.1 percent of whites reported that they had used smokeless tobacco in the previous month (CDC 1996). Among females, 1.1 percent of Afri- can Americans and 2.5 percent of whites reported they had used smokeless tobacco in the previous month. 44 Chapter 2 American Indians and Alaska Natives Data assessing long-term trends in tobacco use among American Indians and Alaska Natives have been unavailable, for the most part, because national surveys and databases have only recently begun to identify persons of American Indian or Alaska Native ancestry. Studies using data from regional surveys or data on specific American Indian tribes have, however, provided useful information about tobacco use among members of these groups. Because the geographic location of American Indian and Alaska Native people reflects unique cultural and historical experiences, researchers should consider these differences when interpreting region-specific data about smoking preva- lence. Data from regional studies also may provide information that is useful in developing culturally appropriate tobacco control efforts. National surveys provide limited capability to assess the level of tobacco use and the effectiveness of tobacco control efforts among American Indians and Alaska Natives. The NHIS, for example, did not be- gin identifying American Indian and Alaska Native respondents until 1978. Because American Indians and Alaska Natives make up a small proportion of the U.S. population, data must be aggregated from several - years to provide meaningful estimates. Also noteworthy is that the data on tobacco use among American Indians and Alaska Natives include some ceremonial use (e.g., in pipes) in addition to daily addictive behavior (see Chapter 4). Anecdotal infor- mation also suggests that standard definitions and classifications of smoking may not accurately reflect smoking habits among American Indians, some of whom may smoke no more than one or two cigarettes per day (Nathaniel Cobb, personal communication, 1994; Roscoe et al. 1995). Yet American Indians who smoke a few cigarettes every day are classified in the <15-cigarettes-per-day category, which may imply a higher overall consumption than actually exists. Such differences in amounts of daily smoking may have important implications for the design of culturally ap- propriate smoking cessation interventions targeting American Indians. Prevalence of Cigarette Smoking Among American Indian and Alaska Native men and women, rates of smoking have been substantially higher than smoking rates in any other USS. subgroup. In the 1987 Survey of American Indians and Alaska Natives (SAIAN) of the National Medical Expenditure Survey, 32.8 percent of respondents reported being current smokers (Lefkowitz and Underwood 1991). This survey—the only nationally representative sample designed to assess the health practices of people of American Indian and Alaska Native ances- try-—targets people who live on or near reservations and who are eligible for services provided by the In- dian Health Service (IHS). The NHIS rate of smoking among American Indians and Alaska Natives for 1987 and 1988 (39.2 percent) was greater than the SAIAN estimate, perhaps because of different modes of administration and sampling (tribally enrolled benefi- ciaries in the SAIAN and the general population of American Indians and Alaska Natives in the NHI1S). In a more recent survey—conducted on reserva- tions between 1989 and 1992 and involving 4,549 Ameri- can Indians 45-74 years old in 13 tribes in Arizona, N orth Dakota, South Dakota, and southeastern Oklahoma—the prevalence of cigarette smoking was higher in nearly all American Indian groups (40.5 percent for men and 29.3 percent for women) than in the general U.S. population, but wide variation was notable (Welty et al. 1995). In this study, known as the Strong Heart Study, the smok- ing prevalence was highest in North Dakota and South Dakota (53.1 percent for men and 45.3 percent for women) and lowest in Arizona (29.7 percent for men and 12.9 percent for women). - According to the NHIS data, the overall preva- lence of cigarette smoking among American Indians and Alaska Natives was 48.2 percent in 1978-1980 and 39.2 percent in 1994-1995. Although the data are im- precise, they suggest a substantial drop in prevalence for men from 1978-1980 to 1983-1985 (Table 13) (NCHS, public use data tapes, 1978-1995). However, no progress for men was observed from 1983-1985 to 1994-1995 and, for women, no progress was observed from 1978-1980 to 1994-1995. Another major source of data on smoking pat- terns among American Indians and Alaska Natives is the BRESS, which, for these analyses, included data collected in 47 states and the District of Columbia (CDC 1992a). The BRFSS data for 1987-1991 show that among Ameri- can Indians and Alaska Natives, 33.4 percent of men and 26.6 percent of women reported that they were current smokers. The 95 percent confidence intervals associated with smoking rates overlap between American Indian and Alaska Native women and men in both surveys. Even though data were aggregated for several years, the small sample sizes of American Indians and Alaska Na- tives in both surveys produced imprecise estimates that make it impossible to determine whether the prevalence of smoking actually differed between men and women. The prevalence of smoking among American Indian and Alaska Native women in the NHIS (35.2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups percent in 1987-1988 and 37.2 percent in 1990-1991) differed substantially from the prevalence found in the 1987-1991 BRFSS (26.6 percent). Similarly, the preva- lence of smoking among American Indian and Alaska Native men in the NHIS (43.5 percent in 1987-1988 and 32.9 percent in 1990-1991) differed appreciably from the prevalence found for men in the 1987-1991 BRFSS (33.4 percent). Methodological differences between the surveys may explain these differences. Household, face-to-face interviews were conducted for the NHIS, whereas telephone interviews were performed for the BRFSS (Goldberg et al. 1991; Sugarman et al. 1992; Leonard et al. 1993). Because telephone coverage in the areas where American Indians and Alaska Natives live tends to be lower than in areas where other ethnic groups live (Goldberg et al. 1991; Sugarman et al. 1992), sometimes as low as 60.4 percent of households (U.S. Bureau of the Census 1994), American Indians and Alaska Natives probably were less likely than others to have been included in the BRFSS surveys. More- over, because telephone service requires financial abil- ity to pay, persons of higher socioeconomic status may have been more likely than other persons to be in- cluded in the BRFSS surveys (Thornberry and Massey 1988). Thus, the BRFSS may have yielded lower smok- ing rates than the NHIS because the BRFSS surveys selected more affluent respondents, who were less likely than others to smoke. Estimated rates and trends in cigarette smoking were not significantly related to educational attain- ment, according to NHIS (Table 13) and SATAN data. However, both surveys suffered from imprecision be- cause of small sample sizes. Number of Cigarettes Smoked Daily NHIS data for 1978-1995 show few variations over time in the number of cigarettes smoked per day among American Indian and Alaska Native smokers (Table 14) (NCHS, public use data tapes, 1978-1995). In the years 1978-1980, 39.9 percent of American In- dian and Alaska Native smokers reported smoking fewer than 15 cigarettes per day, and 25.2 percent re- ported smoking 25 or more cigarettes per day. By 1994— 1995, the proportion of American Indian and Alaska Native smokers who smoked fewer than 15 cigarettes per day was 49.9 percent, whereas the proportion who smoked 25 or more cigarettes per day was 17.0 per- cent. Data from the Strong Heart Study showed that American Indian smokers reported smoking fewer cigarettes per day (range of 6.1 among women in Ari- zona to 15.0 among men in North Dakota and South Dakota) than the national average (Welty et al. 1995). Patterns of Tobacco Use 45 Surgeon General's Report Table 13. Percentage of American Indian and Alaska Native adults who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980" 1983-1985' 1987-1988 1990-1991' 1992-1993 1994-1995 Characteristic % +ciIt % +CTI % +CI % +ClI % +CI % +CI Total 482 58 356 80 392 59 350 69 391 51 392 7.3 Gender Men 63.0 11.0 414129 435 93 329 71 375 93 454 13.1 Women 34.1 10.1 323 88 352 62 372 91 403 86 342 8.7 Age (years) 18-34 53.392 399136 381 71 £4361 93 41.3 87 48.0 11.1 35-54 53.5 11.0 367121 474 80 402 70 451 84 429 113 >55 33.4 15.1 247 113 29.2 10.7 234 149 223 93 105 89 Education$ Less than high school 499 88 287 113 425 83 334 89 426 123 441 142 High school graduate/ 35.0 11.5 36.7 102 35.7 67 354 79 379 74 335 7.8 any college *Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. In the years 1978-1980, American Indian and Alaska Native men were more likely than women to smoke 25 or more cigarettes per day (Table 14). Since 1980, however, the proportion of men smoking 25 or more cigarettes per day has declined. Cigarette consumption data from the BRFSS and the NHIS cannot be compared directly because the BRFSS data are for the mean number of cigarettes smoked daily (CDC 1992a). However, both sources of data indicate that the number of cigarettes smoked is slightly greater among older than among younger American Indians and Alaska Natives. Quitting Behavior State and regional surveys also indicate that the prevalence of smoking cessation remains relatively low among American Indian and Alaska Native smokers compared with smokers in other racial/ethnic groups 46 Chapter 2 (Goldberg et al. 1991; Lando et al. 1992). In the past 17 years, the percentage of American Indians and Alaska Natives who have ever smoked 100 cigarettes and have quit smoking has changed only slightly overall; NHIS data indicate that the prevalence of cessation was 31.6 percent in 1978-1980 and 32.9 percent in 1994-1995 (Table 15) (NCHS, public use data tapes, 1978-1993). During this period, the prevalence of smoking cessa- tion fluctuated substantially for both genders, with similar estimates reported for 1978-1980 and 1994— 1995. The prevalence of smoking cessation among American Indians and Alaska Natives has increased with increasing age: those aged 18-34 years have had the lowest prevalence of cessation, those aged 35-54 years have had intermediate proportions, and those aged 55 years and older have had the highest preva- lence of cessation. The prevalence of cessation in- creased among older American Indians and Alaska Natives; however, no progress occurred among those Tobacco Use Among ULS. Racial/Ethnic Minority Groups Table 14. Percentage of adult American Indian and Alaska Native smokers* who reported smoking <15, 15-24, or >25 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985 1987-1988t 1990-1991' 1992-1993 1994-1995 Characteristic % +CK % +CI % +CI % +CI % +CI % +Cl Total <15 cigarettes 39.9 10.2 38.2 12.5 33.7 7.5 46.3 7.3 50.0 11.9 49.9 14.6 15-24 cigarettes 349 95 48.5 12.5 45.8 7.6 34.7 8.2 32.6 9.3 33.0 12.7 >25 cigarettes 25.2 9.2 13.3 9.6 20.6 5.3 19.1 6.7 17.4 88 17.0 8.3 Gender Men <15 cigarettes 35.8 12.7 22.7 15.2 20.9 10.4 35.5 10.2 38.7 15.9 36.2 28.1 15-24 cigarettes 31.8 12.7 63.6 17.8 53.8 11.6 44.9 14.9 39.8 15.6 42.1 23.1 >25 cigarettes 32.3 14.8 13.7 12.1 25.4 8.7 19.7 10.6 21.5 12.0 21.7 15.7 Women <15 cigarettes 47.1 16.9 48.9 14.6 48.3 11.2 56.2 9.5 58.9 14.7 64.9 12.3 15-24 cigarettes 40.3 17.4 38.1 12.7 36.6 12.2 25.3 7.3 27.0 11.0 23.1 11.2 > 25 cigarettes 12.7 11.2 13.0 12.2 15.1 5.6 18.5 7.8 14.1 11.8 12.0 6.4 Age (years) 18-34 <15 cigarettes 42.0 15.7 45.0 18.7 51.8 15.1 59.5 12.7 49.9 16.7 57.6 18.9 15-24 cigarettes 41.0 11.7 49.1 18.1 40.8 13.3 29.7 11.7 35.0 14.3 29.7 17.0 >25 cigarettes 17.0 11.2 59 7.1 74 5.7 10.8 5.3 15.1 14.4 12.6 10.4 35-54 <15 cigarettes 26.9 15.7 26.6 17.2 213 99 37.3 10.2 46.1 19.1 43.3 17.2 15-24 cigarettes 34.3 15.2 52.1 21.2 40.4 12.9 39.6 10.8 31.1 15.7 32.3 16.1 >25 cigarettes 38.8 19.5 21.3 19.1 38.3 14.9 23.2 10.9 22.9 12.4 24.3 14.6 >55 <15 cigarettes 60.5 23.6 41.3 29.4 20.9 19.3 30.8 12.9 66.1 24.3 14.6 22.4 15-24 cigarettes 19.7 19.6 38.3 31.2 70.0 22.8 35.7 22.9 29.4 24.0 75.5 30.2 >25 cigarettes 19.8 19.9 20.4 33.3 92 98 33.5 30.2 44 63 9.9 19.8 Education$§ Less than high school <15 cigarettes 38.0 13.7 30.2 18.1 19.8 12.7 33.2 14.8 45.0 23.9 37.4 21.7 15-24 cigarettes 38.6 13.9 52.7 20.6 51.1 14.1 39.4 18.6 30.9 17.5 40.1 21.1 >25 cigarettes 23.4 13.1 17.1 20.3 29.1 10.5 27.4 14.1 24.1 22.0 22.5 17.2 High school/any college <15 cigarettes 37.8 17,7 36.9 16.4 31.3 11.6 45.6 9.1 47.5 13.5 57.0 16.3 15-24 cigarettes 27.8 18.9 48.5 17.4 47.9 11.7 33.4 9.7 33.7 12.2 25.8 13.4 >25 cigarettes 34.4 19.1 14.6 13.4 20.8 8.8 21.0 8.7 18.8 9.7 17.2 11.9 “Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 11978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. “Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patteris of Tobacco Use 47 Surgeon General's Report Table 15. Percentage of adult American Indian and Alaska Native ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985 1987-1988 1990-1991* 1992-1993' 1994-1995 Characteristic % +Cl % +Cl % +Cl % +Cl % +Cl % 41 Total 31.6 7.9 37.7 93 36.1 7.5 38.2 8.2 34.6 9.1 32.9 9.6 Gender Men 28.5 11.8 38.2 12.9 37.55 95 44.0 9.7 43.8 15.3 28.3 13.9 Women 36.5 11.8 37.4 12.8 34.3 8.4 31.7 9.8 25.2 7.7 37.2 13.0 Age (years) 18-34 29.5 12.0 30.2 15.1 28.0 8.2 28.3 10.1 20.7 13.4 16.3 13.3 35-54 25.4 12.1 38.0 15.2 34.7 9.5 33.0 8.6 34.8 10.5 29.1 13.4 >55 44.8 18.4 54.1 17.5 50.9 17.3 63.5 19.5 61.7 15.4 81.7 14.8 Education$§ Less than high school 28.4 11.3 43.8 15.7 29.8 12.4 49.4 11.7 37.4 13.1 39.3 15.1 High school/any college 47.3 15.6 39.1 13.3 43.1 9.1 36.0 10.3 36.2 12.3 36.5 11.0 *Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever smokers include current and former smokers. 11978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 95% confidence interval. “Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. aged 18-54 years. Interviews with patients at urban THS clinics in Milwaukee, Minneapolis, Seattle, and Spokane also showed a low prevalence of cessation (29.7 percent) (Lando et al. 1992), compared with 45 percent reported for the total U.S. population during the same time. Data from the NCI Supplement of the 1992-1993 CPS indicate that among American Indians and Alaska Natives aged 18 years and older who were daily smok- ers one year before being surveyed, 62.8 percent re- ported that they were still smoking daily and that they had not tried quitting for at least one day during the previous year (Table 4). Another 28.9 percent had tried quitting for at least one day, 3.7 percent were occasional smokers (i.e., smoked only on some days), 1.8 percent had not smoked for the past 1-90 days, and 2.8 per- cent had not smoked for the past 91-364 days. This distribution was similar to that among whites. 48 Chapter 2 Women of Reproductive Age Since 1978, rates of smoking have remained strik- ingly high among American Indian and Alaska Native women of reproductive age (18-44 years) par- ticipating in the NHIS (Table 16) (NCHS, public use data tapes, 1978-1995). Between 1978 and 1995, the prevalence of cigarette smoking among reproductive- aged American Indian and Alaska Native women changed little overall, and the data are not precise enough to allow meaningful comparisons according to educational attainment. A recent study by Davis and colleagues (1992) confirms that the prevalence of smoking is higher among American Indian women of reproductive age than among their counterparts in other racial/ ethnic groups. The investigators analyzed birth certifi- cates issued in Washington state between January 1, Tobacco Use Amoug U.S. Racial/Ethnic Minority Groups Table 16. Percentage of American Indian and Alaska Native women of reproductive age who reported being current cigarette smokers,” overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988" 1990-1991t 1992-1993 1994-1995" Characteristic G% +c % +CI % +CI % +CI G% +CI % +CI Total 40.2 128 359 11.3 39.2 89 43.3 11.1 39.7 9.4 44.3 12.0 Education$ Less than high school 60.4 23.7 47.6 249 531 189 613 145 82.1 18.6 62.4 30.0 High school/any college 172 13.1 276 117 305 93 429 144 32.7 11.2 45.6 14.4 “Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. +1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 1984, and December 31, 1988, and found that the preva- lence of smoking among American Indian mothers, ad- justed for maternal age and marital status, was 1.3 times higher than the prevalence among white mothers. Data from the 1988 NMIHS indicate that 35 per- cent of American Indian mothers sampled reported smoking cigarettes in the 12 months before delivery (Sugarman et al. 1994). Recent birth certificate data from U.S. final natality statistics show that 20.9 per- cent of American Indian and Alaska Native mothers smoked during pregnancy (Ventura et al. 1997), a slight decline from 23.0 percent in 1989 (Table 6). The preva- lence of smoking among American Indian mothers was higher than all groups in 1989-1995 (Table 6). Young People Cigarette Smoking One of the few studies focusing on tobacco use among American Indian and Alaska Native youths is the MTF, which includes a series of surveys of high school seniors. Between 1976 and 1994, American In- dian and Alaska Native high school seniors had higher rates of cigarette smoking than all of their counterparts, although the rate of decline was more rapid than for whites (Table 7). The prevalence of previous-month cigarette smoking during 1990-1 994 was 39.4 percent among American Indian and Alaska Native females and 41.1 percent among males. During 1985-1989, rates of daily smoking and of smoking one-half pack or more per day were higher among American Indian and Alaska Native youths than among youths of other racial/ethnic groups (Bachman et al. 1991a). Data from a revised version of the Adolescent Health Survey showed that for every grade level after the seventh, American Indian and Alaska Native fe- males were somewhat more likely to be daily cigarette smokers than were American Indian males. The preva- lence of daily cigarette smoking among females in- creased from 8.9 percent in junior high school to 17.8 percent in high school, whereas among males the prevalence of daily cigarette smoking increased from 8.1 percent in junior high school to 15.0 percent in high school (Blum et al. 1992). Smokeless Tobacco Use The use of smokeless tobacco is also high among American Indian and Alaska Native youths. Bruerd (1990) reviewed nine studies of schoolchildren’s use of smokeless tobacco in South Dakota, Montana, Patterns of Tobacco Use 49 Surgeon General's Report Nebraska, Washington, Arizona, New Mexico, and Alaska and found that the prevalence of regular smokeless tobacco use ranged from 18 percent among students in kindergarten through the sixth grade to 55.9 percent among students in the ninth and tenth grades. The percentage of schoolchildren who re- ported ever using or experimenting with smokeless tobacco ranged from 29 to 82 percent. In general, the findings suggested a young age at onset of smokeless tobacco use, similar prevalence of use among adoles- cent boys and girls, and higher overall prevalence of use among American Indian and Alaska Native school- children than among students in other populations. A 1987-1988 survey of 650 American Indian and Alaska Native youths at three IHS sites (Alaska; the Billings region, which encompasses Montana and Wyoming; and the Navajo region, which encompasses portions of Arizona, Colorado, New Mexico, and Utah) indi- cated that these youths were experimenting with and regularly using smokeless tobacco at higher rates than white youths (Backinger et al. 1993). Regional and Tribal Tobacco Use Cigarette Smoking Although a high rate of smoking has been esti- mated nationally for American Indians and Alaska Natives, regional and state differences in tobacco-use patterns are evident when 1988-1992 aggregate data from the BRFSS are considered.. High smoking prevalences were found in Alaska (45.1 percent), the Northern Plains (Montana, Nebraska, North Dakota, and South Dakota) (44.2 percent), and the Northern Woodlands (lowa, Michigan, Minnesota, and Wiscon- sin) (35.6 percent), whereas much lower overall smok- ing prevalences were found in California (25.4 percent) and the Southwest (Arizona, Colorado, New Mexico, and Utah) (17.0 percent) (Table 17) (CDC, public use data tapes, 1988-1992). The prevalence of current ciga- rette smoking varied by geographic region more than twofold for men and nearly threefold for women. For example, 21.3 percent of men and 13.5 percent of women in the Southwest reported that they currently Table 17. Percentage of American Indian and Alaska Native adults who reported being current cigarette smokers,* overall and by region/state, gender, age, and education, Behavioral Risk Factor Surveillance System, 1988-1992 aggregate data Northern Northern Alaska California Plains* Woodlands*t Characteristic % +cit % +CI % +c! % +CI Total 45.1 5.9 25.4 7.0 44.2 7.8 35.6 48 Gender Men 48.4 8.7 27.9 10.5 49.1 11.3 33.0 7.6 Women 41.7 8.0 22.7 8.9 38.4 99 37.6 6.2 Age (years) 18-34 48.5 9.0 20.9 8.7 51.2 12.4 33.4 6.7 35-54 41.5 8.6 344 134 47.2 12.4 454 9.0 >55 41.3 14.6 24.0 20.6 27.33 15.1 270 91 Education Less than high school 43.1 11.2 25.8 15.3 44.5 14.8 40.6 11.0 High school/any college 449 73 32.5 9.7 40.1 9.8 35.3 5.7 *Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. *The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor Surveillance System during this period. We Chapter 2 smoked, compared with 49.1 percent of men and 38.4 percent of women in the Northern Plains (Table 17). The majority of American Indians and Alaska Natives (83.3 percent) responding to the BRFSS smoked 15 or fewer cigarettes per day; this finding was consistent across all states and regions (Table 18) (CDC, public use data tapes, 1988-1992). Overall, female American Indians and Alaska Natives smoked fewer cigarettes than their male counterparts—a finding that was consistent across all states and regions. American Indian smokers in the Northern Plains (13.5 percent) were the most likely to smoke 25 or more ciga- rettes per day. American Indian smokers in the South- west (51.2 percent) and the Pacific Northwest (46.8 percent) had the highest prevalence of cessation, whereas American Indians in the Northern Plains (31.8 percent) and Alaska Natives (37.0 percent) had the low- est prevalence of cessation (Table 19) (CDC, public use data tapes, 1988-1992). In similar analyses of the BRFSS data ag- gregated for 1985-1988, the prevalence of smoking Tobacco Use Among U.S. Racial/Ethnic Minority Groups varied markedly by gender and geographic region (Sugarman et al. 1992). For American Indian men, the prevalence of smoking was highest among those liv- ing in the Plains region (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wiscon- sin) (48.4 percent), followed by those in the West Coast region (California, Idaho, and Washington) (25.2 per- cent) and the Southwest (Arizona, New Mexico, and Utah) (18.1 percent). Similarly, for American Indian women, the prevalence of smoking was highest among those living in the Plains region (57.3 percent), followed by those in the West Coast region (31.6 percent) and the Southwest (14.7 percent). Regional and tribal data on cigarette smoking are also available from a probability sample of American Indians living on or near the northern Montana Blackfeet Reservation and those served by the Native American Center in Great Falls, Montana, in 1987 (Goldberg et al. 1991). Among Blackfeet Indians, 34 percent of men and 50 percent of women reported that they smoked cigarettes. Among American Indians in Pacific Oklahoma Northwest* Southwest* Other* Total % +ClI % +CI % +CI % +CI % +C7] 30.4 7.3 33.1 6.0 17.0 4.6 28.9 4.2 29.2 2.5 36.2 12.7 35.4 9.2 21.3 8.2 36.5 6.4 34.4 4.0 26.0 8.9 31.2 79 13.5 5.0 21.3 5.2 24.2 3.1 33.5 12.6 37.6 9.6 13.3 5.6 30.2 6.8 28.9 3.8 35.0 12.8 30.3 8.4 18.9 8.8 33.6 71 33.8 4.4 21.7 10.6 26.2 14.7 29.8 14.2 18.6 6.6 22.5 5.3 25.1 14.4 42.5 15.4 29.7 12.3 34.0 9.4 33.4 5.6 31.2 8.7 33.9 73 15.1 5.9 29.4 5.0 30.5 3.2 t95% confidence interval. SIncludes persons aged 25 years and older. Source: Centers for Disease Control, public use data tapes, 1988-1992. Patterns of Tobacco Use 5] Surgeon General’s Report Table 18. Percentage of adult American Indian and Alaska Native smokers* who reported smoking <15, 15-24, or >25 cigarettes per day, overall and by region/state, gender, age, and education, Behavioral Risk Factor Surveillance System, 1988-1992 aggregate data Northern Northern Alaska California Plains* Woodlands* Characteristic % +cit % +Cl % +Cl % +CI Total <15 cigarettes 83.7 4.1 88.0 5.0 70.9 7.5 84.6 3.6 15-24 cigarettes 12.2 3.7 8.5 4.4 15.7 5.5 12.3 3.3 2 25 cigarettes 41 22 3.5 2.7 13.5 6.5 3.1 1.46 Gender Men <15 cigarettes 79.3 7.0 87.7 7.4 66.8 11.4 83.9 5.5 15-24 cigarettes 15.2 6.1 8.3 6.4 14.3 7.8 11.7 5.0 2 25 cigarettes 5.5 4.0 4.0 4.1 19.0 10.4 44 2.6 Women <15 cigarettes 88.2 4.2 88.2 6.8 75.8 8.8 85.2 4.6 15-24 cigarettes 9.0 3.9 8.8 5.9 17.3 7.7 12.7 4.3 2 25 cigarettes 2.7 1.9 3.0 3.5 6.9 5.4 2.1 2.0 Age (years) 18-34. <15 cigarettes 87.7 5.1 90.8 5.8 68.1 12.4 87.4 4.5 15-24 cigarettes 8.7 3.8 5.4 4.4 18.8 9.5 10.9 42 2 25 cigarettes 3.6 3.7 3.8 4.0 13.0 10.6 1.7 1.6 35-54 <15 cigarettes 78.5 7.4 82.1 11.0 65.6 12.0 79.5 7.4 15-24 cigarettes 15.6 6.9 16.2 10.8 16.3 8.7 14.9 6.7 225 cigarettes 6.0 3.5 1.7 2.5 18.1 10.6 5.6 4.0 >55 <15 cigarettes 80.7 12.3 89.1 12.8 83.5 13.7 84.9 7.4 15-24 cigarettes 16.8 12.2 5.1 99 8.9 9.8 21 6.8 225 cigarettes 2.6 2.1 5.8 8.4 7.6 10.9 3.0 3.1 Education$ Less than high school <15 cigarettes 85.0 7.7 90.6 9.9 66.3 148 81.7 7.3 15-24 cigarettes 12.0 7.6 5.1 5.8 13.3. 10.5 14.9 6.7 2 25 cigarettes 3.0 2.0 44 8.3 20.4 13.5 34 3.1 High school/any coliege <15 cigarettes 78.2 6.2 83.1 7.7 74.1 8.9 84.2 4.6 15-24 cigarettes 15.8 5.3 13.2 7.2 16.3 7.4 12.0 4.1 > 25 cigarettes 6.1 4.0 3.7 3.2 9.6 6.3 3.9 2.4 *Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. *The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor Surveillance System during this period. 52. Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Pacific Oklahoma Northwest* Southwest* Other’ Total G% +CI % +Cl % +CI % +I % +CI 83.4 6.2 83.0 4.6 92.3 3.7 81.1 3.6 83.3 2.1 9.7 4.6 10.8 3.8 4.5 2.3 11.5 3.1 10.4 1.7 6.9 4.3 6.2 3.0 3.2 3.1 7A 2.2 6.4 1.3 83.3 9.1 80.2 7.1 87.3 7.3 74.7 59 79.3 3.4 8.2 6.7 12.0 5.4 7.2 4.2 14.1 5.0 11.6 2.7 8.5 6.5 7.8 5.0 5.6 6.4 11.1 4.0 91 2.3 83.5 8.4 85.3 6.2 96.4 2.7 87.5 3.9 87.1 24 10.9 6.2 9.8 5.3 2.3 2.3 8.8 3.6 9.2 2.1 5.6 5.9 4.9 3.6 1.2 1.4 3.6 1.8 3.7 1.3 84.0 10.0 83.5 7.2 98.1 2.1 83.5 5.6 85.9 2.9 9.2 71 9.2 5.5 1.8 2.1 11.9 5.2 9.3 2.5 6.8 77 7.4 5.2 0.1 0.2 4.6 2.6 4.8 1.8 74.6 11.9 81.1 7.1 84.8 8.7 74.0 6.6 76.8 3.9 16.0 10.9 12.8 6.2 7.0 4.4 13.3 5.0 13.7 3.3 9.3 6.7 6.1 4.1 8.2 8.2 12.7 5.0 9.4 2.6 90.2 8.4 86.0 11.1 87.8 11.4 87.1 6.1 87.2 4.1 49 5.5 10.9 9.9 9.9 11.2 7.6 4.6 75 3.1 4.8 6.8 3.1 5.6 2.3 2.7 5.3 4.3 5.3 2.8 86.0 12.5 69.7 14.5 80.3 10.9 75.1 8.6 78.6 4.9 9.2 10.8 22.0 13.3 16.4 10.6 11.3 6.7 11.2 3.6 4.8 7.3 8.3 8.2 3.3 4.0 13.6 6.6 10.2 3.8 82.2 7.0 84.7 5.1 92.0 5.4 80.3 4.5 82.1 2.7 10.5 5.6 9.5 4.1 3.6 2.5 12.9 4.0 11.9 2.4 73 4.7 5.8 3.3 4.5 5.0 6.7 2.7 6.0 15 495% confidence interval. SIncludes persons aged 25 years and older. Source: Centers for Disease Control, public use data tapes, 1988-1992. Patterns of Tobacco Use 53 Surgeon General's Report Table 19. Percentage of adult American Indian and Alaska Native smokers who reported they quit smoking,* overall and by region/state, gender, age, and education, Behavioral Risk Factor Surveillance System, 1988-1992 aggregate data Northern Northern Alaska California Plains? Woodlands* Characteristic % tc % +c] % +Cl % +Cl Total 37.0 6.6 44.8 11.9 31.8 8.3 44.3 6.3 Gender Men 37.1 93 44.8 16.2 32.8 11.4 49.5 9.8 Women 36.9 93 44.8 16.9 30.3 11.7 40.0 8.2 Age (years) 18-34 31.2 10.0 298 15.8 15.9 9.4 41.8 9.3 35-54 43.8 9.8 49.2 17.3 32.22 13.4 35.5 9.7 255 42.2 16.1 61.0 28.9 58.2 19.7 62.2 12.6 Education$ Less than high school 38.5 12.6 53.6 22.7 35.1 15.8 48.3 13.0 High school/any college 38.1 7.7 41.8 14.2 37.5 11.6 46.2 7.5 *The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking. *The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor Surveillance System during this period. Great Falls, 63 percent of men and 62 percent of women reported that they smoked. In both areas, rates of smoking were higher among persons aged 25 years and older than among their younger counterparts. For American Indians in Great Falls, those who had a high school education and did not go to college had lower rates of smoking than those with less than a high school education or those with some college education. Gen- der differences in smoking cessation were also ob- served. Among American Indians in Great Falls, 16 percent of men and 19 percent of women had quit smoking; among the Blackfeet American Indians, 34 percent of men and 22 percent of women had quit smoking (Goldberg et al. 1991). Ina 1990 study of members of the Oneida Indian Nation of New York, 71.6 percent of the men and 64.6 percent of the women reported having ever smoked cigarettes (CDC 1990). The prevalence of ever smok- ing cigarettes was lower among men (65.3 percent) and 54 Chapter 2 women (58.2 percent) with 12 or more years of educa- tion than among men (81.3 percent) and women (74.5 percent) with less than 12 years of education. Rates of current smoking among the Oneida Indian Nation fol- lowed similar patterns in terms of educational status: men (34.7 percent) and women (29.1 percent) with 12 or more years of education had a lower prevalence of cigarette smoking than men (59.4 percent) and women (56.9 percent) with less than 12 years of for- mal education. Overall, a greater proportion of men (44.4 percent) than women (40.0 percent) smoked. The prevalence of cessation, on the other hand, was fairly similar for men (37.9 percent) and women (38.1 percent). Similar findings were observed in a survey of people on the Warm Springs Reservation (Warm Springs Confederated Tribes 1993) and in the Western Washington Native American Behavior Risk Factor Survey of the Chehalis, Hoh, Quinault, and Shoalwater Tobacco Use Among U.S. Racial/Ethnic Minority Groups Pacific Oklahoma Northwest? Southwest* Other* Total % +Cl % +CI1 % +Cl G +CI % +CT1 40.7 10.2 46.8 8.0 51.2 10.3 39.8 7.0 41.5 4.0 33.1 15.1 44.8 11.8 51.8 15.0 35.4 9.4 39.2 5.5 47.1 13.8 48.5 11.1 50.3 13.8 46.1 10.5 44.4 5.6 - 27.8 16.1 38.7 12.3 52.7 15.9 28.5 10.0 30.6 5.4 36.9 18.0 52.7 11.7 54.1 16.7 42.2 11.9 44.0 6.6 61.0 16.7 57.4 20.6 38.0 21.2 58.7 12.2 58.2 8.3 45.0 23.5 40.4 18.1 40.9 19.5 39.7 15.3 42.6 8.3 43.5 11.7 47.8 95 53.2 13.6 41.4 8.1 42.7 4.8 195% confidence interval. ‘Includes persons aged 25 years and older. Source: Centers for Disease Control, public use data tapes, 1988-1992. Tribes (Kimball et al. 1990). In a survey of 1,318 adult American Indian and Alaska Native users of Indian clinics in northern California, 40 percent of the respon- dents reported smoking cigarettes (47 percent of the men and 37 percent of the women) (Hodge et al. 1995), Aggregated data from the BRFSS indicate that among American Indian and Alaska Native women of reproductive age, smoking rates were highest among women in Alaska (43.9 percent), the Northern Plains (39.5 percent), and the Northern Woodlands (38.8 percent) and lowest among women in the South- west (11.5 percent) and California (15.3 percent) (Table 20) (CDC, public use data tapes, 1988-1992). Smokeless Tobacco Use The use of smokeless tobacco (chewing tobacco and snuff) among American Indians and Alaska Natives also has varied by state and region. According to the BRFSS data for 1988-1992, the prevalences among men were 24.6 percent in the Northern Plains, 16.8 percent in the Northern Woodlands, 14.3 percent in Oklahoma, 11.6 percent in Alaska, 6.5 percent in the Southwest, and 1.8 percent in the Pacific Northwest (CDC, public use data tapes, 1988-1992). In the Oneida Indian Nation survey, none of the women reported using smokeless tobacco, whereas 17.3 percent of the men reported using it (CDC 1990). More recently, investigators have reported ex- tremely high rates of smokeless tobacco use among Lumbee women in North Carolina (CDC 1995). In 1991, the prevalence of smokeless tobacco use was greatest among Lumbee women 65 years of age and older (51 percent) and lowest among those 25-34 years of age (6 percent). The prevalence was also high among women with less than 12 years of education (42 percent). Oi on Patterns of Tobacco Use Surgeon General's Report Table 20. Percentage of American Indian and Alaska Native women of reproductive age who reported being current cigarette smokers,* overall and by region/state, Behavioral Risk Factor Surveillance System, 1988-1992 aggregate data Northern Northern Alaska California Plains* Woodlands* % +cCTt % +C] % +Cl % +CI 43.9 93 15.3 9.1 39.5 12.3 38.8 7.1 Total I Pacific eer Oklahoma Northwest* Southwest* Other* 24.9 3.9 % +Cl % +Cl % +ClI % +Cl 30.4 12.5 32.6 9.7 11.5 26.7 7.1 “Current cigarette smokers are women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. *The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor Surveillance System during this period. 495% confidence interval. Source: Centers for Disease Control, public use data tapes, 1988-1992. Asian Americans and Pacific Islanders Data needed to assess long-term trends in cigarette smoking among Asian Americans and Pacific Islanders have been unavailable because U.S. surveys, census data, and other national databases have not always included detailed descriptions of race/ethnicity. Although data from specific Asian American and Pacific Islander groups and state surveys have provided information about ciga- rette smoking for certain racial/ethnic subgroups, these data have been limited in quantity and quality. The NHIS first included information about Asian Americans and Pacific Islanders in the 1978 survey. However, because the proportion of Asian Americans and Pacific Islanders in the United States is small, data from several years must be aggregated to increase the precision of estimates. Be- cause of small sample sizes and aggregation of data, racial/ethnic subgroup differences in smoking behav- ior are masked. These differences are important because the category Asian American and Pacific Islander is hetero- geneous in both culture and health behaviors. For ex- ample, this category includes about 32 different national and racial/ethnic subgroups (Austin et al. 1989; Hawks 1989) and nearly 500 languages and dialects (Chen 1993), and smoking patterns among these subgroups vary. 36 Chapter 2 Prevalence of Cigarette Smoking Between 1978 and 1995, the prevalence of smok- ing declined among Asian Americans and Pacific Is- landers, according to NHIS data (Table 21) (NCHS, public use data tapes, 1978-1995). However, patterns between men and women differed. The cigarette smoking prevalence among Asian American and Pa- cific Islander men declined slightly, from 32.5 to 25.1 percent, whereas the prevalence of smoking among Asian American and Pacific Islander women declined approximately 60 percent, from 14.7 to 5.8 percent. Throughout this period, the prevalence of smoking among men remained more than twice that among women; in 1994-1995, men were 4.3 times more likely than women to report current smoking. Number of Cigarettes Smoked Daily From 1978 through 1995, the percentage of Asian American and Pacific Islander smokers who smoked fewer than 15 cigarettes per day increased significantly, according to the NHIS data (Table 22) (NCHS, public use data tapes, 1978-1995). Although large declines from 1978-1980 to 1992-1993 were observed in the prevalence Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 21. Percentage of adult Asian Americans and Pacific Islanders who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988" 1990-1991' 1992-1993 1994-1995" Characteristic % +c &% +C1 % +CI G% +CI % +CI % +CI Total 38 40 24 34 158 24 161 25 16.7 27 153 3.0 Gender Men 325 45 330 62 225 38 245 40 268 47 25.1 5.2 Women 14.7 6.6 96 3.5 92 28 6.6 2.0 6.8 2.7 5.8 2.3 Age (years) 18-34 75 58 216 46 163 35 155 32 157 42 176 53 35-54 287 85 208 48 161 36 171 46 210 47 155 43 >55 W4 47 220 86 12.7 59 15.7 5.4 83 54 92 51 Education Less than high school 231 89 238102 179 65 249 74 134 62 133 79 High school /any college 23.7 3.9 226 4.5 16.7 28 156 29 176 35 144 3.2 *Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their live currently smoked every day or on some days. s and who reported at the time of survey that they *1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. of smoking 25 or more cigarettes per day, recent estimates are imprecise and should be interpreted with caution. Quitting Behavior Between 1978 and 1995, the percentage of Asian Americans and Pacific Islanders who have ever smoked 100 cigarettes and have quit smoking increased some- what, NHIS data indicate (Table 23) (NCHS, public use data tapes, 1978-1995). The prevalence of cessation among women increased from 1987-1988 to 1994-1995, but no consistent pattern was observed among men. During each survey period, the prevalence of cessation was higher among Asian Americans and Pacific Island- ers 55 years of age and older than it was among their younger counterparts (Table 23). Data from the NCI Supplement of the 1992-1993 CPS indicate that among Asian Americans and Pacific Islanders aged 18 years and older who were daily smok- ers one year before the survey, 57.8 percent reported that they were still smoking daily and that they had not tried quitting for at least one day during the previous year (Table 4). Another 32.0 percent had tried quitting for at least one day, 4.8 percent were occasional smokers (Le., smoked only on some days), 2.5 percent had not smoked for the past 1-90 days, and 2.9 percent had not smoked for the past 91-364 days. Among current smokers, Asian Americans and Pacific Islanders were slightly more likely than whites to report trying to quit for at least a day dur- ing the previous year. Women of Reproductive Age The prevalence of current smoking among Asian American and Pacific Islander women of reproductive age (18-44 years) has decreased substantially over Patterns of Tobacco Use 57 Surgeon General's Report Table 22. Percentage of adult Asian American and Pacific Islander smokers’ who reported smoking <15, 15-24, or >25 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980" 1983-1985' 1987-1988' 1990-1991' 1992-1993 1994~1995+ Characteristic % +C % +CI % +CI % +CI % +Cl % x+Cl Total <15 cigarettes 43.3 11.7 53.7 81 536 7.8 604 81 618 94 706 98 15-24 cigarettes 37.0 9.7 353 85 374 74 338 76 371 94 214 8.2 >25 cigarettes 19.7 65 11.0 65 7.0 3.3 3.8 3.9 10 13 8.0 6.5 Gender Men <15 cigarettes 40.1 146 544 94 518 96 592 92 584 11.2 69.1 11.5 15-24 cigarettes 35.8 11.1 362 93 41.2 92 354 86 409 11.2 23.6 10.0 >25 cigarettes 24.1 8.2 94 6.6 70 4.2 5.5 44 0.7 14 73° 74 Women <15 cigarettes 50.4 13.7 51.1 149 644 113 65.8 168 754 11.6 77.3 13.9 15-24 cigarettes 39.6 12.8 32.0 15.2 285 98 268 165 222 11.5 11.5 11.0 >25 cigarettes 10.0 7.7 168 10.1 71 5.1 74 83 23°33 11.2 i111 Age (years) 18-34 <15 cigarettes 42.2 12.2 48.2 104 59.0 11.0 603 10.7 613 13.7 73.2 13.6 15-24 cigarettes 37.3 11.5 405 115 351 105 35.2 105 382 13.7 243 13.2 >25 cigarettes 20.5 8.2 11.3 83 5.9 4.4 45 3.8 0.6 1.1 2.5 3.9 35-54 <15 cigarettes 45.0 17.1 54.9 135 545 10.9 629 13.5 63.6 13.0 65.0 15.2 15-24 cigarettes 35.5 15.0 32.2 13.1 404 110 269 105 349 129 223 118 >25 cigarettes 19.5 90 12.9 81 5.1 4.6 10.1 9.2 16 2.3 12.8 14.0 >55 <15 cigarettes 413 185 67.9 203 41.5 23.2 55.8 185 52.7 39.1 78.0 23.9 15-24 cigarettes 40.9 13.1 26.4 18.4 39.4 25.0 43.3 18.5 47.3 39.1 4.7 93 >25 cigarettes 17.9 14.4 5.7 82 19.1 16.5 0.9 1.8 0.0 0.0 17.3 23.4 Education Less than high school <15 cigarettes 59.6 21.3 66.0 15.2 487 196 729 139 80.2 173 73.8 32.2 15-24 cigarettes 28.6 18.0 233 142 424 198 22.2 133 19.8 17.3 6.2 9.5 >25 cigarettes 11.8 13.2 10.7 98 8.9 95 48 6.0 0.0 0.0 20.0 32.8 High school/any college <15 cigarettes 40.4 124 476 96 530 84 581 98 62.2 114 648 12.0 15-24 cigarettes 394 11.8 393 10.2 394 82 34.7 93 367 114 265 10.7 >25 cigarettes 20.2 74 13.0 8.1 76 42 7.2 5.5 11 1.6 8.7 7.5 “Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers included persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers included persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495%. confidence interval. ‘Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 38 = Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 23. Percentage of adult Asian American and Pacific Islander ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980" 1983-1985' 1987-1988t 1990-1991' 1992-1993t 1994-1995 Characteristic % +c % +ClI % +Cl % +ClI G +CI % +CI Total 399 65 384 65 412 57 490 53 455 65 483 7.2 Gender Men 412 61 342 78 427 69 472 64 422 74 433 87 Women 36.9 140 496 10.2 372 96 554 101 55.0 139 62.2 128 Age (years) 18-34 345 94 258 75 313 7.7 £4341 76 30.7 96 285 10.9 35-54 357 135 455 88 463 80 553 95 441 92 555 101 >55 594 106 489 165 581149 605 110 769 13.2 70.2 14.9 Education Less than high school 37.0 18.7 46.1 17.1 30.1 15.3 37.7 133 504 181 50.3 21.9 High school/any college 452 72 392 73 467 64 548 65 482 73 53.7 8.2 *Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever smokers include current and former smokers. 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 195% confidence interval. 'Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. time, from 16.0 percent in 1978-1980 to 5.7 percent in 1994-1995, NHIS data indicate (Table 24) (NCHS, pub- lic use data tapes, 1978-1995). Overall, the greatest change occurred between 1978 and 1985, when the prevalence of current smoking declined by approxi- mately 50 percent. Since 1985, declines in smoking prevalence have slowed. Recent birth certificate data from U.S. final natality statistics indicate that 3.4 percent of Asian American and Pacific Islander mothers smoked dur- ing pregnancy (Table 6). Smoking rates for pregnant Asian American and Pacific Islander women are gen- erally low—between 0.8 and 5.2 percent for Chinese, Japanese, Filipino, and “other” Asian Americans or Pacific Islanders. Hawaiian mothers, however, havea relatively high smoking rate (15.9 percent). Ventura and colleagues (1995) reported that 3 percent of foreign-born Asian American and Pacific Islander mothers were reported as smokers, compared with 13 percent of their United States-born counterparts. Data on tobacco use among these mothers (except Hawai- ians) may be skewed because California and New York do not report this information, and together these states account for nearly half of births in each Asian Ameri- can and Pacific Islander subgroup (Ventura et al. 1996). Young People Cigarette Smoking Data from MTF surveys—one of the few studies with data on smoking prevalence among Asian Ameri- can and Pacific Islander youths—show that these youths have a lower prevalence of smoking than their counterparts in all other racial/ethnic groups except African Americans (Table 7). According to the 1990- 1994 MTF data on male high school seniors, the prevalence of smoking was 11.6 percent among Afri- can Americans, 20.6 percent among Asian Americans and Pacific Islanders, 28.5 percent among Hispanics, 33.4 percent among whites, and 41.1 percent among Patterns of Tobacco Use 59 Surgeon General's Report Table 24. Percentage of adult Asian American and Pacific Islander women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988' 1990-1991* 1992-1993 1994-1995" Characteristic % +cr % +Cl % x+CI % +CI % +Cl % +Cl Total 16.0 6.7 8.2 3.3 8.8 2.7 6.0 2.4 6.6 2.8 5.7 3.0 Education$ Less than high school 15.0 26.4 7.0 7.3 9.8 8.0 14.1 9.1 3.5 4.0 23 4.6 High school/any college 154 69 8.6 3.4 96 3.4 6.1 3.1 3.7 3.1 5.8 3.5 *Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. American Indians and Alaska Natives. Data on female high school seniors show that the prevalence of smoking was 8.6 percent among African Americans, 13.8 percent among Asian Americans and Pacific Is- landers, 19.2 percent among Hispanics, 33.1 percent among whites, and 39.4 percent among American In- dians and Alaska Natives. As reported by Bachman and colleagues (1991a), during 1985-1989, patterns of daily smoking were similar, with prevalence estimates being lowest among African Americans and Asian Americans and Pacific Islanders. Among Asian American and Pacific Islander high school seniors, 4.4 percent of males and 4.5 percent of females reported smoking one-half pack or more per day. In 1993, Wiecha (1996) surveyed public school students from two middle schools and two high schools in Worcester, Massachusetts. The self- administered questionnaire used items from CDC’s YRBS; every question was written in English, Vietnamese, and Spanish. Vietnamese males were as likely to report cigarette smoking (27.9 percent) as were white males (28.3 percent). The prevalence of ciga- rette smoking among Vietnamese females (3.7 percent) was lower than among African American (15.1 per- cent), Hispanic (29.7 percent), and white (30.6 percent) females. Length of time in the United States was re- 60 Chapter 2 lated to smoking prevalence for males aged 17 years and older: cigarette smoking prevalence was 7.7 per- cent among those who had been in the United States for at least six years and 45.2 percent for those who had been in the United States for less than six years. Smokeless Tobacco Use Wiecha (1996) also queried Worcester students about their use of smokeless tobacco products. The prevalence of previous-month use among males was 12.0 percent for Vietnamese, 10.3 percent for African Americans, 10.8 percent for Hispanics, and 20.5 per- cent for whites. Previous-month use among females was 3.6 percent for Vietnamese, 3.2 percent for Afri- can Americans, 1.9 percent for Hispanics, and 2.7 per- cent for whites. Small sample sizes limit the precision of some of these estimates. State and Local Smoking Estimates Among the diverse subgroups of Asian Ameri- cans and Pacific Islanders, wide variations in lifestyles, health behaviors, and health practices are evident. State and local survey data illustrate the distinct varia- tions in cigarette smoking patterns and behaviors among these ethnic subgroups (Klatsky and Armstrong 1991; CDC 1992c; Blaisdell 1993; McPhee et al. 1993; McPhee et al. 1995; Wewers et al. 1995; Jenkins et al. 1997b). Although prevalence estimates from national surveys indicate that the smoking preva- lence among Asian Americans and Pacific Islanders is lower than the prevalence of smoking in all other racial/ethnic groups and in the overall U.S. popula- tion, state and local surveys show that these estimates vary dramatically between racial/ethnic subgroups of Asian Americans and Pacific Islanders. Racial /ethnic subgroup-specific information on smoking behaviors is needed because broad groupings of these many dis- tinct racial/ethnic groups mask important differences. To characterize smoking and other risk behav- iors more fully for program planning efforts at the lo- cal level, the California State Department of Health Services and two California agencies—Asian Health Services and the University of California, San Fran- cisco, Vietnamese Health Promotion Project—adapted versions of the CDC’s Behavioral Risk Factor Surveys for use with Chinese and Vietnamese residents. The questionnaires were modified for cultural appropri- ateness and translated into Chinese or Vietnamese. The Chinese-language survey included face-to-face interviews with 296 Chinese adults in Oakland, Cali- fornia, between June 1989 and February 1990. In the Vietnamese-language survey, telephone interviews were conducted with 1,011 Vietnamese adults during February and March 1991 (CDC 1992b). Among both Chinese and Vietnamese respondents, men were more likely than women to be current smokers. The high- est smoking prevalence was among men aged 25-44 years, and the prevalence of smoking was lower among men with higher levels of education (Table 25) (CDC 1992b). The mean number of cigarettes smoked per day by smokers was 15.9 among Chinese men, 11.0 among Vietnamese women, and 10.1 among Vietnam- ese men. This number declined with older age and increasing levels of education and income. (Data on Chinese women are unavailable because the number of Chinese women who smoked was too small for analysis.) These surveys also measured acculturation by using several proxy variables, including the percent- age of lifetime spent in the United States, fluency in English, and date of immigration. Among Chinese men, the average number of cigarettes smoked per day increased as the percentage of their lifetime spent in the United States increased (Table 25). Among Viet- namese respondents, the prevalence of smoking was higher among men who immigrated in 1981 or later and who were not fluent in English. Tobacco Use Among U.S. Racial/Ethnic Minority Groups In a more recent statewide telephone survey of 32,125 California households, Burns and Pierce (1992) found that overall, the prevalence of smoking was lower among Asian Americans and Pacific Islanders than among whites, African Americans, and Hispan- ics. This trend was evident among both men and women. Because the survey was conducted only in English or Spanish, Asian Americans and Pacific Is- landers with limited English fluency were unable to participate. This exclusion of recent immigrants and those with the lowest levels of acculturation may have produced a biased estimate of the prevalence of ciga- rette smoking among California’s Asian Americans and Pacific Islanders. In assessing the smoking preva- lence for several racial/ethnic subgroups, Burns and Pierce (1992) found that Chinese reported the lowest prevalence of smoking (11.7 percent), whereas Kore- ans reported the highest prevalence (23.5 percent) (Table 26). Men in all racial/ethnic subgroups were substantially more likely than women to smoke ciga- rettes. For men, the prevalence of smoking was high- est among Koreans (35.8 percent) and lowest among Chinese (19.1 percent). The prevalence of smoking was highest among men aged 25-44 years. Smoking preva- lence declined substantially with increasing education across all racial/ethnic subgroups of men except Japa- nese men. For women, the prevalence of smoking was highest among Japanese (14.9 percent) and Koreans (13.6 percent) and lowest among Chinese (4.7 percent). Smoking prevalence declined with increasing level of education across all racial/ethnic subgroups of women except Chinese. Ina 1978-1985 survey of 13,031 persons of Asian ancestry enrolled in the Oakland, California, Kaiser Permanente Medical Care Program, the prevalence of cigarette smoking varied significantly by Asian sub- group for both men and women (Klatsky and Armstrong 1991). Among men, the prevalence of ciga- rette smoking was highest among Filipinos (32.9 per- cent) and lowest among Chinese (16.2 percent) (Table 27). Among women, the prevalence of smoking was highest among Japanese (18.6 percent) and lowest among Chinese (7.3 percent). Japanese men and women were more likely to smoke one or more packs of cigarettes per day than were their counterparts in other racial/ethnic groups. During 1989, newly arrived Southeast Asian im- migrants were surveyed by the Health Department in King County, Washington, regarding health problems and health risk behaviors (CDC 1992c). Investigators analyzed medical interview records for 274 Vietnam- ese, 147 Laotian, and 112 Cambodian immigrants and found that the smoking prevalence was substantially Patterns of Tobacco Use 61 Surgeon General's Report Table 25. Percentage of Chinese and Vietnamese men who reported they smoke* and the number of cigarettes they smoke per day, by age, education, annual household income, and level of acculturation, Behavioral Risk Factor Surveillance System, California, 1990 and 1991 aggregate data Chinese Vietnamese Characteristic % +CI* cigarettes +CI %e Mean no. +CI cigarettes +Cl Mean no. Age (years) 1-24 t t 25-44 38.5 15.3 45-64 28.1 15.6 265 24.4 12.6 Education Eighth grade or less 30.2 12.4 Some high school 45.5 20.9 High school graduate 28.6 19.4 Some college 0.0 ¢ College or more 20.0 17.5 Annual household income <$10,000 25.5 12.0 $10,000-$24,999 32.1 12.6 $25,000-$50,000 20.0 22.4 > $50,000 t t Acculturation <25% of lifetime in United States 29.8 9.8 225% of lifetime in United States 26.2 13.3 Fluent in English? 1 1 Not fluent in English® 31.8 8.8 Immigration before 1981 NA NA Immigration in 1981 or later NA NA t t 12.3 8.5 10.0 6.5 12.6 9.1 42.4 5.3 10.3 1.3 22.6 12.4 27.4 75 9.9 1.7 15.4 7.5 23.3 15.2 7.3 3.0 15.7 5.5 36.6 11.2 11.9 2.9 11.2 45 39.6 8.3 10.6 1.7 28.0 28.4 40.4 12.8 8.8 24 0.0 t 32.9 7.3 9.9 2.1 10.0 t 26.8 7.7 9.1 27 95 3.9 38.7 11.1 10.3 21 14.7 27 29.9 7.2 10.1 2.0 55.0 t 36.9 7.8 10.1 1.9 t t 29.5 10.1 8.3 3.3 13.0 3.7 NA NA NA NA 22.3 15.9 NA NA NA NA t t 29.7 7.6 10.7 2.6 13.3 3.1 36.6 4.6 10.0 1d NA NA 32.2 5.3 10.5 1.5 NA NA 37.7 6.0 9.8 1.5 *Current cigarette smokers are men who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. Because the number of current smokers who were women was too small for analysis, data for age, education, annual income, and acculturation are provided for men only. *95% confidence interval. *Numbers too small for analysis. SSelf-report of ability to speak English well or fluently. NA = data not available. Source: Centers for Disease Control 1992b. higher among men (42.5 percent) than among women (5.7 percent) (Table 27). Southeast Asian men were 1.6 times as likely to smoke as were other men in Wash- ington, whereas Southeast Asian women were one- fourth as likely to smoke as were other women in the state (CDC 1992c). In a recent review of Hawaii's health surveillance data for 1975-1980, Blaisdell (1993) found that the smoking prevalence was higher among Native Hawai- ians than among persons in other racial/ethnic groups; 62 Chapter 2 61.1 percent of pure Native Hawaiian men and 56.3 percent of part Native Hawaiian men were current smokers (Table 27). According to the 1985 BRFSS data, 42 percent of Native Hawaiian men and 34 percent of Native Hawaiian women were current smokers. Data from the 1989 BRFSS in Hawaii indicate that the prevalence was 28.2 percent among Native Hawaiians (Table 27), which was higher than that among Filipi- nos, Japanese, and whites (Blaisdell 1993). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 26. Percentage of adult Asian Americans and Pacific Islanders who reported being current smokers,* overall and by gender, age, and education, Screener Survey, California, 1990 and 1991 aggregate data’ Characteristic Chinese (%) Filipinos (%) Japanese (%) Koreans (%) —_All Asians (%) Total 11.7 15.9 17.4 23.5 15.9 Age (years) 18-24 9.7 12.2 19.7 26.9 14.6 25-44 12.4 21.0 20.3 26.1 18.1 45-64 11.4 14.4 16.8 16.2 15.3 265 11.4 6.6 9.9 23.2 8.9 Education Less than high school 17.6 19.2 23.4 38.1 21.4 High school 16.7 20.3 21.5 21.3 19.4 Some college 11.2 15.2 16.2 25.3 15.2 College 6.6 11.2 12.3 19.1 10.5 Men Total 19.1 24.0 20.1 35.8 23.5 Age (years) 18-24 13.0 19.1 17.2 34.3 19.0 25-44 20.9 29,2 24.7 44.1 27.1 45-64 19.9 25.8 22.1 22.6 24.0 265 19.8 10.6 11.1 60.6 14.0 Education Less than high school 35.4 32.1 18.4 70.6 36.9 High school 26.3 27.6 28.7 35.3 28.3 Some college 18.1 21.5 19.2 32.4 20.9 College 9.8 18.9 16.5 31.0 15.6 Women Total 4.7 8.9 14.9 13.6 8.9 Age (years) 18-24 5.8 4.0 22.9 19.9 9.5 25-44 5.5 14.6 16.3 13.9 10.4 45-64 2.5 5.] 13.4 9.9 7.4 265 2.6 3.4 8.3 NA 3.8 Education Less than high school 1.7 11.6 28.8 20.9 9.4 High school 9.8 12.7 17.5 14.4 12.6 Some college 4.8 8.7 13.4 19.4 9.5 College 3.2 4.9 7.0 5.2 4.9 “Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. Only English-speaking persons were interviewed. ‘The variables needed to compute confidence intervals were not available. NA = data not available. Source: Burns and Pierce 1992. Patterns of Tobacco Use 63 Surgeon General’s Report Table 27. Summary of selected findings on the percentage of Asian American and Pacific Islander adults who smoke, overall and by gender, 1975-1995 Study Population adults Sources Location/Year Characteristics Total Men Women Klatsky and California, Current smokers Armstrong 1978-1985 Chinese NA 16.2 7.3 1991 Filipino NA 32.9 11.4 Japanese NA 22.7 18.6 Other Asians NA 30.9 12.6 Persons who smoke 21 pack/day Chinese NA 4.1 1.3 Filipino NA 7.1 1.7 Japanese NA 8.2 4.6 Other Asians NA 6.7 1.6 CDC 1992c Washington State, Southeast Asians, by 1989 age (years) 18-29 17.6 29.5 3.0 30-39 26.3 53.7 5.6 40-59 26.6 54.5 8.3 260 28.9 55.9 7.1 Total 23.1 42.5 5.7 Blaisdell 1993 Hawaii, 1975-1980 Pure Native Hawaiians NA 61.1 NA Hawaii, 1975-1980 Part Native Hawalians NA 56.3 NA Hawaii, 1985 Native Hawaiians NA 42 34 Hawaii, 1989 Native Hawaiians 28.2 NA NA McPhee et al. San Francisco and Vietnamese adults 1993 Alameda Counties, 1987 NA 56 9 California, 1989 NA 45 2 1987, 1989 McPhee et al. Santa Clara County, Vietnamese men 1995 California, 1990 NA 36 NA Wewers et al. Franklin County, Cambodians 20.6* 34.0 6.6 1995 Ohio, 1992 (30.3)" (38.8) (21.5) Laotians 27.8 45.6 4.2 (32.9) (48.2) (10.8) Vietnamese 27.6 43.3 6.0 (29.0) (43.3) (9.3) CDC 1997a Alameda County, Korean adults 21 39 6 California, 1994-1995 Jenkins et al. San Francisco and Vietnamese men NA 36.1 NA 1997b Alameda Counties, California, 1990 Jenkins et al. Houston, Texas Vietnamese men 1997b 1990, 1992 1990 NA 39.6 NA 1992 NA 40.9 NA *Figures not in parentheses are from self-report. Figures in parentheses represent cotinine-adjusted prevalences. Persons whose saliva cotinine levels were > 14 ng/mL were considered to be smokers. NA = data not available. 64 Chapter 2 Data collected from several surveys (conducted in 1987, 1989, 1990, and 1992) of Vietnamese men and women living in California, Texas, and Ohio showed that the prevalence of cigarette smoking was substan- tially higher among Vietnamese men than among all U.S. men (Jenkins et al. 1990; McPhee et al. 1993: McPhee et al. 1995; Wewers et al. 1995; Jenkins et al. 1997b). Vietnamese women, however, were signifi- cantly less likely to smoke than were Vietnamese men or other U.S. women (Table 27). Several surveys have been conducted in San Francisco and Alameda Counties, California. In the 1987 survey, which included data from 215 randomly sampled Vietnamese, 56 percent of Vietnamese men reported smoking cigarettes, compared with 9 percent of Vietnamese women (Jenkins et al. 1990). Vietnam- ese men had twice the smoking prevalence of men in the United States. On average, however, the number of cigarettes smoked per day was smaller among Viet- namese men (13.4) than among men in the general U.S. population (23.0). In the 1989 survey of 151 Vietnam- ese adults, 45 percent of Vietnamese men and 2 per- cent of Vietnamese women reported being cigarette smokers (Table 27) (McPhee et al. 1993). The precision of the estimates of smoking prevalence from the 1987 and 1989 surveys is limited by small sample sizes. In the 1990 survey of 1,133 Vietnamese men, which served as the baseline measure in an evaluation of a community-based smoking cessation intervention, 36.1 percent were current smokers. These men smoked an average of 11.1 cigarettes per day (Jenkins et al. 1997b). Another survey of Vietnamese men (n = 1,322), which also served as the 1990 baseline measure in an evaluation of a similar smoking cessation intervention, was conducted in Santa Clara County, California. In this population, 37.9 percent were current smokers; the smokers consumed an average of 9.9 cigarettes per day (McPhee et al. 1995). The comparison data for the two evaluation studies conducted by McPhee and colleagues were obtained from surveys of Vietnamese men living in Houston, Texas (McPhee et al. 1995; Jenkins et al. 1997b). In the 1990 survey (n = 1,581), 39.6 percent of the men were current smokers; in the 1992 survey (n = 1,209), 40.9 percent were current smokers. The mean number of cigarettes smoked daily was significantly lower in 1992 (11.9) than in 1990 (13.2). The 1990 and 1992 survey data showed an asso- ciation between cigarette smoking prevalence and acculturation. In multivariate analyses that included statistical control for education, employment, and pov- erty status, the prevalence of cigarette smoking was elevated among persons with limited English-lan- guage proficiency and persons who had more recently Tobacco Use Among U.S. Racial/Ethnic Minority Groups immigrated to the United States (McPhee et al. 1995; Jenkins et al. 1997b). Data collected from 1,403 South- east Asian immigrant men and women through a household interview indicate that self-reported ciga- rette smoking prevalence is underreported, especially among women (Wewers et al, 1995). Cigarette smok- ing status among Cambodian, Laotian, and Vietnam- ese adults in Franklin County, Ohio, was verified by saliva cotinine assay; a cutoff of 14 ng/mL was used to indicate active smoking. Self-reported smoking prevalence was 40.9 percent for men and 5.6 percent for women. However, results from biochemical verification indicated that 43.7 percent of men and 14.8 percent of women were current smokers. Misclassification as a result of exposure to environmen- tal tobacco smoke is unlikely, given how high the cotinine levels were among self-reported former and never smokers (range 17-331 ng/mL). As other stud- ies have found, current smoking was substantially higher among men than women for all racial/ethnic groups in the study (Table 27) and was higher among respondents with less education. From August 1994 to February 1995, a telephone survey of 676 Korean Americans (aged 18 years and older) was conducted in Alameda County, California (Table 27) (CDC 1997a) . Overall, 39 percent reported that they had smoked at least 100 cigarettes in their lifetimes. Men (70 percent) were more likely than women (13 percent) to have smoked at least 100 life- time cigarettes. Current smoking prevalence was 39 percent for Korean American men in Alameda County—an estimate that was substantially higher than the 19 percent prevalence estimate (from the 1995 California Behavioral Risk Factor Survey) for all men in the state. Conversely, only 6 percent of Korean American women from Alameda County reported current smoking—less than the statewide estimate for women of 14 percent. Cigarette Smoking in Asian Countries Because so many Asian Americans have recently immigrated to the United States, understanding how smoking practices in Asian countries may affect smok- ing practices among Asian Americans here is impor- tant. Currently, however, data are scarce on smoking trends in the countries from which Asian Americans and Pacific Islanders have emigrated. The informa- tion that is available suggests that the prevalence of smoking among men in Asia is much higher than among Asian American men. Various studies from Asian countries indicate a very high cigarette smoking prevalence among men Patterns of Tobacco Use 65 Surgeon General's Report and a relatively low prevalence among women (Weng et al. 1987; Liet al. 1988; Hawks 1989; Koong et al. 1990; Gong et al. 1995; Jenkins et al. 1997a; World Health Organization, unpublished data). In many of these countries, the estimated prevalence of smoking among men exceeds 50 percent. However, the prevalence of smoking among women is generally below 20 percent. Some of these studies indicate that the prevalence of smoking among women increases with age (Weng et al. 1987; Koong et al. 1990). In Pacific Island nations, the prevalence of smoking among men is also very high, with estimates generally exceeding 50 percent, similar to those in Asian countries. Women in the Pa- cific Island nations are less likely to smoke than men, but they are more likely to smoke than women in Asian countries, with prevalence estimates generally exceed- ing 20 percent (World Health Organization, unpub- lished data). Studies also show that smoking prevalences are much higher among Chinese male adolescents than among female adolescents. In a 1988 survey of 8,437 junior high schoo] students and 3,823 senior high school students in Beijing, the self-reported prevalence of ever smoking was 34.4 percent among male junior high school students and 3.9 percent among their fe- male counterparts (Zhu et al. 1992). Among senior high schoo] students, the prevalence of ever smoking was 46.0 percent among males and 5.5 percent among fe- males (Wang et al. 1994). Hispanics No data are available on long-term trends in the prevalence of cigarette smoking among Hispanics in the United States. Before 1978, major U.S. government databases, surveys, and publications limited their clas- sifications of race and ethnicity to “white” and “black,” and no information was available about persons of Hispanic ancestry. When questions about Hispanic ancestry were added to the NHIS in 1978, direct esti- mates of smoking prevalence among Hispanics were possible for the first time. Because Hispanics made up a small proportion of the U.S. population at the time of the initial surveys, survey data must be aggre- gated from several years to provide meaningful estimates. As with previous sections, data in this sec- tion are from the NHISs, which included Hispanic data aggregated as follows: (1) 1978, 1979, and 1980; (2) 1983 and 1985; (3) 1987 and 1988; (4) 1990 and 1991; (5) 1992 and 1993; and (6) 1994 and 1995. Not until the HHANES was administered from 1982 through 1984 was a large enough sample of Hispanics available to assess long-term reconstructed trends in smoking 66 = Chapter 2 through retrospective analysis of smoking prevalence among successive birth cohorts of Hispanics (Escobedo and Remington 1989; Escobedo et al. 1989a). Prevalence of Cigarette Smoking NHIS data indicate that the prevalence of smok- ing declined among Hispanics from 1978 through 1995 (Table 28) (NCHS, public use data tapes, 1978- 1995). Birth cohort data from the HHANES also reflect recent declines in the prevalence of smoking among the three subgroups of Hispanics surveyed: Cuban Americans, Mexican Americans, and Puerto Ricans (Escobedo and Remington 1989). Between 1978 and 1995, the prevalence of smok- ing among Hispanic men and women decreased, al- though smoking prevalence was consistently greater among men than among women, according to the NHIS data (Table 28). Previous analysis of the HHANES birth cohort data showed that after 1970, the prevalence of smoking declined sharply among Mexican American men and less dramatically among Puerto Rican and Cuban American men (Escobedo et al. 1989a). In contrast, the prevalence of smoking changed little or increased among most age groups of Cuban American, Mexican American, and Puerto Rican women. For men participating in the 1982-1984 HHANES, the smoking prevalence ranged from 41.3 percent (among Puerto Ricans) to 43.6 percent (among Mexican Americans) (Escobedo and Remington 1989), compared with 31.6 percent of Hispanic men in the 1983-1985 NHIS. For women participating in HHANES, the smoking prevalence ranged from 23.1 percent (among Cuban Americans) to 32.6 percent (among Puerto Ricans) (Escobedo and Remington 1989), compared with 20.4 percent of Hispanic women in the 1983-1985 NHIS. Several factors help explain why the HHANES estimates for men are at least 10 percentage points higher than the NHIS estimates for men for a compa- rable period and why the HHANES estimates for women also show a higher prevalence than the NHIS estimates for women. Most importantly, the HHANES was more likely to select an immigrant population than the NHIS because HHANES offered respondents the choice of English or Spanish questionnaires. In addi- tion, the HHANES sampled Cuban Americans from Dade County, Florida; Mexican Americans from Ari- zona, California, Colorado, New Mexico, and Texas; and Puerto Ricans from New York, New Jersey, and Con- necticut. On the other hand, the NHIS, administered only in English, is a national sample of the general popu- lation, which includes a wider range of racial/ethnic Table 28. Percentage of adult Hispanics who reported being current cigarette by gender, age, and education, National Health Interview Surveys, aggregate data Tobacco Use Among U.S. Racial/Ethnic Minority Groups smokers,* overall and United States, 1978-1995 1978-1980' 1983-1985 1987-1988t 1990-1991' 1992-1993" 1994-1995' Characteristic % +CR % +Cl % +Cl % +Cl % +tCl % +C1 Total 30.1 19 256 16 236 14 215 14 205 16 189 0.7 Gender Men 376 30 316 29 296 23 278 23 25.9 26 22.9 24 Women 33 20 204 19 184 15 159 16 155 19 15.1 17 Age (years) 18-34 323 27 258 22 236 19 211 19 210 24 198 22 35-54 30.4 2.7 284 32 263 23 257 22 234 27 198 25 >55 29 28 #199 42 182 28 137 26 124 37 143 3.5 Education’ Less than high school 33.4 35 280 26 261 23 229 24 216 27 202 24 High school 52 39 281 38 278 30 276 2.7 242 33 216 34 Some college 327 65 24 40 203 32 199 31 195 42 21.0 41 College 171 66 204 61 13.9 30 161 34 13.1 38 8.7 3.1 *For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 11978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 195% confidence interval. ‘Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. groups and subgroups, including persons who identi- fied themselves as Puerto Rican, Cuban, Mexican, Mexicano, Mexican American, Chicano, Spanish, or of other Latin American origin. Because Hispanics with higher levels of education are less likely to smoke than other groups of Hispanics (Haynes et al. 1990), the slightly different target populations in the HHANES and in the NHIS—which probably differ in educational attainment—may help explain differences in smoking prevalence between the two surveys. Hispanics aged 55 years and older consistently had the lowest rates of cigarette smoking in the NHIS (Table 28), a finding similar to that from the HHANES (Haynes et al. 1990). Rates of cigarette smoking generally have been highest among Hispanics with a high school education or less and lowest among those who have graduated from college (Table 28). This pat- tern also was observed ina smaller survey of Hispanic adults in a semirural city near Albuquerque, New Mexico (Samet et al. 1992). In the 1982-1984 HHANES, having 12 or more years of education was associated with lower rates of cigarette smoking among Cuban American, Mexican American, and Puerto Rican men (Haynes et al. 1990). Among Hispanic women, those with 7-11 years of edu- cation had the highest rates of cigarette smoking. The 1982-1984 HHANES used an eight-item scale to measure level of acculturation in Mexican Americans (Delgado et al. 1990). The variables used to construct the scale were language ability, self-identification, parents’ racial /ethnic identification, and generation in the United States. Among Mexican American women, there was a dose-response relationship between the level of acculturation and Patterns of Tobacco Use 67 Surgeon General's Report Table 29. Percentage of adult Hispanic smokers* who reported smoking <15, 15-24, or >25 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985" 1987-1988' 1990-1991" 1992-1993t 1994-1995" Characteristic % +cH % +ClI % +Cl % +CT % +ClI % +CI Total <15 cigarettes 56.0 45 55.6 4.1 58.3 3.2 64.5 3.3 72.7 3.8 65.0 4.1 15-24 cigarettes 30.7. 43 31.3 3.0 30.9 3.1 29.3 3.2 21.2 3.5 27.3 3.9 >25 cigarettes 13.3. 2.4 13.2 3.0 10.9 2.1 6.2 1.4 6.2 2.0 7.7 2.0 Gender Men <15 cigarettes 52.4 5.9 52.5 5.5 54.9 4.6 62.5 44 71.8 5.2 62.4 5.1 15-24 cigarettes 32.6 5.0 33.0 4.2 32.1 4.6 29.8 4.2 20.7 45 29.9 4.7 >25 cigarettes 15.0 3.6 144 3.9 13.0 2.9 7.7 21 7.6 3.0 7.6 3.7 Women <15 cigarettes 61.4 5.2 59.8 4.9 63.0 4.2 67.6 4.7 74.1 5.3 68.8 5.6 15-24 cigarettes 27.8 5.3 28.8 5.1 29.1 4.2 28.6 4.5 22.0 5.1 23.5 5.1 >25 cigarettes 10.7 3.6 115 3.9 7.9 23 3.8 1.5 3.9 2.0 7.7 3.1 Age (years) 18-34 <15 cigarettes 61.7 6.2 61.4 53 61.6 4.8 69.8 43 78.1 4.7 70.2 6.3 15-24 cigarettes 28.5 5.5 29.2 45 29.3 48 27.8 4.1 173 42 25.1 6.1 >25 cigarettes 99 2.6 94 3.7 91 2.7 2.4 1.1 46 24 4.7 2.5 35-54 <15 cigarettes 49.0 63 445 6.5 56.0 5.0 59.7 49 66.5 6.7 60.4 6.2 15-24 cigarettes 33.4 6.7 35.1 5.0 31.7 4.7 29.6 4.6 25.2 6.1 28.6 5.9 >25 cigarettes 17.7 4.5 20.4 49 12.3 3.5 10.6 2.9 8.2 3.9 11.0 3.8 >55 <15 cigarettes 496 8.6 61.2 9.7 50.8 7.7 55.2 9.7 69.8 13.5 56.2 11.5 15-24 cigarettes 33.3 83 29.2 8.7 34.8 7.5 36.0 10.2 24.6 13.1 32.9 10.5 >25 cigarettes 17.1 7.6 96 58 144 59 8.5 5.5 5.6 45 10.9 7.0 *For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. +1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. age-adjusted (to the 1980 U.S. population) cigarette smoking prevalence; 19 percent of Mexican-oriented women and 28 percent of U.S.-oriented women were current cigarette smokers (Haynes et al. 1990). The unadjusted prevalence of cigarette smoking among US. women aged 18 years and older in 1983 was 29.5 per- cent (CDC 1994c). No clear relationship was observed among Mexican American men (Haynes et al. 1990). 68 Chapter 2 Navarro (1996) used data from the 1990 Califor- nia Tobacco Survey to study level of acculturation in Hispanics (most of whom were of Mexican origin). Level of acculturation was defined based on the lan- guage spoken in the home: persons from English- speaking homes were classified as having a high level of acculturation, and persons from Spanish-speaking homes were classified as having a low level of Table 29. Continued Tobacco Use Among US. Racial/Ethnic Minority Groups 1978-1980* 1983-1985' 1987-1988t 1990-1991 1992-1993" 1994-1995" Characteristic % +CH % ++Cl % +Cl % +C1 % ++4Cl % +CI Education$ Less than high school <15 cigarettes 554 5.0 541 53 59.2 5.1 66.2 5.2 71.1 66 635 7.2 15-24 cigarettes 299 56. 33.7 59 303 47 276 5.1 23.1 61 30.0 7.2 >25 cigarettes 147 43 123 47 105 33 6.2 23 5.8 - 3.6 6.5 3.4 High school <15 cigarettes 534 99 339 75 539 66 609 60 705 72 61.3 7.3 15-24 cigarettes 34.7 94 33.2 71 325 66 326 57 254 7.0 28.7 6.6 >25 cigarettes 11.9 5.9 129 44 136 45 6.5 2.6 42 3.0 10.1 44 Some college <15 cigarettes 50.6 10.3 505 11.8 541 92 S551 86 708 97 555 99 15-24 cigarettes 37.3 10.8 241 96 319 82 351 84 21.0 89 36.1 10.1 >25 cigarettes 12.2 75 255 99 140 64 98 5.3 8.2 5.1 8.4 5.1 College <15 cigarettes 55.6 22.1 50.0 17.1 55.3 11.7 644 11.3 75.8 11.7 71.6 15.7 15-24 cigarettes 17.8 15.2 364 135 296 106 27.1 103 167 10.3 17.9 128 >25 cigarettes 26.7 21.7 13.6 10.1 15.0 9.3 8.5 59 7.5 63 105 10.7 SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. acculturation. The data were analyzed by gender and for three levels of educational attainment (<12, 12, and >12 years). Among men, smoking prevalence varied for those with <12 and 12 years of education; smoking prevalence was highest among whites, intermediate among Hispanics of high acculturation, and lowest among Hispanics of low acculturation. This pattern also existed for women, but in all three of the educa- tion categories. Additionally, in a multivariate analy- sis that controlled for age, gender, educational attainment, and Mexican origin, Hispanics witha low acculturation level were significantly less likely to smoke than those with a high acculturation level. Navarro suggested that level of acculturation may be related to the degree of urbanization of the person’s or family’s residence in the country of origin. For ex- ample, persons living in rural areas of Latin America appear to be less likely to smoke than those living in urban areas (USDHHS 1992). The relationship be- tween cigarette smoking and level of acculturation among Hispanics living in the United States may be confounded by adaptation to industrial and urban societies (Navarro 1996), especially if persons or families from rural areas acculturate more slowly than those from urban areas. Future research into this topic might ideally include information on the person’s or family’s residence in the country of origin. Number of Cigarettes Smoked Daily Between 1978 and 1985, trends in the number of cigarettes smoked per day by Hispanic smokers re- mained stable (Table 29) (NCHS, public use data tapes, 1978-1995). More recently, however, an increasing pro- portion of Hispanic smokers have been smoking fewer than 15 cigarettes per day, and a declining proportion of them have been smoking 25 or more cigarettes per day. For example, in 1978-1980, 13.3 percent of His- panic smokers smoked 25 or more cigarettes per day. By 1994-1995, this proportion was 7.7 percent. From 1978 to 1993, Hispanic men were more likely than Hispanic women to smoke 25 or more ciga- rettes per day, although these differences were not sta- tistically significant (Table 29). Consumption patterns in 1994-1995 were similar across genders. Between 1978 and 1995, the prevalence of smoking 25 or more cigarettes per day declined among Hispanics at all levels of education (Table 29), although only the decline among persons with less than a high school education was statistically significant. Patterns of Tobacco Use 69 Surgeon General’s Report Quitting Behavior In the NHIS, the prevalence of smoking cessa- tion among Hispanic smokers increased moderately between 1978 and 1995 (Table 30) (NCHS, public use data tapes, 1978-1995). No notable differences in smoking cessation between Hispanic men and women were observed. The prevalence of cessation was higher among persons in the older age groups and among college graduates (Table 30). Data from a recent multivariate analysis of the 1991 NHIS (CDC 1993) indicate that after the analysis controlled for gender, age, education, and poverty sta- tus, Hispanics were more likely than whites to stop smoking for at least one day during the previous year. Hispanics who had stopped smoking for at least one day were about as likely as whites to have stopped for at least one month. Overall, Hispanic smokers were slightly more likely than whites to have quit smoking for at least one month. Data from the NCI Supplement of the 1992-1993 CPS indicate that among Hispanics aged 18 years and older who were daily smokers one year before the sur- vey, 59.8 percent reported that they were still smoking daily and that they had not tried quitting for at least one day during the previous year (Table 4). Another 28.5 percent had tried quitting for at least one day, 5.6 percent were occasional smokers (i.e., smoked only on some days), 2.5 percent had not smoked for the past 1-90 days, and 3.6 percent had not smoked for the past 91-364 days. This distribution was similar to that among whites, with the exception that slightly more Hispanics had become occasional smokers. Table 30. Percentage of adult Hispanic ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988 1990-1991* 1992-1993t 1994-1995" Characteristic % +c % +Cl % +C1 % +C1 % +Cl % +CI Total 35.0 28 393 28 428 24 441 26 442 3.1 462 3.2 Gender Men 355 34 405 41 4430 33 430 36 458 41 482 43 Women 342 43 376 43 425 34 456 35 416 45 43.1 45 Age (years) 18-34 279 42 326 32 337 36 343 35 314 43 325 49 35-54 372 39 392 52 449 3.7 453 36 464 47 496 4.9 >55 510 55 372 76 604 50 671 56 703 69 681 64 Education$§ Less than high school 30.5 36 37.7 40 433 36 455 44 428 50 476 5.1 High school 457 71 400 60 412 46 419 44 442 60 445 62 Some college 385 98 47.8 69 55.0 63 526 6.1 52.8 88 49.1 7.6 College 594 142 522103 592 72 566 73 640 89 711 91 *The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever smokers include current and former smokers. 11978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. ‘Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 70 Chapter 2 Women of Reproductive Age From 1978 to 1995, a large proportion of Hispanic women of reproductive age (18-44 years) have smoked cigarettes, although this proportion has been declining over time (Table 31) (NCHS, public use data tapes, 1978-1995). Some evidence suggests that the prevalence of smoking among women of reproductive age varies according to the country of origin, with Cuban Ameri- can women (22.6 percent) and Mexican American women (23.2 percent) reporting cigarette smoking in lower proportions than Puerto Rican women (33.5 per- cent) (Pletsch 1991). In a comparison of data from the HHANES and the National Health and Nutrition Ex- amination Survey (NHANES), Guendelman and Abrams (1994) found that Mexican American women of reproductive age were less likely than their white counterparts to smoke cigarettes at each of the repro- ductive stages (interconception, pregnancy, lactation, and postpartum). Tobacco Use Among US. Racial/Ethnic Minority Groups The National Survey of Family Growth collected data in 1982 and 1988 on the smoking behavior of females 15-44 years of age during their most recent pregnancy. In 1982, 17.2 percent of Hispanic women reported smoking during their most recent pregnancy, compared with 13.7 percent in 1988 (Pamuk and Mosher 1992; Chandra 1995). More recent data from US. final natality statistics indicate that smoking rates for Hispanics during pregnancy declined from 8 per- cent in 1989 to 4.3 percent in 1995 (Table 6). Hispanic adolescent mothers were about as likely as older Hispanic mothers to have smoked (USDHHS 1994). Hispanic mothers report generally low rates of tobacco use, ranging from 1.8 to 4.1 percent for Mexi- can, Cuban, Central American, and South American mothers to 8.2 to 10.4 percent for Puerto Rican and “other” Hispanic mothers and those of unknown Hispanic origin (Table 6). Ventura and colleagues (1995) reported that 3 percent of foreign-born or Puerto Table 31. Percentage of Hispanic women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985 1987-1988t 1990-1991 1992-1993' 1994-1995" Characteristic % +CH % +CI % +CI % +CI % +CI % +CI Total 25.5 2.7 22.2 2.2 19.8 1,7 16.7 1.8 17.3 2.3 16.4 2.0 Education$§ Less than high school 29.2 43 24.4 4.4 23.5 4.0 17.6 3.7 17.0 44 17.0 3.7 High school 21.3 5.6 27.6 5.3 24.1 3.7 214 3.6 25.1 5.3 21.4 4.7 Some college 12.9 7.5 21.5 6.7 15.9 46 19.5 4.2 17.0 6.1 16.5 5.23 College 17.3. 12.0 16.7 8.3 12.7 4.7 15.2 5.0 12.9 58 5.1 4.1 *For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. +1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 199] data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 95% confidence interval. “Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patterns of Tobacco Use 71 Surgeon General's Report Rican-born Hispanic mothers smoked, compared with 9 percent of their United States-born counterparts (Ventura et al. 1995). Data on tobacco use among these mothers may be skewed because California and New York do not report this information, and together these states account for almost half of all Hispanic births (Ventura et al. 1996). The National Pregnancy and Health Survey, con- ducted between October 1992 and August 1993 and sponsored by NIDA, provides nationally representa- tive data on the prevalence of prenatal drug use among Hispanic females of reproductive age (15-44 years). According to National Pregnancy and Health Survey data, 5.8 percent of Hispanic women reported using cigarettes during their pregnancies (NIDA 1994). In the 1985 and 1990 NHISs, questions related to smok- ing were asked of women aged 18—44 years who had given birth within the past five years. In 1985, 16.8 percent of Hispanic women smoked during the 12 months before the birth and 10.3 percent smoked after learning of their pregnancy; in 1990, 12.1 percent smoked during the year before birth and 8 percent af- ter learning of their pregnancy (Floyd et al. 1993). Young People Cigarette Smoking Despite the dearth of information on tobacco use among Hispanic youths, several studies have been able to identify trends in smoking initiation and patterns of tobacco use by analyzing data from the HHANES, the MTF surveys of high school seniors (Figure 3), and small local surveys (for example, Smith et al. 1991; Dusenbury et al. 1992; Vega et al. 1993). HHANES data have shown that smoking initia- tion increased rapidly among Cuban Americans, Mexi- can Americans, and Puerto Ricans between ages 11 and 15 years, peaked between ages 15 and 19 years, and declined after the age of 20 years (Escobedo et al. 1990). In all age groups, smoking initiation rates were higher among males than among females. Slight variations in smoking initiation by level of education were found when the HHANES data were combined for all three Hispanic subgroups (although these were three separate surveys, it was necessary to combine three groups to estimate trends for all three groups). Hispanics with less than a high school education had the highest rates of smoking initiation, with an earlier age of onset and a more accelerated rate of smoking initiation during young adolescence, than Hispanics with more years of schooling. Hispan- ics with a high school education had intermediate rates 72 Chapter 2 of smoking initiation, whereas those with more than a high school education had slightly lower smoking initiation rates. Because educational attainment is a reliable (Liberatos et al. 1988) although limited (Mont- gomery and Carter-Pokras 1993) indicator of socioeco- nomic status, these data suggest that an association between smoking initiation and socioeconomic status may exist among Hispanics, as it does for the general U.S. population. However, these differences in smok- ing initiation by educational attainment were not as large as those found among whites. In addition, data from the 1994-1995 (combined) NHSDAs indicate that among persons aged 30-39 years, Hispanic men and women were less likely to become daily smokers than whites (Table 11) (USDHHS, Substance Abuse and Mental Health Ser- vices Administration, public use data tapes, 1994— 1995). Among persons in this age group who had ever smoked daily, the initiation patterns among Hispan- ics were more like those of African Americans than those of whites. The average ages for first trying a cigarette and for becoming a daily smoker were about one year higher for Hispanic men than for white men and about two years higher for Hispanic women than for white women (Table 11). Among high school seniors who participated in the MTF in 1985-1989, 23.8 percent of Mexican Ameri- can males, 22.0 percent of Puerto Rican and Latino males, 18.7 percent of Mexican American females, and 24.7 percent of Puerto Rican and Latina females smoked cigarettes in the previous month (Bachman et al. 1991b). In addition, 11.6 percent of Mexican Ameri- can males, 13.3 percent of Puerto Rican and Latino males, 8.1 percent of Mexican American females, and 13.3 percent of Puerto Rican and Latina females smoked cigarettes daily in the previous month. The prevalence of smoking one-half pack of cigarettes or more per day was somewhat higher among males (5 to 6 percent) than among females (2 to 4 percent). Between 1976 and 1989, the prevalence of daily smoking declined among Mexican American high school seniors of both genders and among Puerto Rican and Latina females, according to the MTF data (Bachman et al. 1991b). Decreases occurred be- tween 1976 and 1984 among Mexican American males and between 1980 and 1989 among Puerto Rican and Latina females. Among Mexican American females, decreases in the prevalence of daily smoking occurred between 1976 and 1984, and no decline was observed in more recent years. In contrast, little change in the prevalence of daily smoking was observed among Puerto Rican and Latino males over the entire survey period (Bachman et al. 1991b). Recent data indicate that rates of smoking are generally lower among Hispanic youths than among white youths. The 1989 TAPS showed that 11.8 per- cent of Hispanics reported some level of cigarette smoking, compared with 17.7 percent of whites and 6.2 percent of African Americans (Moss et al. 1992). However, patterns may differ for migrant and resident youths. Ina recent study of 214 migrant Hispanic ado- lescents enrolled in school in San Diego, the prevalence of cigarette smoking within the 30 days preceding the survey increased by school grade, from a low of 10 percent of 9th graders to 14 percent of 10th graders, 21 percent of 11th graders, and 18 percent of 12th graders (Lovato et al. 1994). Also, acculturation may influence smoking behavior. In a study of sixth and seventh graders in Dade County, Florida, Vega and col- leagues (1993) found that cigarette smoking was more frequent among United States-born Cuban American children (23.8 percent) than among foreign-born Cuban Americans (15.1 percent). According to the 1995 YRBS, 34.0 percent of His- panic high school students and 38.3 percent of white high school students smoked on one or more days during the previous month (CDC 1996). Hispanic stu- dents were significantly more likely than African American students (19.2 percent) to have smoked dur- ing the previous month. Regarding more frequent smoking, Hispanic youths (10.0 percent) and African American youths (4.5 percent) were less likely than white youths (19.5 percent) to have smoked on at least 20 days during the previous month. Lowry and colleagues (1996) analyzed cross- sectional data on 6,321 adolescents (aged 12-17 years) from the YRBS supplement to the 1992 NHIS. His- panics were significantly less likely than whites to have smoked in the previous 30 days. This analysis con- trolled statistically for the educational level of the re- sponsible adult, for family income, for the age and gender of the adolescent, and for whether the adoles- cent was in or out of school. In an analysis comparing measured carbon monoxide from expired air with self- reported smoking among a sample of seventh- through tenth-grade New York State public school students, Wills and Cleary (1997) found that the self-report sen- sitivity was slightly lower for Hispanics than for whites but that the magnitude of the effect was small. When self-reported smoking rates were adjusted for carbon monoxide values, ninth- and tenth-grade Hispanic students had significantly lower smoking prevalences than whites. Recent findings from focus groups conducted at several U.S. sites suggest that Hispanic parents may be more likely than white parents to express clear anti- Tobacco Use Among U.S. Racial/Ethnic Minority Groups smoking messages and that smoking by Hispanic ado- lescents may be a sign of disrespect toward parents (Mermelstein et al. 1996). According to the 1996 MTF surveys, the preva- lence of previous-month smoking (estimated by com- bining 1995 and 1996 data) among Hispanic high school seniors (25.4 percent) was intermediate to that among African American seniors (14.2 percent) and white se- niors (38.1 percent) (Institute for Social Research, Uni- versity of Michigan, unpublished data from the 1996 MTF surveys). Asimilar pattern was observed for tenth- grade students: previous-month smoking prevalences were 23.7 percent for Hispanics, 32.9 percent for whites, and 12.2 percent for African Americans. However, among eighth-grade students, the Hispanic-white difference was attenuated: 19.6 percent of Hispanics, 22.7 percent of whites, and 9.6 percent of African Ameri- cans were previous-month smokers. Trends in daily smoking among high school seniors show that rates for Hispanics have been consistently lower than for whites since 1977 and higher than for African Americans since the early 1980s (Figure 3). The MTF surveys suggest that rates of smoking among Hispanics have increased in the 1990s. The prevalence of previous-month smoking (based on two- year rolling averages) among eighth-grade students was 16.7 percent in 1992 and 19.6 percent in 1996; among tenth-grade students, the prevalence was 18.3 percent in 1992 and 23.7 percent in 1996; and among high school seniors, the prevalence was 21.7 percent in 1990 and 25.4 percent in 1996 (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). Simi- larly, YRBS data indicate that the prevalence of previ- ous-month smoking among Hispanic high school students was 25.3 percent in 1991 (USDHHS 1994) and 34.0 percent in 1995 (CDC 1996). Other Risk Behaviors Using data from the YRBS supplement to the 1992 NHIS, Escobedo and colleagues (1997) observed asso- ciations (USDHHS 1994) between cigarette smoking among Hispanic adolescents and specific behaviors com- promising to health. Marijuana use, binge drinking, and weapon carrying were significantly associated with ciga- rette smoking among Hispanic adolescent males; mari- juana use, binge drinking, multiple sexual partners, and physical fighting were associated with cigarette use among Hispanic adolescent females. The analysis controlled statistically for age, ethnicity, gender, paren- tal educational level, region of the country, and other risk behaviors. Patterns of Tobacco Use 73 Surgeon General's Report Smokeless Tobacco Use Recent trends in smokeless tobacco use among Hispanic adolescents have changed little. According to the MTF surveys, previous-month smokeless tobacco use (based on two-year rolling averages) was reported by 4.2 percent of eighth-grade Hispanic students in 1992 and 5.2 percent in 1996; among tenth-grade students, the prevalence was 6.2 per- cent in 1992 and 4.0 percent in 1996; and among high school seniors, the prevalence was 4.4 percent in 1987 and 8.1 percent in 1996 (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). YRBS data indicate that the prevalence of previous-month use among Hispanic high school students was 5.5 per- cent in 1991 (USDHHS 1994) and 4.4 percent in 1995 (CDC 1996). Hispanic adolescent males are much less likely than white adolescent males to use smokeless tobacco. Among male high school students participating in the 1995 YRBS, for example, 5.8 percent of Hispanics and 25.1 percent of whites had used smokeless tobacco during the previous month (CDC 1996). Prevalence among females was 3.1 percent for Hispanics and 2.5 percent for whites. Retrospective Analyses of Smoking Prevalence Among African Americans and Hispanics Because of the lack of long-term national survey data on smoking behavior among racial/ethnic groups, retrospective analysis is the only way to reconstruct smoking prevalences for African Americans before 1965 and for Hispanics before 1978. The retrospective method of constructing smoking prevalences for suc- cessive birth cohorts of men and women in the U.S. population was first reported by Harris (USDHEW 1979; Harris 1983). Harris’s methodology later served as the basis for a report in which smoking prevalences were presented for Cuban American, Mexican Ameri- can, and Puerto Rican men and women (Escobedo and Remington 1989). Most recently, the NCI (1991) published some results of an analysis of birth cohorts of whites and African Americans. Another type of ret- rospective analysis has also been used to estimate long- term trends in cigarette smoking. This approach has been the basis of two published reports, one that pre- sented smoking trends among Hispanics in various age groups (Escobedo et al. 1989a) and another that pre- sented smoking trends among Hispanic young adults (Escobedo et al. 1989b). For this section of the report, both types of retrospective analysis were used to gen- erate information not previously available. Prevalence of Cigarette Smoking Among Successive Birth Cohorts The following detailed analysis of smoking trends over time—according to gender and educational rt Chapter 2 attainment ot defined birth cohorts (based on the year of birth)—uses data from the 1987 NHIS (for African Americans) and the 1982-1984 HHANES (for Hispan- ics).. The smoking histories of respondents were con- structed according to the ages they reported cigarette smoking initiation and cessation. Information about these two smoking-related events was then used to classify each respondent as a nonsmoker, current smoker, or former smoker from birth to interview and to calculate the proportion of people smoking each year in each birth cohort. (See Appendix 5 for a discussion of the valida- tion of this methodology.) The resulting birth cohort curves (Figures 7-10) represent smoking prevalences of each cohort for each year from birth to interview (throughout childhood, adolescence, and adulthood) (NCHS, public use data tapes, 1978, 1979, 1980, 1982- 1984, and 1987 and 1988 combined). By comparing the curves among successive birth cohorts, one can examine smoking trends over time for those cohorts. African Americans The prevalence of smoking among successive birth cohorts of African American men with at least a high school education has declined gradually, with the peak and age-specific smoking prevalences for the most recent cohort (1958-1967) being lower than the prevalences for previous cohorts’ curves (Figure 4). In contrast, little progress has been made in re- ducing the prevalence of cigarette smoking among successive birth cohorts of African American men with less than a high school education (Figure 7). Although smoking prevalences declined slightly for successive cohorts, the peak prevalence for the most recent co- hort continues to be nearly as high as that for previ- ous cohorts. In addition, smoking prevalences during adolescence among African Americans with less than a high school education did not decrease between suc- cessive birth cohorts. Despite initial increases in smoking prevalence among successive birth cohorts of African American women with at least a high school education, prevalences have declined in recent years (Figure 8). The declines in prevalence among African American women with at least a high school education are not as marked as the declines observed among successive birth cohorts of African American men of a similar educational background. Smoking prevalences among African American women with less than a high school education have increased markedly, with the most recent cohort (1958-1967) showing the highest peak (Figure 8). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Hispanics Among six successive birth cohorts of Hispanic men with at least a high school education covering the years 1908-1967, the peak prevalence of smoking in- creased gradually for the first three cohorts but declined beginning with the 1938-1947 cohort (Figure 9). In ad- dition, the rate of increase in smoking prevalence dur- ing adolescence slowed markedly for the most recent cohort compared with rates for previous cohorts. The smoking prevalence pattern among succes- sive birth cohorts of Hispanic men with less than a high school education (Figure 9) is similar to the pat- tern among African American men with a similar edu- cational background. Smoking prevalences have declined slightly since the early 1950s, when the high- est prevalence was observed for the 1918-1927 cohort. The slight decline in smoking prevalence among successive birth cohorts of Hispanic women with at least a high school education is similar to the decline among African American women with a similar edu- cational background (Figure 10). However, the decline Figure 7. Cigarette smoking prevalence among successive birth cohorts of African American men, by education, National Health Interview Surveys, United States, 1978-1980, 1987, and 1988* 80> High school 70,4 education 60- Vv - é 5054 5 40-4 zo & 30-4 207 10-4 0 1910 1920 1930 1940 1950 1960 1970 1980 Year Birth cohorts: mms 1908-1917 ----- 1918-1927 1928-1937 805 Less than a high 79- school education,. 60-4 504 40- 30- 204 10- 0 To 1910 1920 1930 1940 1950 1960 1970 1980 Year Percentage ecee 1938-1947 mmm 1948-1957 —— 1958-1967 *Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth to interview, they provide information about the smoking prevalence of each cohort during childhood, adolescence, and adulthood. Sources: National Center for Health Statistics, public use data tapes, 1978-1980, 1987 (Cancer Control Supplement and Epidemiology Supplement), and 1988; Escobedo and Peddicord 1996. Patterns of Tobacco Use 75 Surgeon General's Report among Hispanic women began more recently, with the 1938-1947 cohort. The peak prevalence for the most recent cohort of Hispanic females with at least a high school education was similar to the peak prevalence for African American women of the same educational level (25 percent). The smoking prevalences among successive birth cohorts of Hispanic women with less than a high school education increased slightly over time and then lev- eled off (Figure 10). In addition, the prevalence of smoking during adolescence increased much more rapidly in the most recent birth cohort than in previ- ous cohorts. However, the overall pattern of smoking prevalence in this subgroup of Hispanic women does not show the dramatic increases observed in succes- sive birth cohorts of African American women with a similar educational background. The peak prevalence for the most recent birth cohort of Hispanic women with less than a high school education (34 percent) was substantially lower than the peak prevalence for the corresponding cohort of African American women (54 percent). The slight changes in smoking prevalences among successive birth cohorts of Hispanic women, regardless of educational background, may be the re- sult of the larger proportion of Mexican American women who compose these subgroups. Although few changes have been observed in the prevalence of smoking among successive birth cohorts of Mexi- can American women, in recent birth cohorts of Cuban American and Puerto Rican women, more women have smoked cigarettes than those in previ- ous cohorts (Escobedo and Remington 1989). Had more Cuban American and Puerto Rican women been included in the HHANES, the pattern may well have been different. The results of these birth cohort analyses show that educational attainment is the most powerful pre- dictor of temporal trends in smoking prevalence. In both racial/ethnic groups, men, and to a lesser extent women, with at least a high school education have made progress in reducing cigarette smoking. How- ever, men with less than a high school education, re- gardless of race/ethnicity, are as likely to smoke now as they were in previous decades. Recent cohorts of African American women with less than a high school education are now substantially more likely to smoke than their counterparts in previous decades. Figure 8. Cigarette smoking prevalence among successive birth cohorts of African American women, by education, National Health Interview Surveys, United States, 1978-1980, 1987, and 1988* 804 High school 70 education 60 50-4 40 30 20-4 10- “ Percentage 0 T —T 1910 1920 1930 1940 1950 1960 1970 1980 Year Birth cohorts: mmm 1918-1917 ~---- 1918-1927 1928-1937 80> Less than a high 70+ school education 60- 50- 404 30-4 20- 10- 0 ’ ‘1 T t— | 1910 1920 1930 1940 1950 1960 1970 1980 Year Percentage 1938-1947 meme 1948-1957 1958-1967 *Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth to interview, they provide information about the smoking prevalence of each cohort during childhood, adolescence, and adulthood. Sources: National Center for Health Statistics, public use data tapes, 1978-1980, 1987 (Cancer Control Supplement and Epidemiology Supplement), and 1988; Escobedo and Peddicord 1996. 76 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Figure 9. Cigarette smoking prevalence among successive birth cohorts of Hispanic men, by education, Hispanic Health and Nutrition Examination Survey, 1982-1984* 80> High school 80> Less than a poets 70 education 704 high school wf 60-1 ee ges 60- education uv uv ge 504 B® 50- 5 40- 5 40-4 2 30 £ 30- 20- 20- 10 10-— 0 T 0 T 7 T I T 1910 1920 1930 1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 Year Year Birth cohorts: ws 1908-1917 ---++ =1918-1927 1928-1937 sere 1938-1947 mem 1948-1957 —— 1958-1967 “Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth to interview, they provide information about the smoking prevalence of each cohort during childhood, adolescence, and adulthood. Sources: National Center for Health Statistics, public use data tapes, 1982-1984; Escobedo and Peddicord 1996. Figure 10. Cigarette smoking prevalence among successive birth cohorts of Hispanic women, by education, Hispanic Health and Nutrition Examination Survey, 1982-1984* 80> High school 807 Less than a high 704 education 704 school education 60 4 60- ov v ep 50-4 % 50 & & 5 40+ & 40+ = g 2 30- 2 30 20-4 20- 10- 10- 0 T 0 T ri pat T T 1910 1920 1930 1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 Year Year Birth cohorts: mee 1918-1917 ----- 1918-1927 1928-1937 e=e== 1938-1947 mmm 1948-1957 ——— 1958-1967 “Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth to interview, they provide information about the smoking prevalence of each cohort during childhood, adolescence, and adulthood. Sources: National Center for Health Statistics, public use data tapes, 1982-1984; Escobedo and Peddicord 1996. Patterns of Tobacco Use 77 Surgeon General’s Report Long-Term Trends in Cigarette-Smoking Initiation Another type of birth cohort analysis was con- ducted to determine long-term trends in smoking among, young adults (20-29 years of age) by gender and educa- tional attainment. Information on smoking history was determined during the years that each person was 20-29 years of age. For each year, the prevalence of smoking was determined by dividing the number of smokers aged 20-29 years by the total number of persons aged 20-29 years in that year. Unlike the birth cohort analysis de- scribed in the preceding section of this chapter, in this analysis the group for which prevalences are computed changes from year to year because new respondents en- ter the group when they are 20 years old and leave it when they become 30 years old. The information for African Americans was ob- tained from NHIS data collected in 1978, 1979, 1980, 1987, and 1988, whereas the information for Hispan- ics was obtained from HHANES data collected in 1982-1984. African Americans Up until the early 1970s, African American men had substantially higher rates of smoking initiation than African American women (Figure 11). Within each gender group, significant education-related differences were not observed until the 1950s, when rates of smoking initiation among male high school graduates began to decline sharply and rates among females with less than a high school education began to increase. Rates among less educated females surged dramatically between 1970 and 1980. After 1980, rates of smoking have consistently declined among each of these subgroups of African Americans except males with less than a high school education. Hispanics Significant education-related differences in rates of smoking initiation have been evident only among Hispanic males. Around 1940, Hispanic males who graduated from high school began showing Figure 11. Reconstructed prevalence of smoking among African American adults aged 20-29 years, by gender and education, National Health Interview Surveys, United States, 1910-1988 80 704 Men with less 60- ames = thana high school education » 50-4 —.. Menwitha high Bb school education < - @ 40 Women with less a than a high a 30 4 school education Women with a 20- — _ highschool education 10-4 0 | 1910 1920 1930 1940 1950 1960 1970 1980 1990 Year Source: National Center for Health Statistics, public use data tapes, 1978, 1979, 1980, 1987, and 1988 combined. 78 Chapter 2 appreciably lower smoking rates than Hispanic males with less than a high school education (Figure 12). These differences increased in the 1960s and even more rapidly in the mid-1970s. No consistent differences in smoking rates by education were observed among Hispanic females. Cigarette Brand Preferences Knowing what influences cigarette brand prefer- ence among smokers is believed to be important be- cause this information can be used to develop counteradvertising strategies. In the late 1970s and the 1980s, the 12 most commonly used brands of ciga- rettes—Marlboro, Winston, Salem, Kool, Pall Mall, Kent, Benson & Hedges, Camel, Merit, Vantage, Virginia Slims, and Newport—were used by at least 76 percent of all current U.S. smokers, according to data from the 1986 Adult Use of Tobacco Survey (AUTS) and the 1978- 1980 and 1987 NHISs (Table 32). Brand use varied some- what by race/ethnicity. For example, the top brands Tobacco Use Among U.S. Racial/Ethnic Minority Groups preferred by African Americans were Kool, Newport, Salem, and Winston, whereas whites preferred Marlboro, Winston, Salem, and Benson & Hedges. These differences in part reflect the greater use of mentholated cigarettes by African Americans (Cummings et al. 1987; USDHHS 1989). Fifty-five percent of all African American smokers reported us- ing one of three brands that were available only in mentholated form (Newport, Kool, and Salem). Simi- lar patterns and percentages of brand preferences were observed in the 1987 NHIS (Table 32). Hymowitz and colleagues (1995) recently stud- ied menthol cigarette smoking among adults who par- ticipated in a stop-smoking study. Among African Americans who smoked menthol cigarettes (n = 174), the top reasons given for smoking menthols were as follows: 83 percent said that menthol cigarettes tasted better than nonmenthol cigarettes, 63 percent said that they had always smoked menthol cigarettes, 52 per- cent said that menthol cigarettes were less harsh to the throat than nonmenthol cigarettes, 48 percent found inhalation to be easier with menthol cigarettes, and 33 Figure 12. Reconstructed prevalence of smoking among Hispanic adults aged 20-29 years, by gender and education, Hispanic Health and Nutrition Examination Surveys, 1920-1984 80 70- Men with less 60 mums = thana high school education vy. 50 ~.-,. Men witha high g school education § 40- : = *. Women with less oe than a high 30 school education 20-44 Women witha ——— high school education 10 0 T |! 1920 1930 1940 1950 1960 1970 1980 1990 Year Source: National Center for Health Statistics, public use data tapes, 1982-1984. Patterns of Tobacco Use 79 Surgeon General’s Report Table 32. Percentage of self-reported cigarette brand use among adult current cigarette smokers, overall and by race/ethnicity and gender, National Health Interview Surveys (NHIS) 1978-1980 com- bined, Adult Use of Tobacco Survey (AUTS) 1986, and NHIS 1987 Benson & Hedges Camel Kent Kool Marlboro Sample Survey Size* % +c % +Cl % +CI % +Cl % +Cl NHIS 1978-1980 African Americans Total 1,540 6.0 1.6 1.3. 0.7 16 0.6 28.0 4.0 3.8 1.3 Men 750 4.0 1.7 2.3 1.2 1.1 08 31.3 4.7 4.2 17 Women 790 8.1 2.4 0.3 0.4 2.2 0.8 244 45 3.3 1.6 Whites Total 13,228 4.2 0.6 44 0.5 48 0.5 6.3 0.6 17.55 1.1 Men 6,675 2.7 0.5 6.9 0.7 40 0.6 6.8 0.8 20.3 1.5 Women 6,553 5.8 0.8 1.7 04 5.7 0.6 5.8 0.7 144 1.2 AUTS 1986 African Americans Total 388 92 3.5 0.9 1.2 0.6 0.6 19.9 49 67 3.1 Men 176 4.6 3.8 1.2 2.0 0.5 0.5 19.6 7.2 10.2 5.5 Women 212 13.8 5.7 05 1.2 0.7 0.7 20.3 6.7 3.2 2.9 Whites Total 3,693 41 0.8 49 0.9 2.7 2.7 4.2 0.8 28.3 18 Men 1,883 29 0.9 79 15 2.3 23 4.7 1.2 32.4 2.6 Women 1,810 5.5 13 15 0.7 3.2 3.2 3.5 1.0 23.7 2.4 NHIS 1987 African Americans Total 428 6.3 2.7 2.6 2.0 2.5 2.3 24.8 5.4 2.7 1.5 Men 174 2.2 1.8 34 33 2.1 2.8 30.3 8.6 3.1 2.2 Women 254 11.2 5.1 1.7 2.2 3.0 3.7 18.4 5.5 23 19 Whites Total 1,860 5.8 1.2 3.8 1.1 3.1 09 3.7 1.0 31.1 2.6 Men 934 3.8 14 5.7 1.6 2.1 1.0 3.6 1.3 38.8 3.5 Women 926 8.1 2.1 1.6 1.7 4.3 1.6 3.7 14 22.0 3.1 *Unweighted sample size. tIn the NHIS, “other” includes other brands, no particular brand, and roll-your-own cigarettes; in the AUTS, “other” includes other brands. percent said that they could inhale menthol cigarettes more deeply. Among a small sample (n = 39) of whites who smoked menthol cigarettes, 74 percent said that menthol cigarettes tasted better than nonmenthol ciga- rettes, 51 percent said that menthol cigarettes were more soothing to the throat, 39 percent said that they had 80 Chapter 2 always smoked menthol cigarettes, and 21 percent found inhalation to be easier with menthol cigarettes. Evaluating changes in young smokers’ brand preferences is especially important because it can help identify factors that influence their choices and may suggest ways to discourage them from starting Tobacco Use Among U.S. Racial/Ethnic Minority Groups Pall Merit Newport Mall Salem Virginia Vantage Slims Winston Other’ G% +tCl % +Cl % «Cl % +l % +C] % +CI % +Cl G% +I 14 0.6 5.2 2.3 69 1.5 15.9 2.0 1.3 09 5.6 2.7 96 25 12.7 2.8 14° 09 47 28 40 13 19.4 2.7 43 04 1.2 0.4 54 O04 90 07 40 0.6 1.2 O04 6.4 0.6 7.9 0.8 47 0.6 1.2 O04 4.2 0.5 10.3 1.0 0.1 O04 23.4 5.2 23 18 174 4.6 0.0 0.0 26.2 8.0 2.8 3.0 13.2. 6.5 0.1 0.5 20.5 6.7 1.8 2.2 19.7 6.6 49 0.9 24 0.6 3.5 07 8.2 1.1 46 1.2 27 09 39 11 64 14 5.3 13 21 08 29 09 10.4 1.7 13 #11 19.6 5.7 22 1.2 12.7 38 08 1.2 219 9.1 2.1 1.46 11.9 «54 19 2.0 16.9 5.3 2.3 1.7 13.5 4.7 4.5 1.0 28 0.9 25 0.8 7.0 14 41 14 2.5 1.2 3.2 1.2 54 1.9 49 13 3.2 13 15 08 8.9 2.1 0.9 05 26 0.9 1.9 21 145 2.0 0.7 0.2 0.2 0.3 13.4 3.3 13.6 2.5 1.1 08 5.2 19 10.3 2.1 156 3.2 3.5 O04 2.2 03 13.3 0.9 23.9 1.1 3.5 0.6 0.2 0.1 15.5 1.2 20.6 14 3.5 0.5 44 05 10.8 1.0 27.55 14 04 0.8 34 2.2 6.5 3.0 94 3.6 05 13 03 1.0 8.8 5.1 10.2 5.5 04 1.0 64 4.0 42 3.3 85 4.6 3.6 0.7 3.0 0.7 11.0 1.2 19.2 1.6 3.5 1.0 04 0.4 13.0 19 154 2.0 3.8 1.1 6.0 1.3 8.8 1.6 23.6 24 0.5 0.5 1.9 1.2 11.7 4.0 W.2 3.5 0.0 60.0 05 0.8 12.9 63 88 44 1000«1.2 34 24 10.3 4.8 14.1 5.0 26 08 3.8 0.9 123 19 170 19 28 1.0 01 0.2 13.6 2.7 143 2.5 24 11 8.2 2.0 10.7 2.6 20.55 2.8 495% confidence interval. Sources: National Center for Health Statistics, public use data tapes, 1978-1980 and 1987; Centers for Disease Control, public use data tapes, 1986. to smoke (Hunter et al. 1986; Pierce et al. 1991a). Data from the 1989 TAPS show that among adolescents who usually bought their own cigarettes (61.9 percent), Marlboro was the most popular brand among whites (71.4 percent) and Hispanics (60.9 percent), and the mentholated brands of Newport (61.3 percent), Kool (10.9 percent), and Salem (9.7 percent) were preferred by African Americans (Table 33) (CDC 1992d). In the 1993 TAPS, the most popular brands were still Marlboro among whites (63.5 percent) and Hispanics (45.4 percent) and Newport among African Americans (70.4 percent) (Table 33). Patterns of Tobacco Use 81 Surgeon General's Report Table 33. Percentage of self-reported cigarette brand use among adolescent current cigarette smokers,* by race/ethnicity, Teenage Attitudes and Practices Surveys (TAPSs), 1989 and 1993 Benson & S Hedges Camel Kool Marlboro Merit Newport ample Survey Sizet % +cTt % +Cl % +Cl % +I % +Cl % +I TAPS 1989 Race African American 41 33 64 3.1 62 10.9 9.1 8.7 9.7 0.0 0.0 613 15.7 White 807 13 12 84 2.2 0.6 0.5 714 34 0.5 0.5 5.6 1.6 Ethnicity Hispanic 46 3.7 4.9 7.6 8.6 5.8 6.1 60.9 15.0 0.0 00 12.8 9.5 Non-Hispanic 817 13° 1.2 8.1 2.1 0.8 0.6 69.1 3.5 0.5 0.5 8.0 1.9 TAPS-II 1993 Race African American 41 17 33 0.0 0.0 11.9 10.9 85 8.5 8 8 70.4 14.1 White 646 0.2 04 144 3.1 05 08 63.5 43 NA NA 8.7 2.4 Ethnicity Hispanic 50 0.0 0.0 10.1 7.7 45 8.6 45.4 14.9 NA NA 34.0 15.1 Non-Hispanic 647 03 0.4 13.6 3.1 09 08 60.9 4.3 NA NA 11.0 2.5 Virginia Salem Vantage Slims Winston Other Sample Survey Size’ % HCI % +Cl % +Cl % %+Cl] % +l TAPS 1989 Race African American 41 9.7 7.2 0.0 0.0 NA NA 0.0 0.0 2.9 5.8 White 807 1.0 607 0.1 0.2 NA NA 3.4 13 7.6 2.0 Ethnicity Hispanic 46 28 54 0.0 0.0 NA NA 0.0 0.0 6.5 7.6 Non-Hispanic 817 15 0.8 O1 0.2 NA NA 3.3 1.3 73 19 TAPS-IT 1993 Race African American 41 14 2.7 NA NA 0.5 1.0 0.0 0.0 5.5 6.0 White 646 1.0 0.8 NA NA 1.0 1.0 1.2 0.1 94 28 Ethnicity Hispanic 50 0.0 0.0 NA NA 0.0 0.0 6.0 8.1 0.0 0.0 Non-Hispanic 647 1.10 (08 NA NA 1.1 «1.0 08 0.7 104 2.9 *Current smokers are adolescents aged 12-18 years who reported smoking cigarettes on 1 or more of the 30 days preceding the survey. ‘Unweighted sample size. #95% confidence interval. SNumbers are too small for meaningful analysis; this brand is included in the “other” category. NA = data not available. Sources: National Center for Health Statistics, public use data tapes, 1989; Centers for Disease Control and Prevention, public use data tapes, 1993. 82 Chapter 2 A notable change in brand preferences occurred between 1989 and 1993, however. The percentage of adolescents purchasing Marlboro cigarettes decreased 13 percent, whereas the percentage of those purchas- ing Camel cigarettes increased 64 percent and the percentage of those purchasing Newport cigarettes increased 55 percent (CDC 1994a). The declining pref- erence for Marlboro cigarettes was greatest among Hispanics (CDC 1992d). Increases in brand preference were greatest among white adolescents who preferred Camel cigarettes and among Hispanic adolescents who preferred Newport cigarettes. In 1993, the brands of cigarettes most commonly smoked among a small Tobacco Use Among U.S. Racial/Ethnic Minority Groups sample of Vietnamese middle and high school students in Worcester, Massachusetts, were Marlboro (71.0 per- cent) and Camel (9.7 percent) (Wiecha 1996). Data from the 1989 and 1993 TAPSs indicate that brand preference is more concentrated among adoles- cents than among adults. In both surveys, the three most popular brands for each racial/ethnic group were purchased by at least 80 percent of adolescent smok- ers. Both surveys identified very small numbers of smokers among African American adolescents (41 in 1989 and 45 in 1993) and Hispanic adolescents (46 in 1989 and 50 in 1993); thus, brand preference estimates for these groups are imprecise. Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior In this chapter, smoking prevalence has been shown to vary by racial/ethnic minority group and by educational attainment. Because educational at- tainment varies among racial/ethnic groups and is related to smoking prevalence, the question arises as to whether racial/ethnic differences in smoking can be explained by differences in educational attainment. A previous analysis of the 1985 NHIS data showed that controlling for selected measures of so- cioeconomic status, such as employment status and poverty level, reduced differences in the smoking prevalence between African Americans and whites (Novotny et al. 1988). Although education, together with such variables as income and occupation, is often used to create a composite measure of socioeconomic status, many researchers have used education as a single proxy in- dicator of socioeconomic status because education is often associated with many lifestyle characteristics (Liberatos et al. 1988). In addition, education data are usually more accurate and easier to collect than income and occupation data (Liberatos et al. 1988). Findings in this report indicate that the prevalences of cigarette smoking, smoking cessation, and heavy smoking are all associated with race/ ethnicity and educational attainment. Because racial/ ethnic group and educational attainment are often in- terrelated, multivariable models were used in this analysis to distinguish how each variable influences smoking behavior. Data were derived from the NHISs for 1987, 1988, 1990, and 1991 (Table 34) (NCHS, pub- lic use data tapes, 1987, 1988, 1990, and 1991). The multivariable logistic regression technique was used to assess the odds ratios of smoking behaviors for African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics compared with whites, before and after ad- justing for the effects of educational attainment.’ Four separate logistic regression models were constructed for different measures of smoking behavior: current smoking, ever smoking, heavy smoking (among cur- rent smokers), and smoking cessation (among ever smokers). Four design variables were created to rep- resent the racial/ethnic groups (African Americans, American Indians and Alaska Natives, Asian Ameri- cans and Pacific Islanders, and Hispanics), with whites serving as the reference group. Similarly, two design ' Let B,, = logistic regression coefficient for the ith ethnicity group before education was included, and B,, = logistic regression coefficient for the ith ethnicity group after education was included. Then §,,- B,, measures education’s confounding effect on the relationship between smoking and ethnicity. The variance of B,,- B,, can be approximated as var(B,,) + var(B,.); and the standard error, SE(B,, - B,,), is the square root of the variance. In terms of the more commonly used measure, odds ratio (OR), the following relationship exists: OR,,/OR, = exp(B, - B,,). The 95 percent confidence interval for OR,,/OR,, can then be computed as exp((B,, - B,,) + 1.96 X SE(B,, - B,,)]. Education’s confounding effect on the relationship between smoking and ethnicity is determined to be statistically significant if the 95 percent confidence interval for OR,,/OR,, does not include 1.0. Patterns of Tobacco Use 83 Surgeon General's Report Table 34. Relationship between smoking status and race/ethnicity among adults,* before and after controlling for education, National Health Interview Surveys, United States, 1987, 1988, 1990, and 1991 aggregate data Not controlling Controlling Effect of for education for education education? Smoking status Race/ethnicity OR,t cis OR, cI OR,/OR, CI Current’ African Americans 1.11 1.06, 1.16 0.96 0.91, 1.00 1.16 1.08, 1.24 Hispanics 0.74 0.70, 0.79 0.58 0.54, 0.62 1.29 1.18, 1.42 Asian Americans and Pacific Islanders 0.51 0.45, 0.58 0.54 0.47, 0.62 0.94 0.78,1.14 American Indians and Alaska Natives 1.46 1.16, 1.85 1.20 0.95, 1.51 1.22 0.88, 1.70 Whites 1.0 referent 1.0 referent 1.0 referent Former! African Americans 0.65 0.61, 0.70 0.74 0.69, 0.78 0.89 0.81, 0.97 Hispanics 0.97 0.90, 1.05 1.16 = 1.07, 1.26 0.84 0.75, 0.94 Asian Americans and PacificIslanders 0.95 0.80, 1.13 0.88 0.74, 1.05 1.08 0.85, 1.38 American Indians and Alaska Natives 0.66 0.47, 0.92 0.74 0.53, 1.02 0.89 0.56, 1.41 Whites 1.0 referent 1.0 referent 1.0 referent Heavy** African Americans 0.19 0.16,0.21 0.18 0.16, 0.20 1.04 0.87, 1.25 Hispanics 0.25 0.21, 0.30 0.23 0.20, 0.28 1.08 0.84, 1.38 Asian Americans and Pacific Islanders 0.17 0.11, 0.26 0.17 0.11, 0.27 0.97 0.52, 1.83 American Indians and Alaska Natives 0.74 0.58, 0.95 0.70 ~=—-0..55, 0.90 1.05 0.74, 1.49 Whites 1.0 referent 1.0 referent 1.0 referent Ever’t — African Americans 0.82 0.79, 0.86 0.76 0.72, 0.79 1.09 1.02, 1.16 Hispanics 0.63 0.60, 0.67 0.55 0.52, 0.58 1.15 1.06, 1.24 Asian Americans and Pacific Islanders 0.39 0.35, 0.43 0.40 0.36, 0.44 0.97 0.83, 1.13 American Indians and Alaska Natives 1.21. 1.05, 1.40 1.09 0.93, 1.27 1.11 = 0.90, 1.38 Whites 1.0 referent 1.0 referent 1.0 referent “Includes persons aged 25 years and older. +Education was evaluated at three levels: less than high school education, high school education, and at least some college. 4OR, = odds ratio not controlling for education; OR, = odds ratio controlling for education. Odds ratios were calculated as follows: OR jp/ORn = exp(Bio- Bi), Where Bo is the logistic regression coefficient for the ith ethnic group before controlling for education, and B;, is the coefficient after controlling for education. Other variables in the logistic models include age, gender, marital status, geographic region, and year of survey. 895% confidence interval. ‘Current cigarette smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. The association presented is for current smoking compared with former and never smoking. IFormer smokers are those who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking cigarettes. The association presented is for former smoking compared with current smoking. “Heavy smokers include current smokers who reported at the time of survey that they were smoking 25 or more cigarettes per day. The association presented is for heavy smoking compared with current smoking of 1-24 cigarettes per day. **Ever smokers are those who reported at the time of survey that they had smoked at least 100 cigarettes in their lives, regardless of their current smoking status. The association presented is for ever smoking compared with never smoking. Sources: National Center for Health Statistics, public use data tapes, 1987, 1988, 1990, and 1991; Escobedo et al. 1995. S84. Chapter 2 variables were created to represent persons with and without a high school education, with persons having at least some college education serving as the refer- ence group. In addition to including race/ethnicity and education, the logistic regression models included the year of the survey, age, gender, marital status, and geographic region. Education was first omitted from and then en- tered in these models. The difference in estimated co- efficients before and after the inclusion of education was computed for each of the four design variables representing the different racial/ethnic groups. The variance of this difference was estimated to be the sum of the variances of the two coefficients. The 95 per- cent confidence interval of the difference was com- puted by using this variance estimate. The difference in coefficients was translated into the ratio of the odds ratios before and after adjusting for education (Table 34) (Escobedo et al. 1995). Current Smoking Before adjustment for education, the data indi- cated that African Americans as well as American Indians and Alaska Natives were more likely than whites to be current smokers (Table 34). Hispanics as well as Asian Americans and Pacific Islanders were substantially less likely than whites to be current smok- ers. After adjustment for the confounding effects of education, the odds ratios for current smoking among African Americans and Hispanics decreased signifi- cantly (Table 34). Thus, when the data were adjusted for educa- tion, current smoking among African Americans did not differ from whites—an indication that the differences in the unadjusted rates were probably attributable to factors related to differences in educa- tional attainment. For Hispanics, current smoking was lower than for whites, and adjustment for the confounding effects of education further accentuated these differences. Smoking Cessation African Americans as well as American Indians and Alaska Natives who had ever smoked were sub- stantially less likely than whites to have quit smoking (Table 34). When education was included in these models, the odds ratio for smoking cessation increased, suggesting that lack of education accounts for some but not all of the low rates of quitting in these two groups. Before adjustment for education, the data showed that Hispanics were as likely as whites to quit Tobacco Use Among U.S. Racial/Ethnic Minority Groups smoking. However, after adjustment for education, the data showed that Hispanics were more likely than whites to quit smoking. Thus, the unadjusted smok- ing cessation rate was lower among both African Americans and Hispanics than among whites partially because of confounding by educational attainment. A similar magnitude of change was observed among American Indians and Alaska Natives, but this differ- ence was not statistically significant. Educational at- tainment does not explain why African Americans are less likely than whites to quit smoking. Heavy Smoking Members of all four racial/ethnic groups were less likely than whites to be heavy smokers, before and after the data were adjusted for the effects of educa- tion (Table 34). These differences were greatest between whites and Asian Americans and Pacific Is- landers and were smallest between whites and Ameri- can Indians and Alaska Natives. Because the odds ratio of heavy smoking changed little after adjustment for education, the differences in heavy smoking between racial/ethnic groups appear to be independent of factors associated with educational attainment. Ever Smoking Before the data were adjusted for the effects of education, all racial/ethnic groups except Ameri- can Indians and Alaska Natives were substantially less likely than whites to have ever smoked (Table 34). After adjustment for education, the odds ratios for ever smoking among African Americans and Hispanics de- clined even further, and these declines were statisti- cally significant. This finding suggests that if African Americans and Hispanics had socioeconomic status more comparable with that of whites, they would be even less likely ever to smoke than whites. Differences in current smoking, quitting, and ever smoking between whites and Asian Americans and Pacific Islanders also were found. Asian Americans and Pacific Islanders were less likely than whites to be current smokers, substantially less likely to be ever smokers, but also slightly less likely to have quit smok- ing. After adjustment for education, the odds ratios associated with these smoking behaviors changed little (Table 34). Thus, the lower smoking prevalences among Asian Americans and Pacific Islanders may be related to factors other than education—presumably cultural factors associated with being an Asian Ameri- can or a Pacific Islander in the United States. Patterns of Tobacco Use 85 Surgeon General's Report Occasional Smoking In addition to smoking more cigarettes each day, whites who currently smoke are generally more likely than members of other racial/ethnic groups to smoke ona daily basis. According to the 1993, 1994, and 1995 combined NHISs, 15.2 percent of whites who smoked were occasional (i.e., nondaily) smokers, compared with 26.0 percent of African Americans, 22.2 percent of American Indians and Alaska Natives, 33.1 percent of Asian Americans and Pacific Islanders, and 35.5 per- cent of Hispanics. Only the estimate for American In- dians and Alaska Natives did not differ significantly from that for whites (data not shown) (NCHS, public use data tapes, 1993, 1994, 1995). Husten and colleagues (1998) used data from the 1991 NHIS to study persons who had ever smoked 100 lifetime ciga- rettes but who had never smoked on a daily basis. Among the ever smokers, African Americans (12.0 percent), American Indians and Alaska Natives (15.0 percent), Asian Americans and Pacific Islanders (12.1 percent), and Hispanics (16.8 percent) were all signifi- cantly more likely than whites (6.2 percent) never to have smoked daily. In gender-specific multivariate analyses that controlled for income, age, and educa- tion, African Americans, Hispanics, and others (Ameri- can Indians and Alaska Natives combined with Asian Americans and Pacific Islanders) were significantly more likely never to have smoked daily. Exposure to Environmental Tobacco Smoke Data on exposure to environmental tobacco smoke (ETS) among members of U.S. racial/ethnic minority groups are extremely limited. In the 1991- 1993 NHIS, nearly one-third of all respondents indi- cated exposure to ETS at home three or more days per week (Table 35) (NCHS, public use data tapes, 1991- 1993). African Americans (37.6 percent) and Ameri- can Indians and Alaska Natives (36.9 percent) were more likely than other groups to report such levels of exposure to ETS at home. These findings are consis- tent with smoking prevalence data presented earlier in this chapter. Similar patterns exist among nonsmok- ers, although the occurrence of higher levels of expo- sure (three or more days) is reduced by 40 to 60 per- cent among nonsmokers compared with the total population. Among Asian American, Pacific Islander, American Indian, and Alaska Native nonsmokers, women had substantially more prolonged exposure than men. Using 1988-1991 NHANES II] data on persons aged 17 years and older who did not use tobacco, Pirkle and colleagues (1996) found that 36.9 percent of Afri- can Americans, 35.1 percent of Mexican Americans, and 37.4 percent of whites reported that they were exposed to ETS either at home or at work. Wagen- knecht and colleagues (1993) analyzed data collected in 1985 and 1986 from 3,300 persons aged 18-30 years who were recruited in four urban centers (Birming- ham, Chicago, Minneapolis, and Oakland). African Americans were more likely than whites to report home exposure to ETS and to report that they spent time mostly with smokers. Using 1988 NHIS data on 86 Chapter 2 the number of smokers in the home, Overpeck and Moss (1991) estimated that 42.4 percent of U.S. children aged five years and younger were living ina household with asmoker. In 1988, African American children were more likely to be living with a smoker (51.3 percent) than were white children (41.6 percent), and non-Hispanic chil- dren (43.2 percent) were more likely to be doing so than were Hispanic children (35.8 percent). In recent years, small-scale studies have reported on potential exposure to ETS among young people in US. racial/ethnic groups. For example, in two rural Alaska villages, an analysis of saliva samples from chil- dren in the Alaska Native Head Start program showed that 44 percent of the children (3-6 years of age) had cotinine concentrations indicative of exposure to ETS (Etzel et al. 1992). Recent research has compared levels of cotinine (a metabolite of nicotine) in biological flu- ids and hair of children, young adults, and adults (Pattishall et al. 1985; Wagenknecht et al. 1993; Crawford et al. 1994; Knight et al. 1996; Pirkle et al. 1996). Most of these investigations (Pattishall et al. 1985; Crawford et al. 1994; Knight et al. 1996; Pirkle et al. 1996) reported that African Americans who did not use tobacco had higher cotinine levels than whites, even after ETS exposure and other factors were taken into account. Further factors, including possible racial differences in nicotine absorption and metabolism (Pattishall et al. 1985; Benowitz et al. 1995; Clark et al. 1996; Knight et al. 1996) and measurement issues, need to be consid- ered (see Racial/Ethnic Differences in Nicotine Metabo- lites in Chapter 3 for further discussion of this topic). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 35. Percentage of all adults and nonsmokers who reported levels of exposure to environmental tobacco smoke in the home, by race/ethnicity and gender, National Health Interview Surveys, United States, 1991-1993 aggregate data African Asian Americans/ American Indians/ H Americans Pacific Islanders Alaska Natives Hispanics Whites ome exposure* % +cr % +ClI % +Cl % +Cl % +CI Total (%)t All adults 0-2 days Total 60.8 1.3 78.55 2.8 60.9 4.5 74.4 1.7 66.9 0.6 67.1 Men 57.3 2.0 76.7 3.7 67.3 6.4 72.6 2.3 66.1 0.7 66.1 Women 63.5 1.5 80.4 3.9 54.9 5.6 76.0 2.1 67.5 0.7 68.0 >3 days Total 37.6 0.7 20.5 2.9 36.9 4.4 24.5 1.6 31.9 0.6 31.7 Men 41.1 2.0 21.9 3.7 30.8 6.1 26.3 2.2 32.7 0.7 32.7 Women 34.8 1.5 190 0=—3.8 42.7 5.9 22.7 2.1 31.3 0.7 30.8 Nonsmokers 0-2 days Total 80.4 1.3 87.6 2.5 84.6 4.5 86.6 14 85.7 0.5 85.3 Men 80.1 2.1 92.0 2.8 90.0 4.9 87.2 2.0 85.2 0.7 85.1 Women 80.6 1.5 84.0 3.7 78.8 7.0 86.1 1.9 86.2 0.6 85.4 >3 days Total 18.3 1.2 11.7 2.5 13.5 4.3 12.6 1.4 13.5 0.5 13.9 Men 18.6 2.0 7.0 2.7 9.5 4.8 12.0 1.9 14.0 0.7 14.0 Women 15.1 1.5 15.5 3.6 17.8 6.4 13.0 2.0 13.1 0.6 13.8 *Home exposure was the average number of days per week that anyone was inside the home, as reported by respondents answering “ves” to the question, “Does anyone smoke cigarettes, cigars, or pipes anywhere inside this home?” However, these percentages include persons who indicated no exposure. Percentages exclude “don’t know” and “not ascertained” responses regarding the number of days; therefore, the sum may not total 100%. *95% confidence interval. ‘Total includes persons of other, unknown, or multiple ethnicities and unknown Hispanic origin. Source: National Center for Health Statistics, public use data tapes, 1991-1993. Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use Cigarette Smoking The most recent data from the 1994 and 1995 com- bined NHISs show that the age-adjusted prevalence of current cigarette smoking was highest among American Indians and Alaska Natives (36.0 percent), intermediate among African Americans (26.5 percent) and whites (26.4 percent), and lowest among Hispan- ics (18.0 percent) and Asian Americans and Pacific Is- landers (14.2 percent) (Table 36) (NCHS, public use data tapes, 1994-1995). Among all racial/ethnic groups except American Indians and Alaska Natives, men had significantly higher rates of cigarette smoking than women. Using data from the NCI Supplement of the 1992-1993 CPS, Shopland and colleagues (1996) re- ported patterns similar to those seen in the NHIS for African Americans, Asian Americans and Pacific Is- landers, Hispanics, and whites (data on American In- dians and Alaska Natives were not included in their report). From 1978 through 1995, the age-adjusted Patterns of Tobacco Use 87 Surgeon General’s Report prevalence of smoking declined for African Americans, Asian Americans and Pacific Islanders, and Hispanics overall and for both men and women (Figures 13-15) (NCHS, public use data tapes, 1978-1995). A differ- ent picture emerges for American Indians and Alaska Natives. Although a fairly substantial decline in prevalence was observed, particularly among men, for American Indians and Alaska Natives from 1978- 1980 to 1983-1985, prevalence did not change overall or for men from 1983-1985 to 1994-1995 or for women from 1978-1980 to 1994-1995. Table 36. Age-adjusted prevalence of current cigarette smoking” among adults, overall and by race/ ethnicity and gender, National Health Interview Surveys, United States, 1994 and 1995 aggregate data African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +crt % +ClI % +CI % +CI % +CI Total 26.5 1.7 36.0 6.0 14.2 2.7 18.0 1.5 264 0,7 Men 314 26 39.3 9.5 23.8 5.1 21.7 2.3 28.1 1.0 Women 22.2 1.8 32.9 8.0 5.4 2.1 14.6 1.8 25.0 0.9 *Current cigarette smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. Data were age-adjusted to the 1990 U.S. census population. *95% confidence interval. Source: National Center for Health Statistics, public use data tapes, 1994-1995. Figure 13. Trends in the age-adjusted prevalence of current cigarette smoking among African American, American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white adults, National Health Interview Surveys, United States, 1978-1995 aggregate data 70 60- African 50- Americans » American Bb 40 =:=:+ Indians and = Alaska Natives v Oo D 30 pewece Asian a. 2e a ee Americans oe etm mwenencccccce and Pacific 20- em emencceces Islanders 10- eceeces Hispanics —— Whites a a 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year Note: Data were age-adjusted to the 1990 U.S. census population. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 88 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Figure 14. Trends in the age-adjusted prevalence of current cigarette smoking among African American, Percentage American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white men, National Health Interview Surveys, United States, 1978-1995 aggregate data 70- P, 0 wey 6 ‘s African “e Americans 505 “Sy “e,, American os wee Indians and 404 teats See, a Alaska Natives Asian 30 Americans and Pacific Islanders 2074 evece Hispanics 10-4 — Whites QT TT TIT 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year Note: Data were age-adjusted to the 1990 U.S. census population. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Figure 15. Trends in the age-adjusted prevalence of current cigarette smoking among African American, Percentage American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white women, National Health Interview Surveys, United States, 1978-1995 aggregate data 70- 60-4 African == Americans 50-7 American =.a+s Indians and 40- wiere Alaska Natives oe eee eS Tee Asian 30 Americans and Pacific Pemecwencce Islanders 20 ww mwenerecccwcccncce OP Pe mecwnwccccccccccceoes eeece Hispanics 10- — Whites OO 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year Note: Data were age-adjusted to the 1990 U.S. census population. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patterns of Tobacco Use 8&9 Surgeon General's Report Table 37. Cigarette smoking status*t and number of cigarettes smoked per day? among adults, overall and by race/ethnicity and gender, National Health Interview Surveys, United States, 1987, 1988, 1990, and 1991 aggregate data African American Indians/ Asian Americans/ Characteristic Americans Alaska Natives Pacific Islanders Total Never smokers 54.6 41.1 70.6 Former smokers 15.4 21.9 13.4 Current smokers 30.1 37.1 16.0 Cigarettes smoked per day <15 cigarettes 59.6 39.7 58.1 15-24 cigarettes 32.4 40.4 35.3 225 cigarettes 8.0 19.9 6.5 Men Never smokers 44.6 36.1 56.8 Former smokers 19.6 26.0 19.6 Current smokers 35.9 38.0 23.6 Cigarettes smoked per day <15 cigarettes 54.1 27.5 56.1 15-24 cigarettes 36.3 49.7 37.8 225 cigarettes 9.6 22.8 6.1 Women Never smokers 62.6 46.0 85.3 Former smokers 12.0 17.9 6.9 Current smokers 25.4 36.2 7.8 Cigarettes smoked per day <15 cigarettes 65.8 52.3 64.6 15-24 cigarettes 27.9 30.9 27.6 225 cigarettes 6.3 16.8 7.9 Note: For racial/ethnic-specific data on cigars, pipes, chewing tobacco, snuff, or any form of tobacco, see Table 38. *Never smokers are those who reported that they had never smoked at least 100 cigarettes; former smokers are those who reported smoking at least 100 cigarettes in their lives but who reported at the time of survey that they did not currently smoke; and current smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. '95% confidence intervals for cigarette smoking status do not exceed 40.6% for whites, 1.4% for African Americans, +3.1% for Asian Americans and Pacific Islanders, +6.6% for American Indians and Alaska Natives, +0.5% for all non-Hispanics, 1.7% for all Hispanics, +2.3% for Mexican Americans, 5.2% for Puerto Ricans, +6.5% for Cuban Americans, +3.3% for other Hispanics, and £0.5% for the total population. Analyses of aggregated NHIS data from the 1987, 1988, 1990, and 1991 surveys indicate differing patterns in the prevalence of current smoking, never smoking, former smoking, and cigarette consumption among members of the four racial/ethnic groups (Table 37) (NCHS, public use data tapes, 1987, 1988, 1990, and 1991). The prevalence of current cigarette smoking was highest among American Indians and Alaska Natives (37.1 percent) and lowest among Asian Americans and 90 Chapter 2 Pacific Islanders (16.0 percent). The prevalence of never smoking cigarettes was highest among Asian Americans and Pacific Islanders (70.6 percent) and lowest among American Indians and Alaska Natives (41.1 percent). Rates of former cigarette smoking were highest among whites (26.0 percent) and lowest among, Asian Americans and Pacific Islanders (13.4 percent). Overall, men were more likely than women to be cur- rent or former smokers, whereas women were more Tobacco Use Among U.S. Racial/Ethnic Minority Groups Hispanics All Cuban Puerto Mexican Other Hispanics Americans Ricans Americans Hispanics Whites Total§ 60.3 61.9 58.7 61.0 59.3 46.7 49,2 17.2 17.5 16.3 16.8 18.4 26.0 23.8 22.5 20.7 25.0 22.2 22.4 27.3 27.0 61.4 43.3 52.2 68.4 57.9 26.8 33.4 30.0 40.1 36.7 25.7 44.8 32.0 42.3 8.6 16.6 11.1 5.9 10.1 28.3 24.3 49.8 49.6 52.4 48.9 50.6 38.9 40.7 21.6 24.1 19.4 22.) 20.8 32.1 29.6 28.6 26.3 28.3 29.0 28.6 29.1 29.6 58.8 38.5 52.1 65.9 52.4 21.7 29.1 30.9 39.9 31.7 27.2 35.7 42.9 41.2 10.3 21.6 16.2 6.9 11.9 35.4 29.7 69.5 71.1 63.3 2.7 66.5 53.9 56.8 13.4 12.5 14.0 17 16.3 20.4 18.6 17.0 16.4 22.7 15.5 17.2 21.7 24.6 65.2 49,2 52.3 72.8 65.9 32.1 38.1 28.8 40.4 41.1 23.2 26.6 46.9 43.5 6.0 10.5 6.6 4.0 17.5 21.1 18.4 195% confidence intervals for the number of cigarettes smoked daily do not exceed +0.8% for whites, +2.2% for African Americans, +9.7% for Asian Americans and Pacific Islanders, +10.4% for American Indians and Alaska Natives, +0.9% for all non-Hispanics, +3.4% for all Hispanics, +4.7% for Mexican Americans, +8.6% for Puerto Ricans, +12.4% for Cuban Americans, +6.8% for other Hispanics, and +0.8% for the total population. ‘Includes persons of other, unknown, or multiple ethnicities and of unknown Hispanic origin. Source: Centers for Disease Control and Prevention 1994c. likely than men never to have smoked. Among Afri- can Americans, Asian Americans and Pacific Island- ers, and all Hispanics except Cuban Americans, the majority of current smokers reported smoking fewer than 15 cigarettes per day, whereas whites, American Indians and Alaska Natives, and Cuban Americans were more likely than others to report smoking 25 or more cigarettes per day. For all groups except Puerto Ricans, women were much more likely than men to report smoking fewer than 15 cigarettes per day. Pipe and Cigar Use The prevalence of current pipe or cigar use has been higher among American Indians and Alaska Na- tives than among other racial/ethnic groups, accord- ing to aggregated data from the 1987 and 1991 NHISs (Table 38) (NCHS, public use data tapes, 1987 and 1991), Current pipe or cigar use occurred primarily among men; use was negligible among women of all racial/ethnic groups. The prevalence of cigar or pipe Patterns of Tobacco Use 91 Surgeon General's Report Table 38. Percentage of adults who reported using cigars, pipes, chewing tobacco, snuff, or any form of tobacco, overall and by race/ethnicity and gender, National Health Interview Surveys, United States, 1987 and 1991 aggregate data* African American Indians/ Asian Americans/ Characteristic Americans Alaska Natives Pacific Islanders Cigar smoking* Total 1.8 2.7 1.1 Men 3.9 5.3 2.2 Women 0.1 0.2 0.1 Pipe smoking? Total 11 3.5 1.2 Men 2.4 6.9 2.3 Women 0.0 0.0 0.0 Cigar or pipe smoking*? Total 2.5 4.9 1.7 Men 5.6 9.8 3.3 Women 0.1 0.2 0.1 Any tobacco smoking* Total 32.6 36.4 16.0 Men 40.2 37.3 24.0 Women 26.5 35.6 7.8 Use of chewing tobacco! Total 2.0 3.1 0.2 Men 2.7 5.3 0.4 Women 1.5 0.8 0.0 Use of snuff** Total 1.4 1.8 0.5 Men 0.9 3.2 0.9 Women 1.9 0.4 0.0 Use of chewing tobacco or snuffi** Total 3.0 4.5 0.6 Men 3.1 7.8 1.2 Women 2.9 1.2 0.0 Use of any tobacco product** Total 35.2 40.2 16.8 Men 42.4 43.9 25.6 Women 29.3 36.6 7.9 Note: For racial/ethnic-specific data on cigarette smoking, see Table 37. *95% confidence intervals do not exceed +0.7% for whites, +2.1% for African Americans, +4.0% for Asian Americans and Pacific Islanders, +9.6% for American Indians and Alaska Natives, +0.7% for all non- Hispanics, +2.2% for all Hispanics, +2.9% for Mexican Americans, +7.0% for Puerto Ricans, +8.0% for Cuban Americans, +3.9% for other Hispanics, and +0.7% for the total population. ‘Includes persons who reported they had smoked at least 50 cigars in their lives and who reported at the time of survey that they currently smoked a cigar. Includes persons who reported they had smoked a pipe at least 50 times in their lives and who reported at the time of survey that they currently smoked a pipe. SIndicates a value of >0 and <0.05. smoking among men was highest among American ceremonial and addictive daily pipe smoking, and this Indians and Alaska Natives (9.8 percent) and lowest factor may partially account for the high prevalence among Puerto Ricans (1.5 percent). Unfortunately, the of pipe smoking among American Indian and Alaska 1987 and 1991 NHISs did not distinguish between Native men. 92 Chapter 2 Tobacco Use Among ULS. Racial/Ethnic Minority Groups Hispanics All Cuban Puerto Mexican Other Hispanics Americans Ricans Americans Hispanics Whites Total 1.1 1.0 0.7 0.6 1.9 2.3 2.1 2.1 2.5 1.3 15 3.8 4.8 4.4 0.1 0.0 0.1 0.0 0.2 0.1 0.1 0.5 11 0.1 0.7 0.8 1.4 1.3 1.0 2.6 0.2 1.5 1.7 2.9 2.7 0.0 0.0 0.0 0.0 0.0 0.1 0.08 1.3 2.1 0.8 1.2 2.1 3.3 3.0 2.7 5.1 1.5 2.7 4.3 6.7 6.2 0.1 0.0 0.1 0 0.2 0.1 0.1 22.7 22.5 22.1 26.8 21.7 29.6 29.1 29.3 30.8 29.4 31.9 27.2 33.2 33.4 16.8 16.9 14.8 23.1 16.9 26.3 25.2 0.4 0.0 0.4 0.1 0.5 2.0 1.8 0.7 0.0 0.8 0.3 1.1 4.1 3.5 0.1 0.0 0.1 0.0 0.1 0.1 0.3 0.5 0.1 0.6 0.3 0.8 1.9 1.7 1.0 0.3 1.0 0.6 1.6 3.8 3.2 0.1 0.0 0.2 0.0 0.0 0.3 0.4 0.8 0.1 0.9 0.3 1.1 3.4 3.1 1.5 0.3 15 0.6 2.3 6.8 5.9 0.1 0.0 0.3 0.0 0.1 0.3 0.6 23.4 22.7 22.9 27.4 22.4 32.2 31.5 30.4 31.2 30.7 32.8 28.4 38.0 37.6 17.0 17.0 15.1 23.3 17.1 26.8 26.0 “Includes current users of cigarettes, cigars, or pipes. Includes persons who reported they had used chewing tobacco at least 20 times in their lives and who reported at the time of survey that they currently chewed tobacco. “Includes persons who reported they had used snuff at least 20 times in their lives and who reported at the time of survey that they currently used snuff. "Includes users of cigarettes, cigars, pipes, chewing tobacco, or snuff. Source: Centers for Disease Control and Prevention 1994c. A 1996 survey of U.S. students aged 14-19 years each racial/ethnic group, males were significantly found that white (28.9 percent) and Hispanic (26.2 per- more likely than females to have smoked at least one cent) students were slightly more likely than African cigar during the previous year. Use among females American students (19.3 percent) to report having ranged from 13.4 percent in African Americans to 20.0 smoked at least one cigar during the previous year. In percent among Hispanics. The prevalence of more Patterns of Tobacco Use 93 Surgeon General's Report frequent cigar use did not differ by race/ethnicity; 3.6 percent of African Americans, 2.5 percent of Hispanics, and 2.3 percent of whites reported that they had smoked at least 50 cigars during the previous year (CDC 1997b). Use of Smokeless Tobacco American Indians and Alaska Natives were the most likely (4.5 percent) to use chewing tobacco or snuff, according to aggregated data from the 1987 and 1991 NHISs, whereas Asian Americans and Pacific Island- ers (0.6 percent) as well as Hispanics (0.8 percent) were the least likely to use smokeless tobacco (Table 38). Conclusions Among all racial/ethnic groups except African Ameri- cans, men were much more likely than women to use chewing tobacco or snuff. Among African American women, the use of smokeless tobacco has been high- est among those aged 65 years and older (CDC 1994c). These findings are consistent with those in published studies (Bauman et al. 1989; Novotny et al. 1989; Rouse 1989), although they differ somewhat from the 1985 CPS estimates for males aged 16 years and older; these estimates showed rates of reported snuff use among African Americans (0.7 percent) and whites (2.2 per- cent) that were significantly lower than the NHIS- based rates reported here (Marcus et al. 1989). 1. In 1978-1995, the prevalence of cigarette smoking declined among African American, Asian Ameri- can and Pacific Islander, and Hispanic adults. However, among American Indians and Alaska Natives, current smoking prevalence did not change for men from 1983 to 1995 or for women from 1978 to 1995. 2. Tobacco use varies within and among racial/ ethnic groups; among adults, American Indians and Alaska Natives have the highest prevalence of tobacco use; African American and Southeast Asian men also have a high prevalence of smok- ing. Asian American and Hispanic women have the lowest prevalence. 3. Inall racial/ethnic groups discussed in this report except American Indians and Alaska Natives, men have a higher prevalence of cigarette smoking than women. 4. Inall racial/ethnic groups except African Ameri- cans, men are more likely than women to use smokeless tobacco. 5. Cigarette smoking prevalence increased in the 1990s among African American and Hispanic ado- lescents after several years of substantial decline among adolescents of all four racial/ethnic minor- ity groups. This increase is particularly striking among African American youths, who had the greatest decline of the four groups during the 1970s and 1980s. 6. Since 1978, the prevalence of cigarette smoking has remained strikingly high among American Indian 94. Chapter 2 and Alaska Native women of reproductive age and has not declined as it has among African Ameri- can, Asian American and Pacific Islander, and Hispanic women of reproductive age. 7. Declines in smoking prevalence were greater among African American, Hispanic, and white men who were high school graduates than they were among those with less formal education. Among women in these three groups, education- related declines in cigarette smoking were less pronounced. 8. Educational attainment accounts for only some of the differences in smoking behaviors (current smoking, heavy smoking, ever smoking, and smoking cessation) between whites and the racial / ethnic minority groups discussed in this report. Other biological, social, and cultural factors are likely to further account for these differences. 9. Compared with whites who smoke, smokers in each of the four racial/ethnic minority groups smoke fewer cigarettes each day. Among smok- ers, African Americans, Asian Americans and Pa- cific Islanders, and Hispanics are more likely than whites to smoke occasionally (less than daily). 10. The data in general suggest that acculturation in- fluences smoking patterns in that individuals tend to adopt the smoking behavior of the current broader community; however, the exact effects of acculturation on smoking behavior are difficult to quantify because of limitations on most available measures of this cultural learning process. Appendix 1. Sources of Data Tobacco Use Among U.S. Racial/Ethnic Minority Groups Most of the data reported in this chapter were collected through a number of large-scale surveys conducted by the federal government or private researchers. When data from one period were insuffi- cient (e.g., because of small sample size) for estimat- ing the prevalence of a risk factor or a behavior, they were combined with similar data for several periods, provided the prevalence under consideration had not changed rapidly over the periods being aggregated. This process, used in some of the NHIS and BRFSS analyses, increased the reliability and stability of preva- lence estimates (CDC 1992e). The data reported in this chapter are limited in several ways. For example, because some racial / ethnic groups were underrepresented in the data sources, the smal] number of responses may not be representative of the group as a whole. Moreover, most surveys have been conducted in English only, thus limiting the validity of the responses of individu- als with limited proficiency in English, particularly among Asian Americans, Pacific Islanders, and His- panics. In addition, some surveys have used tele- phone surveys (excluding persons who lack telephone service) or school surveys (excluding youths who dropped out of school or who were frequently absent from class); these surveys have thus excluded a num- ber of respondents who may be at increased risk for cigarette smoking. Despite these limitations, the pat- terns described in this chapter are the first and largest effort to present a comprehensive perspective on ciga- rette use among members of racial/ethnic minority groups in the United States. National Health Interview Survey (NHIS) Since 1965, the CDC’s NCHS has collected data on tobacco use through the NHIS, which uses a prob- ability sample of noninstitutionalized adult civilians in the United States (NCHS 1975, 1985a, 1989). Some NHISs have excluded adults 18 and 19 years of age; however, this report uses data from surveys that have included respondents who were aged 18 years and older (i.e., 1978, 1979, 1980, 1983, 1985, 1987, 1988, 1990, 1991, 1992, 1993, 1994, and 1995). Most interviews were conducted in the home; when respondents could not be interviewed in person, telephone interviews were conducted, The overall NHIS response rate for surveys on smoking has remained at least 85 percent (NCHS 1985a). Overall, sample sizes have ranged from 10,342 in 1980 to 86,332 in 1966. In this report, data have been adjusted for nonresponse and have been weighted to provide national estimates. Confidence intervals have been calculated by using standard er- rors generated by the Professional Software for Survey Data Analysis (GSUDAAN) (Shah et al. 1991). Responses from various administrations of the NHIS have been aggregated to produce more stable results for Hispanics, Asian Americans and Pacific Islanders, and American Indians and Alaska Natives. Hispanic Health and Nutrition Examination Survey (HHANES) The NCHS conducted the HHANES from 1982 through 1984 to assess the health and nutritional status and needs of Cuban Americans, Mexican Ameri- cans, and mainland Puerto Ricans. No other equiva- lent source of recent data is available for Hispanics. This survey sampled Mexican Americans from Ari- zona, California, Colorado, New Mexico, and Texas; Cuban Americans from Dade County, Florida (Miami); and Puerto Ricans from New York, New Jersey, and Connecticut. Demographic and cigarette smoking in- formation were collected from Hispanics aged 20-74 years. All interviews were conducted in the home or in a mobile examination center. NCHS estimates that the HHANES data represent approximately 76 percent of the 1980 Hispanic-origin population. All data in this report have been adjusted and weighted for the complex sample design, nonresponse bias, potential noncoverage bias, and regional nature of the sample (NCHS 1985b). Behavioral Risk Factor Surveillance System (BRFSS) The CDC’s National Center for Chronic Disease Prevention and Health Promotion coordinates the state surveillance of behavioral risk factors through the BRFSS, initiated in 1981 (Gentry et al. 1985; Remington et al. 1988). Each state that participates in the BRFSS provides estimates of numerous risk behaviors for the state’s population of persons aged 18 years and older. Patterns of Tebacco Use 95 Surgeon General's Report States collect data through random digit-dialed telephone interviews. BRFSS sample sizes have ranged from 476 in Indiana in 1984 to 3,988 in California in 1992. Since 1991, at least 1,178 persons have been sampled in each state. In this report, the data have been weighted to reflect the age, race/ethnicity, and gender distribution of each participating state. Ninety- five percent confidence intervals have been calculated by using the Standard Errors Program for Computing of Standardized Rates from Sample Survey Data (SESUDAAN) (Shah 1981). Adult Use of Tobacco Survey (AUTS) Since 1964, the AUTS has been conducted peri- odically to determine rates of tobacco use as well as descriptive information on smoking patterns among representative samples of the U.S. population. Infor- mation gathered has included a history of individual use of any tobacco product as well as attitudes and beliefs about smoking-related issues. The AUTS was conducted in 1964, 1966, 1970, and 1975 by the USDHEW's National Clearinghouse for Smoking and Health, and the most recent survey was conducted in 1986 by the CDC’s Office on Smoking and Health. In the 1986 AUTS, a computer-assisted telephone inter- view protocol (random-digit dialing) was used to sur- vey 13,031 noninstitutionalized civilian U.S. adults (>17 years of age). Population estimates were obtained by weighting the sample according to smoking status, age, race/ethnicity, gender, education, and geographic region (USDHHS 1990b). Monitoring the Future (MTF) Surveys Each spring since 1975, the University of Michigan’s Institute for Social Research, with grants from NIDA, has surveyed nationally representative samples of high school seniors as part of the MTF. Sample sizes have ranged from 15,850 to 18,448. The data in this report have been weighted to provide na- tional estimates. Analyses were conducted on data collected for 1976-1994. Data from subsequent years were obtained from published reports (e.g., Johnston et al. 1996) and from the University of Michigan’s In- stitute for Social Research. Since 1991, data have been collected for eighth- and tenth-grade students. Some data from these surveys are cited in this report (Johnston et al. 1993b, 1995a, 1996). 96 Chapter 2 Youth Risk Behavior Survey (YRBS) The CDC developed the Youth Risk Behavior Sur- veillance System to measure six categories of priority health-risk behaviors, including tobacco use, among adolescents. Data were collected through national, state, and local school-based surveys of high school stu- dents, conducted during the spring of odd-numbered years, and a national household-based survey of youths aged 12-21 years, conducted during 1992 (Kolbe 1990; Kolbe et al. 1993; CDC 1996). Data from the 1991 and 1995 national school-based surveys and the 1992 na- tional household survey are cited in this report (USDHHS 1994; CDC 1996; Lowry et al. 1996). The national school-based YRBSs each used a three-stage cluster sample design to draw a nationally representative sample of ninth- to twelfth-grade stu- dents in public and private schools in all 50 states and the District of Columbia. Schools having a substantial proportion of African American and Hispanic students were oversampled. The questionnaire was adminis- tered in the classroom by trained data collectors. The data were weighted to provide national estimates. The 1992 YRBS was a follow-back survey to the 1992 NHIS. The sample of young people aged 12-21 years was drawn from families who were interviewed for the 1992 NHIS. Participants responded in person. Respondents listened through a headset to an audio- cassette containing previously recorded questions. Respondents recorded their responses on answer sheets, which were returned to the interviewers in sealed envelopes. The data were weighted to provide national estimates. Teenage Attitudes and Practices Survey (TAPS) In 1989 and 1993, the U.S. Public Health Service conducted the TAPS to collect data on knowledge, at- titudes, and practices regarding tobacco use from a national household sample of adolescents (aged 12-18 years) through telephone interviews. The 1993 TAPS included a longitudinal component (TAPS-II) in which 7,960 (87.1 percent) of the 9,135 respondents to the 1989 TAPS were reinterviewed; these respondents were 15- 22 years of age during TAPS-II. TAPS-II also included 4,992 persons from a new probability sample. In this report, data on 9,135 TAPS respondents and 7,311 TAPS- II respondents have been analyzed. Data have been weighted to provide national estimates, and confidence intervals have been calculated by using the standard errors generated by the SUDAAN (Shah et al. 1991). Appendix 2. Measures of Tobacco Use Tobacco Use Among U.S. Racial/Ethnic Minority Groups Several measures of tobacco use among members of racial/ethnic groups can be derived from state and national surveys and other data sources. The most common measures include cigarette smoking and ces- sation; the number of cigarettes smoked daily; and the use of cigars, pipes, and smokeless tobacco. Cigarette Smoking and Cessation The NHIS gathers information ona range of ciga- rette smoking behaviors, using some of the following terms and measurements: e For 1978-1991, current smokers are defined as those who have smoked 100 or more cigarettes in their lifetime and who report at the time of survey that they currently smoke. For 1992-1995, current smokers are defined as those who have smoked at least 100 cigarettes in their lives and who report at the time of survey that they currently smoke ev- ery day or on some days. e Former smokers are those who have smoked 100 or more cigarettes in their lifetime and who do not currently smoke. ¢ Never smokers are those who have smoked fewer than 100 cigarettes in their lifetime. e Ever smokers consist of current smokers and former smokers. e The prevalence of cessation (or quit ratio) is defined as the percentage of ever smokers who are former smokers (Fiore et al. 1989; USDHHS 1989, 1990a). NHIS data on age at initiation of regular smok- ing and on duration of abstinence for former smokers have been used to reconstruct the prevalence of ciga- rette smoking for the decades in this century before systematic surveillance of cigarette smoking was conducted (NCI 1991). Information such as the respondent’s date of birth, age at initiation of smok- ing, and age at cessation for former smokers can be used to assess the smoking status of a respondent for any given year. Similar analyses have been reported in previous Surgeon General’s reports (USDHHS 1980, 1985) and in the literature (Harris 1983; Escobedo and Remington 1989; Pierce et al. 1991b). The BRFSS has routinely reported estimates of “regular” cigarette smoking. Current regular smok- ers are defined as those (1) who report that they have smoked >100 cigarettes and that they currently smoke and (2) who do not respond that they are occasional smokers when asked to report the average number of cigarettes they smoke daily. The use of a measure of current regular smoking generally results in median prevalence estimates that are about 0.7 to 1.0 percent- age points lower than those estimates that include current occasional smokers (CDC 1994c). The BRFSS defines and calculates the prevalence of smoking ces- sation in the same manner as is done in the NHIS. In the MTF surveys, current cigarette use patterns are defined as any use of cigarettes within the 30 days preceding the survey. This same definition was used for current alcohol, marijuana, cocaine, and any other illicit drug use. Number of Cigarettes Smoked Daily Cigarette consumption traditionally has been reported in three categories: (1) smoking fewer than 15 cigarettes per day, (2) smoking between 15 and 24 cigarettes per day, and (3) smoking 25 or more ciga- rettes per day. In the NHISs and the BRFSS surveys, respondents were asked to report the actual number of cigarettes smoked per day. In the 1978-1991 NHISs, cigarette consumption was defined as the average number of cigarettes that current smokers reported smoking each day. Starting in 1992, however, current smokers who reported that they smoked only on some days were asked to report the number of days out of the past 30 days that they smoked any cigarettes and the average number of ciga- rettes they smoked on the days that they smoked. The MTF survey asks respondents how fre- quently they have smoked during the previous 30 days. Possible responses are “not at all,” “less than one cigarette per day,” “one to five cigarettes per day,” “about one-half pack per day,” “about one pack per day,” “about one and one-half packs per day,” and “two packs or more per day.” Use of Cigars, Pipes, and Smokeless Tobacco The 1987 and 1991 NHI5s defined current cigar smokers as those who had smoked 50 or more cigars in their lifetime and who were current cigar smokers, and they defined current pipe smokers as those who had smoked 50 or more pipes full of tobacco and who Patterns of Tobacco Use = 97 Surgeon General's Report were current pipe smokers. Current snuff users were defined as those who had used snuff 20 or more times and were currently snuff users. The same logic was used to classify chewing tobacco users. In the BRFSS surveys, smokeless tobacco users were defined as those who said that they had ever used smokeless tobacco (such as chewing tobacco or snuff) and who were current users of any smokeless tobacco products. Appendix 3. Patterns of Cigarette Use Among Whites Table 39. Percentage of white adults who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic %e +cirt % +c] % +Cl % +Cl Total 42.1 0.6 42.4 0.5 37.0 0.7 36.4 0.8 Gender Men 51.1 0.8 51.8 0.8 43.2 0.8 41.9 1.0 Women 34.0 0.7 33.9 0.7 31.6 1.0 31.7 1.1 Age (years) 18-34 48.6 1.0 48.3 0.9 41.3 1.0 40.7 1.6 35-54 48.5 0.9 48.7 0.9 42.8 0.9 41.9 1.1 255 26.3 0.9 27.4 0.9 25.1 0.9 24.9 1.1 Education$ Less than high school NA A 41.3 0.9 37.1 1.0 36.9 1.3 High school 41.94 0.7 44.3 1.0 39.0 0.9 38.1 1.3 Some college NA NA 44.4 1.8 38.5 1.4 37.9 2.0 College 40.45 1.3 35.2 1.8 28.6 1.5 28.2 1.7 1985 1987 1988 Characteristic % +CTI % +ClI % +Cl % +ClI Total 29.9 0.7 29.0 0.7 28.2 0.6 25.9 0.6 Gender Men 31.8 1.0 30.6 0.9 30.3 0.9 27.8 0.9 Women 28.2 0.9 27.5 0.8 26.3 0.7 24.1 0.8 Age (years) 18-34 33.6 1.2 32.2 1.1 31.9 1.1 29.7 1.0 35-54 33.7 1.2 33.7 1.0 32.1 1.0 29.9 1.0 >55 21.5 1.0 20.2 0.9 19.7 0.8 16.8 0.8 Education$ Less than high school 33.7 1.6 34.8 1.6 33.7 1.3 32.0 1.5 High school 33.1 1.2 32.6 1.1 32.6 1.0 30.0 1.0 Some college 30.3 1.6 28.5 13 27.8 1.3 24.9 1.2 College 18.3 1.2 16.9 1.0 16.2 1.0 13.7 0.9 *Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data exclude those whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 98 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1976¢ 1977+ 1978 1979 1980 1983 % +CI % +C1 % +Cl % +Cl % +I % +CI 35.9 0.7 35.0 0.7 34.0 12 33.4 08 33.0 11 32.3 0.7 40.7. 1.1 39.0 1.0 373 19 36.6 1.0 36.5 1.6 346 1.1 31.9 1.0 318 1.1 31.1 13 30.6 1.0 298 15 30.2 09 40.0 1.2 38.9 15 37.0 18 37.3 1.3 35.2 1.8 36.0 1.2 41.2 14 41.11.11 40.5 2.0 38.4 13 38.8 2.0 374 13 25.0 1.1 25.1 1.1 23.6 17 23.6 0.9 24.3 1.6 25 1.1 36.6 1.5 35.7 13 35.6 2.2 35.1 15 35.5 2.0 35.3 1.6 376 14 378 14 37.0 19 35.3 1.3 34.9 2.0 34.8 1.3 376 21 37.0 18 34.1 3.4 35.7 1.8 33.9 3.1 328 1.9 27.2 17 25.9 17 23.8 2.6 23.2 1.6 244 23 20.1 1.5 1991 1992 1993 1994 1995 G% +CI % +CI % +CI % +CI % +I 26.0 0.6 27.2 «60.8 254 08 25.5 0.7 25.6 1.0 275 09 286 1.2 27.0 1.2 28.2 11 27.1 15 2746 07 25.9 1.1 24.0 1.0 23.1 09 241 13 298 1.0 32.8 15 30.1 1.4 29.3 14 297 18 30.0 1.0 30.1 1.3 29.3 1.4 28.9 12 28.3 1.6 173 08 175 12 15.8 11 16.2 11 17.8 13 33.3 1.5 32.0 2.0 31.8 2.6 31.9 18 33.3 2.6 30.6 0.9 31.9 1.4 291 #13 298 13 30.2 17 249 12 25.9 17 249 1,7 25.7 17 241 1.9 13.8 09 148 13 13.5 13 123 11 14.0 1.6 *The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for whites aged 18 years and older. Estimates for persons in the 18-34 year old age category were statisti- cally adjusted to produce estimates that approximate those for whites aged 18-34 years. *95% confidence interval. 5Includes persons aged 25 years and older. “Levels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Patterns ef Tobacco Use 99 Surgeon General's Report Table 40. Percentage of adult white smokers* who reported smoking <15, 15-24, and > 25 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic % +crt % +CI % +CI % +Cl Total <15 cigarettes 33.1 1.1 31.7 0.8 29.7 0.9 27.7 1.2 15-24 cigarettes 453 08 45.9 0.9 45.0 0.9 44.7 1.2 225 cigarettes 21.6 0.7 22.4 0.7 25.4 0.9 27.6 1.1 Gender Men <15 cigarettes 26.6 1.0 25.8 1.0 24.4 1.2 21.5 1.6 15-24 cigarettes 46.7 1.1 47.2 1.2 45.2 1.2 44.5 1.9 225 cigarettes 26.7 0.9 27.0 1.0 30.4 1.2 34.1 1.7 Women <15 cigarettes 418 13 39.5 1.2 35.9 1.1 34.5 1.7 15-24 cigarettes 434 13 44.3 1.3 44.7 1.1 45.0 1.6 225 cigarettes 148 09 16.2 1.0 19.4 0.9 20.5 1.2 Age (years) 18-34 <15 cigarettes 34.7 14 33.9 1.3 31.6 1.2 30.9 1.8 15-24 cigarettes 474 15 48.2 1.3 46.9 1.2 46.3 1.8 225 cigarettes 17.9 1 17.9 1.0 21.6 1.2 22.8 1.6 35-54 <15 cigarettes 29.0 1.1 26.7 1.1 24.7 11 21.4 1.6 15-24 cigarettes 45.1 1.2 45.5 1.3 44.2 1.2 42.9 1.8 225 cigarettes 28.0 1.2 27.8 11 31.1 1.1 35.7 1.7 255 <15 cigarettes 40.1 1.9 38.8 1.9 36.3 1.6 32.7 2.4 15-24 cigarettes 415 1.9 42.2 1.9 42.7 14 44.7 2.4 225 cigarettes 18.4 15 18.8 1.5 21.1 1.5 22.7 2.3 Education$§ Less than high school <15 cigarettes NA NA 30.7 1.3 28.6 1.5 25.7 2.0 15-24 cigarettes NA NA 45.8 1.3 44.3 1.2 45.1 2.1 225 cigarettes NA NA 23.5 1.2 27.0 14 29.2 1.8 High school <15 cigarettes 31.15 1.0 28.5 1.4 26.2 1.4 25.7 2.0 15-24 cigarettes 45.9% 1.1 46.9 1.7 47.3 14 44.7 2.3 225 cigarettes 23.0° 0.9 24.6 1.4 26.5 1.3 29.6 1.9 Some college <15 cigarettes NA NA 29,4 2.7 27.1 24 23.1 3.1 15-24 cigarettes NA NA 44.6 3.0 43.1 2.8 42.7 3.3 225 cigarettes NA NA 26.0 2.6 29.8 2.2 34,2 2.6 College <15 cigarettes 33.2% 2.0 35.0 3.] 31.7 2.1 27.9 3.9 15-24 cigarettes 423° 2.2 39.2 3.2 40.2 2.8 43.0 3.8 >25 cigarettes 24.5° 2.0 25.9 2.8 28.1 3.1 29.1 3.4 *Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data exclude those whites who indicated they were of Hispanic origin. For 1965-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. 100° Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1976" 1977" 1978 1979 1980 1983 % +Cl % +Cl % +l % +Cl % +Cl % +l 278 12 26.9 12 23.7 15 244 10 23.2 16 23.8 1.2 45.2 13 43.6 14 447 17 44.7 13 446 19 46.8 14 27.0 12 275 1.4 316 16 30.9 12 32.2 19 294 13 220 1.6 205 13 178 19 20.0 12 17.7 2.2 178 15 45.2 1.6 416 17 43.6 2.5 43.1 17 44.3 27 45.1 2.0 328 17 335 18 38.6 2.3 36.9 «17 38.0 2.7 37.1 1.6 34.0 17 33.7 1.6 30.1 24 29.2 16 29.3 2.1 30.1 17 45.1 1.8 458 19 458 23 465 19 448 26 484 19 210 15 210 16 24.1 2.3 244 15 25.9 23 215 16 30.0 «1.8 29.9 17 25.2 9 2.2 265 17 25.2 27 275 1.9 47.3 1.9 459 19 478 2.6 474 18 48.0 29 49.9 2.0 226 1.9 21.9 9 24 270 2.7 26.1 15 26.9 2.6 22.7 17 22.7 17 21.2 18 190 23 19.2 15 176 2.6 18.0 17 43.3 2.0 42.6 2.0 415 27 418 2.2 40.5 2.9 42.6 2.2 340 «18 36.3 2.0 395 2.4 39.0 2.2 419 3.4 394 2.2 32.0 9 2.5 31.6 26 28.9 3.6 28.8 2.6 28.7 3.2 26.0 25 43.8 2.7 42.9 2.9 43.9 41 441 3.0 44.7 3.7 47.3 2.9 24.2 2.3 25.6 25 27.2 37 27.2 2.5 26.6 3.3 26.7 25 26.7 19 26.2 92.1 23.3 29 23.1 2.0 21.2 3.0 204 2.2 445 2.2 43.3 27 441 = 3.3 440 26 44.9 3.7 454 2.9 28.8 2.2 305 2.3 32.7 2.4 32.9 22 33.9 3.6 34.30 2.7 24.2 18 22.7 17 224 2.5 205 17 21.0 27 21.3 18 46.3 2.3 45.6 2.1 43.8 27 46.0 2.3 446 3.5 46.0 23 29.5 2.2 31.7 24 33.8 2.9 33.5 2.1 344 3.4 32.7 2.2 26.2 3.6 278 = 3.2 18.9 3.2 22.0 3.0 18.0 42 212 29 418 3.4 414 3.6 44.2 57 42.1 3.2 45.9 5.5 46.3 3.6 32.0 3.4 30.8 3.1 37.0 5.5 35.9 3.0 36.0 47 325 34 30.4 3.7 304 9 3.1 25.8 5.2 296 = 3.7 27.7 5.0 284 38 41.2 44 40.2 38 41.1 5.9 37.2 3.9 35.2 5.4 40.9 4.2 284 = 3.3 294 3.7 33.2 47 33.2 3.6 37.1 57 30.7 4.2 *The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for whites aged 18 years and older. Estimates for persons in the 18-34 year old age category were statisti- cally adjusted to produce estimates that approximate those for whites aged 18-34 years. 95% confidence interval. “Includes persons aged 25 years and older. ‘Levels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. Patterns of Tobacco Use 101 Surgeon General's Report Table 40. Continued 1985 1987 1988 1990 Characteristic % +c %o +CI % +CI % +CI Total <15 cigarettes 26.1 1.1 25.4 1.0 24.7 1.0 27.9 1.1 15-24 cigarettes 43.6 1.3 43.7 1.1 45.7 1.1 45.2 1.2 225 cigarettes 30.3. 1.2 30.9 1.1 29.6 1.0 26.9 1.2 Gender Men <15 cigarettes 20.1 1.6 20.6 14 20.4 1.3 21.7 14 15-24 cigarettes 426 1.9 40.6 1.6 43.9 1.6 43.9 1.8 225 cigarettes 37.3 18 38.8 1.6 35.7 1.6 34.5 1.9 Women <15 cigarettes 32.1 1.6 30.3 1.5 29.3 1.5 34.5 1.6 15-24 cigarettes 44.7 17 46.9 1.6 47.5 1.6 46.6 1.6 225 cigarettes 23.2 14 22.8 1.4 23.3 1.2 19.0 1.4 Age (years) 18-34 <15 cigarettes 31.1 19 29.8 1.7 29.3 1.7 34.9 1.9 15-24 cigarettes 45.2 2.0 45.6 1.8 47.7 1.8 47.3 1.9 225 cigarettes 23.8 1.7 24.6 1.5 22.9 1.5 17.8 1.6 35-54 <15 cigarettes 19.0 1.7 20.1 1.6 18.1 1.5 20.4 1.6 15-24 cigarettes 41.1 21 41.3 1.8 43.7 1.8 43.4 2.0 225 cigarettes 39.9 2.1 38.6 1.5 38.3 1.8 36.2 2.0 255 <15 cigarettes 27.7 24 26.3 1.6 27.7 2.0 29.1 2.5 15-24 cigarettes 44.7 26 44.6 1.8 45.0 2.2 44.5 2.5 225 cigarettes 276 23 29.2 1.9 27.2 2.1 26.4 2.3 Education$ Less than high school <15 cigarettes 19.5 9 2.2 19.9 2.1 19.1 1.8 19.5 2.2 15-24 cigarettes 443 27 44.2 2.4 44.5 2.4 48.6 2.9 225 cigarettes 36.2 2.7 35.8 2.4 36.5 2.4 31.9 2.7 High school <15 cigarettes 23.1 1.8 22.8 1.5 0.5 1.4 24.5 1.7 15-24 cigarettes 445 21 43.4 1.8 47,7 1.8 45.8 1.9 225 cigarettes 32.4 19 33.8 1.8 31.8 1.6 29.6 1.8 Some college <15 cigarettes 263 2.8 24.9 2.3 25.6 2.3 27.8 2.6 15-24 cigarettes 42.0 3.1 43.0 2.8 43.2 2.7 43.5 3.1 225 cigarettes 317 9 2.9 32.2 2.7 32.2 2.4 28.7 2.8 College <15 cigarettes 30.5 3.4 31.0 3.1 32.4 2.9 35.1 3.3 15-24 cigarettes 37,9 3,7 39.9 3.4 39.5 3.2 39.6 3.4 225 cigarettes 31.6 3.6 29.2 3.0 28.1 2.9 25.3 3.3 495% confidence interval. SIncludes persons aged 25 years and older. 102. Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1991 1992 1993 1994 1995 % +CI % +C! % +CI % +CI 7) +CI 29.8 1.2 31.7 1.5 32.5 1.7 35.6 1.8 35.0 2.0 45.0 1.3 43.3 1.6 44.9 1.7 44.4 1.9 41.8 2.1 25.2 1.2 25.0 1.4 22.6 1.4 20.0 1.4 23.2 1.8 24.6 1.6 25.8 1.9 27.5 2.4 30.5 2.5 28.0 2.6 43.4 1.7 41.8 2.4 43.0 2.5 44.3 2.7 41.6 3.0 31.9 1.8 32.4 2.2 29.5 2.3 25.1 2.2 30.4 2.8 35.0 1.6 37.7 2.3 37.6 2.3 40.8 2.5 42.3 2.8 46.6 17 44.9 2.2 46.8 2.4 44.5 2.4 41.9 2.8 18.4 1.3 17.4 1.6 15.6 1.8 14.6 Lg 15.8 2.0 36.5 2.0 37.4 2.6 39.5 3.0 42.5 3.0 44.3 3.4 46.1 2.1 43.9 2.5 45.6 2.8 45.4 3.1 41.] 3.4 17.5 1.7 18.6 2.2 15.0 2.0 12.1 1.7 14.6 2.9 23.9 1.6 26.8 2.3 27.6 2.6 29.6 2.6 31.0 3.0 43.4 1.9 42.3 2.8 44.1 2.5 42.9 2.6 41.6 3.0 32.7 1.9 30.9 2.4 28.3 2.4 27.6 2.5 27.4 2.6 29.1 2.1 29.9 3.2 30.0 3.4 34.6 3.6 27.0 3.4 46.2 2.4 44.2 3.6 45.2 4.] 45.9 4.1 43.2 4,2 24.7 2.2 25.9 2.9 24.8 3.1 19.5 3.2 29.8 4.2 21.4 2.2 24.6 3.2 25,3 3.5 25.6 3.5 19.9 3.7 43.8 2.6 41.5 3.7 45.9 4.0 44.5 4.5 45.4 4.8 34.8 2.7 33.9 3.7 28.8 3.7 29.9 4.1 34.7 4.6 25,7 1.6 26.7 23 28.2 2.5 30.5 2.7 29.2 2.8 47.7 1.9 46.3 2.8 46.2 2.7 46.8 2.9 45.0 3.1 26.6 1.9 27.0 2.4 25.6 2.4 22.7 2.3 25.8 3.0 33.0 2.7 33.7 3.7 34.0 3.7 36.8 4.4 40.2 4.6 43.6 2.9 42.0 3.6 44.3 4.3 44.0 4.0 39.2 4.6 23.4 2.4 24.3 3.5 21.8 3.4 19.2 3.3 20.6 3.8 35.3 3.4 43.2 4.5 42.] 5.4 48.7 5.4 50.6 5.6 42.9 3.4 37.6 4.6 37.7 5.0 36.9 5.3 34.0 5.5 21.8 2.9 19.2 4.1 20.2 3.8 14.4 3.7 15.4 3.8 Patterns of Tobacco Use 103 Surgeon General’s Report Table 41. Percentage of adult white ever smokers who have quit,” overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic % +cr % +l % +c % +l Total 25.2 0.6 25.3 0.6 34.3 0.8 36.1 0.9 Gender Men 28.9 0.8 28.9 0.8 39.0 1.0 41.0 11 Women 19.6 0.9 19.6 0.9 27.8 0.9 29.6 1.4 Age (years) 18-34 17.6 0.9 16.9 0.9 25.9 1.1 26.2 1.7 35-54 24.5 1.0 25.0 0.9 33.5 1.1 35.2 1.2 255 38.3 1.6 38.2 1.5 47.5 1.3 51.0 1.8 Education Less than high school NA NA 26.4 1.0 34.6 1.2 36.2 1.6 High school 25.4" 0.8 25.1 1.2 34.5 1.0 36.3 15 Some college NA NA 28.4 2.2 37.1 1.6 39.5 2.5 College 33.2" 1.6 38.5 2.3 49.7 2.3 50.6 2.4 1985 1987 1988 1990 Characteristic % +Cl Te +Cl %e +Cl % +Cl Total 46.6 1.0 46.2 0.9 47.7 0.9 50.9 1.0 Gender Men 51.0 13 50.5 1.2 51.1 1.2 54.2 1.3 Women 41.0 1.3 40.9 1.3 43.5 1.1 47.0 1.2 Age (years) 18-34 32.4 1.5 31.4 1.4 32.3 1.5 35,1 1.6 35-54 46.2 1.6 44.6 1.5 45.9 1.4 48.6 15 255 62.2 1.6 63.1 1.5 65.0 1.3 68.9 1.3 Education$ Less than high school 46.5 2.1 44,3 1.9 45.7 1.7 47.8 2.0 High school 44.5 1.6 44.8 1.4 45.0 14 48.2 1.5 Some college 48.7 2.3 48.9 19 50.7 1.9 54.0 1.9 College 63.7 2.2 63.0 2.1 64.6 1.8 68.7 1.9 *Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data exclude those whites who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever smokers include current and former smokers. *The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for whites aged 18 years and older. Estimates for persons in the 18-34 year old age category were statisti- cally adjusted to produce estimates that approximate those for whites aged 18-34 years. 104 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1976" 1977" 1978 1979 1980 1983 % +l % +l % +tCl % +l % +l % +l 36.5 1.0 36.3. 1.0 39.5 17 40.5 1.2 40.8 1.7 42.0 1.0 41.3 13 414 11 44.7 21 45.3 13 45.2 2.1 46.6 14 30.4 15 30.0 15 32.8 2.0 34.3 17 35.0 2.4 36.2 14 253 13 268 18 29.1 2.3 29.4 15 30.5 2.3 29.1 15 36.5 17 35.2 15 36.7 2.6 39.7 18 39.8 2.6 40.3 17 516 19 50.7. 1.9 56.0 2.7 55.5 1.6 54.5 2.9 59.0 18 37.1 1.9 368 17 39.1 2.7 41.2 19 39.7 3.0 41.5 21 36.6 17 36.1 19 39.0 2.3 40.2 18 40.7 2.7 419 17 39.7 2.8 39.4 2.2 44.9 3.9 41.7 24 43.5 4.3 446 2.6 494 27 50.2 28 545 3.9 55.6 2.7 54.2 3.9 579 27 1991 1992 1993 1994 1995 % +CI % +tCl % +l % +l % +l 50.5 0.9 48.5 13 51.6 1.3 51.0 1.3 50.5 16 54.2 1.2 52.0 17 546 17 53.7 17 52.9 2.2 46.2 13 444 18 48.1 1.7 478 19 47.6 21 319 15 274 = 2.0 314 2.0 29.0 2.2 315 2.6 48.7 14 48.0 1.9 48.6 2.0 49.3 19 48.6 24 68.8 13 68.1 2.0 718 18 721 1.8 68.0 2.2 46.0 2.0 49.1 2.7 49.2 3.4 47.1 28 46.5 3.3 48.0 14 45.6 2.0 49.8 19 48.5 2.1 47.2 24 54.9 1.9 53.6 2.7 55.1 2.6 54.7 2.8 55.7 3.0 678 18 64.2 2.6 68.1 2.6 70.8 2.6 66.1 3.4 495% confidence interval. ‘Includes persons aged 25 years and older. ALevels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Patterns of Tobacco Use 105 Surgeon General's Report Table 42. Percentage of white women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 1976. Characteristic % +CI % +Cl % +Cl % +Cl % 3¢C1 Total 42.2 1.1 41.5 11 36.8 12 373 #17 364 1:5 Education Less than high school NA NA 48.0 2.2 467 20 505 31 494 44 High school 442 14 413 18 366 18 382 25 380 25 Some college NA NA 438 38 375 32 352 43 348 44 College 413 29 346 44 272 26 255 33 250 3.4 1977" 1978 1979 1980 1983 Te +ClI % +CI % +CI % +Cl % +CI Total 36.8 1.5 35.6 2.1 36.0 1.4 33.2 1.9 35.5 1.3 Education$§ Less than high school 476 39 561 59 520 39 539 70 536 46 High school 373 25 384 32 373 24 334 36 394 24 Some college 35.3 3.6 31.8 5.8 36.3 4.3 32.2 5.3 30.8 3.2 College 247 36 201 43 #219 #27 228 44 178 25 1985 1987 1988 1990 1991 % +CI % +CI % +Cl % +ClI % +ClI Total 32.5 13 311 #4411 30.39 10 279 141 28.7 1.1 Education$§ Less than high school 91 44 606 37 579 39 584 43 596 38 High school 37.1 2.1 36.5 18 35.7 18 344 18 365 20 Some college 28.8 2.7 292 22 292 23 245 21 25.1 2.0 College 1449 22 151 #17 £4142 16 £109 15 11.8 «1.5 1992 1993 1994 1995 % +Cl % +CI % +CI % +Cl Total 30.7 16 291 14 306 416 282 18 Education$§ Less than high school 555 60 60.1 62 561 72 31.7 78 High school 383 28 386 27 40.2 29 370 34 Some college 283 2.9 234 28 272 3.2 260 36 College 1443 2.2 1.5 2.0 116 #23 153 29 “Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data exclude those whites who indicated they were of Hispanic origin. For 1965-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. ‘The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates that approximate those for white women aged 18-44 years. *95% confidence interval. ‘Includes persons aged 25 years and older. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. 106 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 43. Percentage of white adults who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 ageregate data 1978-1980* 1983-1985' 1987-1988 1990-1991t 1992-1993 1994-1995t Characteristic % +CH % +CI % +C1 % +C1 % +C1 % +CI Total 33.5 07 309 06 286 05 259 05 264 06 259 O07 Gender Men 36.8 1.0 329 08 305 O07 276 07 278 O08 276 0.9 Women 305 08 290 07 269 06 244 06 250 08 244 08 Age (years) 18-34 36.7 1.1 346 09 320 08 298 08 316 1.1 31.3 1.2 35-54 39.0 1.0 35.1 10 329 07 300 07 29.7 10 287 11 >55 23.7 O08 21.9 07 199 07 171 06 167 O08 168 09 Education$ Less than high school 35.3 12 344 13 £342 11 #42326 11 #49319 16 338 417 High school 35.6 1.1 33.8 09 326 08 303 07 306 10 303 11 Some college 348 13 31.2 13 282 10 249 09 254 12 247 1:3 College 236 1.2 #1990 10 165 O07 138 07 4142 09 13.3 1. “These data exclude whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently Smoked every day or on some days. +1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 195% confidence interval. ‘Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patterns of Tobacco Use 107 Surgeon General's Report Table 44. Percentage of adult white smokers” who reported smoking <15, 15-24, or >25 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988t 1990-1991' 1992-1993' 1994-1995' Characteristic % +cH % +I % +Cl % +ClI % +C] % +CI Total <15 cigarettes 24.0 0.7 25.1 0.8 25.0 0.7 28.9 0.8 32.1 1.1 35.3 1.3 15-24 cigarettes 44.7 0.9 449 0.9 447 08 45.1 0.9 44.0 1.2 43.1 14 >25 cigarettes 31.4 0.9 30.0 0.9 30.3 0.8 26.1 0.9 23.9 1.1 21.6 1.1 Gender Men <15 cigarettes 18.9 0.9 19.1 1.2 20.5 1.0 23.2 1.1 26.6 1.6 29.3 18 15-24 cigarettes 43.5 13 43.7 13 42.3 1.1 43.6 13 42.3 18 43.0 2.0 >25 cigarettes 37.6 1.3 37.2 14 37.3 1.2 33.2 1.3 31.1 1.6 27.7 18 Women <15 cigarettes 29.4 1.1 31.3 1.2 29.8 1.0 34.7, 1.2 37.7 1.6 41.6 1.9 15-24 cigarettes 459 13 46.2 1.3 47.2 1.1 46.6 1.2 45.7 1.6 43.2 1.8 >25 cigarettes 24.7 1.1 22.55 1.1 23.0 0.9 18.7 1.0 16.6 1.2 15.2 1.4 Age (years) 18-34 <15 cigarettes 25.9 13 296 13 29.6 1.2 35.7 1.4 38.3 2.0 43.3 2.2 15-24 cigarettes 476 1.2 47.1 14 46.7 13 46.7 1.5 446 1.9 43.4 2.3 >25 cigarettes 26.5 13 23.3 1.2 23.8 1.1 17.6 1.2 17.1 15 13.3 1.6 35-54 <15 cigarettes 18.8 1.0 18.6 1.4 19.1. 1.1 22.2 1.1 27.2 1.7 30.3 2.0 15-24 cigarettes 41.4 1.6 41.7 1.7 42.55 13 43.4 15 43.1 18 42.2 2.0 >25 cigarettes 39.8 1.5 39.7. 1.7 38.4. 1.3 34.4 1.5 29.7 1.6 275 1.8 >55 <15 cigarettes 28.8 1.7 27.0 1.7 27.0 1.4 29.1 1.6 299 2.5 30.5 2.5 15-24 cigarettes 44.2 2.0 458 1.8 44.8 1.6 45.4 1.7 44.7 2.7 44.4 29 >25 cigarettes 27.1 1.7 27.2 1.7 28.2 1.5 25.5 1.6 25.4 2.2 25.0 2.7 *These data exclude those whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 108 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 44. Continued 1978-1980' 1983-1985' 1987-1988 1990-1991t 1992-1993 1994-1995t Characteristic " % +C % 4Cl % 4Cl % 4Cl % 4Cl = % FCI Education$§ Less than high school <15 cigarettes 227 14 199 16 195 14 205 16 249 23 228 26 15-24 cigarettes 44.2 19 44.8 2.0 44.3 1.7 46.1 1.9 43.5 28 45.0 3.3 >25 cigarettes 33.1 1.6 35.4 1.9 36.1 1.7 33.4 1.9 31.6 2.7 32.2 3.1 High school <15 cigarettes 21.1 1.2 224 13 216 1.0 25.1 12 274 16 299 20 15-24 cigarettes 451 19 451 15 456 13 468 14 462 19 459 21 >25 cigarettes 33.8 1.7 32.5 1.5 32.8 1.2 28.1 1.4 26.4 1.7 24.2 1.9 Some college <15 cigarettes 20.4 1.9 24.3 2.3 25.3 1.6 30.5 1.9 33.8 2.7 38.5 3.2 15-24 cigarettes 43.5 21 43.7 25 431 20 435 22 431 28 417 31 >25 cigarettes 36.2 24 320 24 317 17 260 18 231 23 £199 25 College <15 cigarettes 28.2 28 29.6 27 31.7 23 35.2 24 427 34 49.7 39 15-24 cigarettes 376 29 392 2.7 397 23 413 23 376 33 353 38 >25 cigarettes 34.2) 2.5 31.2 2.6 28.6 2.1 23.5 2.2 19.6 2.7 15.0 2.6 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. “Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patterns of Tobacco Use 109 Surgeon General’s Report Table 45. Percentage of adult white ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985 1987-1988' 1990-1991" 1992-1993 1994-1995" Characteristic % +clt % +C1 % +ClI % +Cl % +tCl % +Cl Total 40.3 1.1 44.7 0.8 46.9 0.7 50.7 0.7 50.0 0.9 50.7. 1.0 Gender Men 45.1 1.2 493 1.0 50.8 0.9 54.2 0.9 53.2 1.2 53.3 1.4 Women 34.1 14 39.1 1.0 42.2 0.9 46.6 09 46.1 13 47.7 14 Age (years) 18-34 29.6 1.3 31.1 1.1 31.8 1.1 33.5 1.1 29.2 15 30.2 1.7 35-54 39.0 1.3 43.9 13 453 1.1 48.6 1.1 48.3 13 49.0 1.5 >55 554 14 60.9 1.2 64.1 1.0 68.9 0.9 699 13 70.1 1.4 Education’ Less than high school 40.3 1.4 445 1.8 45.0 14 46.9 1.5 49.1 2.1 46.8 2.2 High school 40.0 1.5 43.5 1.1 449 1.1 48.1 1.0 47.6 1.5 47.9 1.6 Some college 429 1.8 47.1 18 498 1.4 54.5 1.3 543 18 55.2 2.0 College 55.0 2.2 61.6 1.7 63.8 1.4 68.2 1.4 66.1 1.9 68.4 2.2 ‘These data exclude those whites who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not current smokers, and ever smokers include current and former smokers. 11978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 195% confidence interval. ‘Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 110 = Chapter 2 Tobacco Use Among ULS. Racial/Ethnic Minority Groups Table 46. Percentage of white women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988' 1990-1991' 1992-1993" 1994-1995" Characteristic % +CcH % +CI G% +CI % +ClI % +Cl % +CI Total 35.3 1.2 33.7 1.0 30.7 0.8 28.3 0.8 30.0 1.2 29.4 1.2 Education Less than high school 53.4 3.0 545 3.4 59.2 2.7 59.0 3.0 57.5 4.2 53.9 5.2 High school 36.6 1.8 38.0 1.7 36.1 1.4 35.5 1.3 38.5 2.1 38.6 2.3 Some college 34.2 2.8 29.6 2.1 29.2 1.7 24.8 1.5 26.0 2.1 26.6 2.4 College 21.7 1.9 16.0 1.6 14.6 1.2 11.4 1.0 13.0 14 13.5 1.8 *These data exclude whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. +1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patterns of Tobacco Use 111 Surgeon General's Report Appendix 4. Patterns of Cigarette Use Among Among African Americans Table 47. Percentage of adult African Americans who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic % +clt % +Cl % +CI % +Cl Total 45.8 1.5 45.9 1.7 41.4 1.8 44.0 2.2 Gender Men 60.4 2.8 60.1 2.5 52.9 2.0 54.4 3.9 Women 33.7 2.3 34.2 2.3 32.2 2.5 36.4 2.6 Age (years) 18-34 53.2 2.8 52.4 29 46.0 2.8 46.2 3.5 35-54 50.3 3.0 52.6 2.9 47.0 2.2 53.3 3.8 255 27.0 3.2 24.8 3.1 25.1 2.3 28.0 3.8 Education Less than high school 44.6 2.4 41.0 21 43.3 3.2 High school 4464 2.0 51.9 4.6 45.4 3.8 49.1 43 Some college 52.9 7.8 43.0 6.0 37.3 8.6 College 47.55 5.8 39.6 8.5 34.2 6.4 44.9 9.1 1985 1987 1988 1990 Characteristic % +cr % +CI % +Cl % +Cl Total 35.0 1.8 32.9 1.6 31.7 1.6 26.2 15 Gender Men 39.9 3.0 38.7 2.8 36.6 2.5 32.6 2.4 Women 31.2 2.2 28.2 1.8 27.8 1.9 21.2 1.6 Age (years) 18-34 34.0 2.8 32.6 2.4 31.5 2.4 25.0 2.2 35-54 42.3 3.4 38.6 2.8 36.0 2.6 32.6 2.7 255 27.7 3.0 25.9 2.9 26.4 2.7 19.2 2.4 Education’ Less than high school 39.6 3.0 37.7 2.9 35.0 2.5 30.6 2.8 High school 39.1 3.4 38.7 2.9 38.8 2.9 31.9 2.5 Some college 35.0 4.9 34.2 4.0 31.9 3.7 25.7 3.8 College 28.4 6.1 18.3 3.9 20.9 4.6 17.5 3.8 “Data collected before 1978 do not distinguish between blacks of Hispanic origin and non-Hispanic blacks; these data exclude those African Americans who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. *The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year old age category were statistically adjusted to produce estimates that approximate those for African Americans aged 18-34 years old. 112. Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1976 1977' 1978 1979 1980 1983 % +Cl % +CI % itl % +1 % +Cl % +CI 40.8 2.1 40.7. 25 37.55 37 37.3 24 37.1 3.3 35.8 2.2 493 33 47.3 4.0 46.1 5.5 445 3.7 449 44 40.8 3.5 34.6 3.1 35.9 3.1 31.1 45 31.6 2.5 31.0 43 31.8 2.6 442 3.1 444 3.9 39.1 58 38.0 3.2 39.9 45 35.8 3.2 46.9 37 46.9 42 46.0 6.1 444 3.9 40.5 69 42.1 4.1 27.5 33 299 43 244 5.2 27.0 4.0 27.5 66 279 42 38.9 2.8 40.2 3.9 36.7 48 37.3 3.6 33.7 65 374 3.9 445 47 48.2 49 40.6 5.1 405 48 476 7.2 394 43 494 7.5 41.8 7A 46.0 9.9 35.5 64 30.8 87 344 63 36.3. 10.3 37.1 84 37.3 13.5 36.3 75 294 88 28.4 73 1991 1992 1993 1994 1995 % +l % xl % +CI % HitCI % H+tCl 294 1.6 27.8 2.0 26.0 2.0 27.2 2.3 25.8 2.6 35.5 2.7 32.3 3.5 324 34 33.9 4.0 28.8 37 245 19 24.1 2.2 21.0 2.2 21.8 2.2 235 31 270 2.4 22.4 3.0 216 33 22.0 3.4 19.9 34 38.3 2.7 38.0 3.7 33.6 3.6 34.7 3.9 33.6 4.6 20.7 2.7 224 3.5 22.3 4.1 24.0 4.0 23.0 3.8 35.4 3.0 34.4 45 33.9 45 35.3 45 34.1 5.0 34.9 2.6 323 37 314 3.8 31.6 45 31.0 5.0 318 3.8 28.4 48 26.6 4.4 27.6 54 25.2 5.1 18.0 42 224 6.6 13.9 4.6 15.7 52 17.6 54 t95% confidence interval. SIncludes persons aged 25 years and older. 4Levels presented for 1965 are for persons w some college or were college graduates. Source: National Center for Health Statistics, public use data tapes, 1965-1995. ho had a high school education or less and persons who attended Patterns of Tobacco Use 113 Surgeon General's Report Table 48. Percentage of adult African American smokers* who reported smoking <15, 15-24, or >25 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic % +clt % +Cl %e +Cl % +Cl Total <15 cigarettes 56.9 2.7 55.8 2.5 55.5 2.5 58.3 3.2 15-24 cigarettes 35.5 2.5 36.2 2.5 36.0 2.4 33.0 3.1 225 cigarettes 7.6 1.4 8.0 1.3 8.6 14 8.7 1.8 Gender Men <15 cigarettes 49.1 3.3 48.3 3.2 49.6 3.2 52.9 5.0 15-24 cigarettes 42.0 3.3 41.8 3.1 40.7 3.1 36.5 4.9 225 cigarettes 9.0 1.9 9.9 19 9.7 1.7 10.6 2.9 Women <15 cigarettes 68.0 3.7 66.1 3.8 62.8 2.8 64.3 4.0 15-24 cigarettes 26.3 3.5 28.5 3.5 30.0 2.5 29.1 3.8 225 cigarettes 5.7 1.9 5.5 1.7 7.2 1.7 6.6 2.3 Age (years) 18-34 <15 cigarettes 59.7 4.0 57.3 3.9 58.5 3.2 64.0 3.9 15-24 cigarettes 33.0 3.7 35.0 4.0 34.0 3.2 27.8 4.0 225 cigarettes 7A 2.1 7.7 2.1 7.4 2.0 8.2 2.4 35-54 <15 cigarettes 51.4 3.9 52.0 3.9 50.7 3.2 49.3 6.2 15-24 cigarettes 39.9 3.8 39.1 3.7 38.7 3.6 39.4 5.7 225 cigarettes 8.7 2.2 8.9 2.3 10.6 2.0 11.3 3.5 255 <15 cigarettes 65,2 6.4 63.3 6.9 59.3 5.9 65.3 7.9 15-24 cigarettes 29.8 6.4 30.6 7.2 34.3 5.6 31.4 8.2 225 cigarettes 5.1 3.0 6.1 3.5 6.5 2.1 3.4 2.6 Education§ Less than high school <15 cigarettes NA NA 55.3 3.5 52.5 3.9 55.8 5.5 15-24 cigarettes NA NA 36.0 3.3 38.0 3.7 35.8 5.3 225 cigarettes NA NA 8.7 2.0 9.5 2.1 8.4 2.6 High school <15 cigarettes 55.8° 3.1 50.6 5.7 52.7 43 52.9 8.0 15-24 cigarettes 35.9° 3.0 40.4 7.9 37.9 4.4 37.4 6.6 >25 cigarettes 8.35 1.8 9.1 3. 9.4 2.8 9.8 41 Some college <15 cigarettes NA NA 59.0 10.4 49.9 10.1 56.4 12.5 15-24 cigarettes NA NA 32.1 9.4 37.1 8.9 29.5 11.0 225 cigarettes NA NA 9.0 5.8 13.0 6.5 14.1 10.5 College <15 cigarettes 546° 9.1 60.9 10.1 69.0 11.1 64.8 15.1 15-24 cigarettes 36.12 8.5 32.3, 10.1 23.4 9.7 30.2 143 225 cigarettes 93° 53 6.8 5.3 7.6 7.3 5.1 7.1 “Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic African Americans; these data exclude those African Americans who indicated they were of Hispanic origin. For 1965-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. ‘The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were Statistically adjusted to produce estimates for the total population, males, and females that approximate those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year old age category were Statistically adjusted to produce estimates that approximate those for African Americans aged 18-34 years old. 114 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1976+ 1977+ 1978 1979 1980 1983 % +Cl % +CI % +Cl G% +CI % +Cl % +ClI 52.4 3.9 547 48 57.0 5.1 55.9 3.2 55.2 5.7 54.9 3.9 39.0 3.7 35.7 4.4 34.0 4.6 33.3 3.1 338 48 35.6 3.7 8.6 2.1 9.8 21 9.1 2.8 10.8 1.6 11.0 3.3 95 2.4 447 47 48.4 5.9 49.5 7.3 51.5 4.9 48.8 9.2 51.4 5.7 442 44 35.3 5.2 37.3 6.3 36.3 47 38.7 68 36.5 5.3 11.2 3.0 12.6 3.9 13.2 5.1 12.2 2.6 12.5 55 12.1 4.1 60.3 5.8 61.2 6.2 65.0 7.0 60.8 4.4 62.1 6.8 58.5 5.1 33.8 5.9 36.1 5.6 30.4 6.4 30.0 3.8 28.5 6.3 34.6 5.0 6.0 2.2 6.9 23 4.6 3.0 9.2 2.6 9.4 3.2 6.9 2.5 56.5 5.5 59.4 5.8 60.3 7.9 60.5 5.2 57.8 6.0 57.7 5.7 35.9 5.3 34.8 6.3 31.5 7.0 31.1 4.3 33.1 6.3 33.0 5.2 7.6 2.6 8.0 3.4 8.2 4.2 8.4 2.5 9.1 3.8 9.4 3.7 44.8 6.5 51.6 7.3 53.0 8.4 48.4 5.1 56.1 10.5 47.6 6.4 44.0 6.9 35.4 6.2 37.2 7.5 36.2 45 32.1 9.2 40.6 6.1 11.3 3.4 13.0 3.6 98 48 15.4 4.3 11.8 7.1 11.9 4.4 57.4 6.4 51.1 8.6 56.1 12.6 59.1 8.7 46.5 11.9 61.7 88 36.9 6.8 40.2 7.5 33.9 12.5 33.3 8.6 38.9 10.6 32.9 8.6 5.8 3.7 8.7 4.5 10.0 7.2 7.6 4.1 14.7 10.4 5.4 4.0 504 58 54.1 7.0 53.4 9.2 52.8 5.7 53.9 9.4 52.8 6.6 41.2 5.1 35.2 5.6 35.4 8.3 32.9 5.2 32.6 9.1 34.0 6.3 8.3 3.3 10.7 32 11.3 5.4 14.3 4.2 13.6 7.3 13.2 5.1 48.4 6.9 53.9 7.9 60.4 95 53.5 5.6 48.9 9.1 52.6 7.0 44.3 6.2 34.0 7.4 31.1 9.1 36.1 6.3 35.8 8.1 42.1 6.9 73 31 12.1 4.8 8.5 55 10.4 4.4 15.3 5.6 5.4 3.1 54.7 11.7 495 12.0 41.5 17.6 57.0 115 447 18.2 50.2 12.1 29.2 9.9 428 127 46.1 168 30.1 9.2 42.7 18.5 37.1 117 16.1 7.9 7.7 6.0 12.5 9.0 13.0 6.8 125 11.0 12.7 7.9 449 149 48.1 15.6 71.9 17.1 47.5 13.2 65.7 18.7 51.6 15.3 38.8 13.9 37.9 15.6 226 12.5 40.1 15 31.1 18.3 36.7 14.8 16.3 13.0 14.0 9.6 5.5 9.8 12.5 9.2 3.3 64 11.7. 10.9 495% confidence interval. SIncludes persons aged 25 years and older. ALevels presented for 1965 are for persons some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Patterns of Tobacco Use who had a high school education or less and persons who attended 115 Surgeon General’s Report Table 48. Continued 1985 1987 1988 1990 Characteristic % +cr % +l % +¢1 % +Cl Total <15 cigarettes 55.8 3.2 61.2 2.9 56.4 2.7 59.9 3.2 15-24 cigarettes 35.0 2.9 31.0 2.8 34.6 2.5 34.2 3.2 225 cigarettes 9.3 1.9 7.8 1.6 9.0 1.6 6.0 1.5 Gender Men <15 cigarettes 52.8 5.2 55.3 4.2 51.0 4.1 52.6 4.7 15-24 cigarettes 36.2 4.3 35.8 4.4 38.2 3.8 40.1 4.7 225 cigarettes 11.0 3.2 8.9 2.4 10.8 2.9 7.3 2.3 Women <15 cigarettes 58.7 3.9 67.9 3.5 62.2 3.9 68.8 3.6 15-24 cigarettes 33.7 3.8 25.7 3.2 30.7 3.6 26.9 3.4 225 cigarettes 7.6 2.0 6.5 1.8 7.2 2.0 4.3 1.7 Age (years) 18-34 <15 cigarettes 56.4 5.4 66.2 4.5 62.1 4.0 67.5 4.9 15-24 cigarettes 35.4 4.8 27.6 4.0 29.4 3.7 25.8 4.6 225 cigarettes 8.2 3.0 6.2 2.3 8.5 2.4 6.7 2.5 35-54 <15 cigarettes 53.1 4.8 54.9 4.6 49,2 4.3 51.9 49 15-24 cigarettes 35.9 4.6 34.9 4.6 40.5 4.4 42.2 4,7 225 cigarettes 11.0 3.0 10.1 2.4 10.3 2.5 5.9 2.2 255 <15 cigarettes 59.6 6.5 61.5 7.1 56.8 7.3 60.8 6.9 15-24 cigarettes 31.8 6.6 31.8 6.9 35.3 6.7 34.9 6.8 225 cigarettes 8.6 4.1 6.7 3.8 7.9 3.4 4.3 2.7 Education® Less than high school <15 cigarettes 57.9 5.0 62.8 4.3 51.4 4.5 54.1 5.8 15-24 cigarettes 31.8 4.8 27.7 4.5 38.0 4.5 39.2 5.7 225 cigarettes 10.3 3.2 9.5 2.9 10.6 3.0 6.7 2.6 High school <15 cigarettes 52.4 5.5 57.6 5.2 58.9 4.7 60.6 5.1 15-24 cigarettes 39.8 5.4 34.2 4.9 32.3 4.6 34.0 5.0 225 cigarettes 7.9 2.8 8.2 2.9 8.9 2.5 5.4 2.1 Some college <15 cigarettes 47.6 8.9 57.7 7.0 55.0 7.2 57.1 7.8 15-24 cigarettes 37.6 8.3 35.3 6.7 34.0 6.8 37.6 78 225 cigarettes 14.8 6.6 7.0 3.9 11.0 4,9 5.4 3.7 College <15 cigarettes 50.5 12.6 56.8 12.1 54.0 13.5 67.9 11.6 15-24 cigarettes 35.0 11.6 34,7 11.7 40.8 13.5 28.1 11.1 225 cigarettes 145 12.8 8.5 5.8 5.2 4.0 4.0 4.0 495% confidence interval. SIncludes persons aged 25 years and older. 116 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1991 1992 1993 1994 1995 % +CI % +ClI % +ClI %e +Cl % +CI 61.2 3.0 61.4 4.3 65.6 4.2 65.3 4.8 62.5 5.2 30.0 2.8 33.3 3.9 28.5 41 27.2 4.3 29.7 4.8 8.7 1.8 5.3 1.7 6.0 2.1 7.5 3.2 7.8 2.7 57.5 4.4 55.7 6.8 63.3 6.2 64.1 7.0 57.6 7A 31.7 4.0 39.0 6.3 29.2 5.9 25.2 5.8 32.5 7.2 10.8 2.8 5.3 2.4 7.4 3.4 10.7 5.6 9.9 4.5 65.7 3.5 67.5 49 68.4 5.8 66.7 5.5 69.7 9.7 28.0 3.4 27.3 4.5 27.5 5.7 29.8 5.5 22.1 8.2 6.2 1.9 5.2 2.0 41 2.2 3.5 1.7 8.2 6.0 66.9 4.6 68.5 6.6 70.6 7.9 71.5 7.3 68.3 8.5 27.3 4.4 27.7 6.5 22.8 7.0 22.3 7.0 24.4 8.1 5.7 2.5 3.8 2.1 6.6 3.8 6.2 3.1 7.2 4.4 56.7 4.4 59.0 6.0 62.2 6.0 60.6 7.3 57.2 7.3 32.7 4.0 34.9 5.7 31.2 6.1 31.1 6.4 33.5 7.0 10.7 2.8 6.1 2.7 6.6 3.2 8.4 5.8 9.4 4.2 60.0 6.8 54.3 8.8 64.6 10.3 66.2 9.6 67.1 9.1 29.3 6.5 39.8 8.5 32.0 10.4 26.2 8.4 28.4 8.5 10.7 4.3 5.9 3.9 3.4 3.6 7.6 6.6 4.5 3.7 60.0 5.2 56.2 8.2 59.4 8.1 59.3 8.7 52.3 8.6 28.7 4.8 36.6 8.0 30.9 8.2 32.0 79 33.0 8.4 11.3 3.5 7.2 3.4 9.7 5.0 8.6 6.1 14.8 6.8 57.6 49 61.3 6.1 64.6 6.9 63.9 8.3 64.1 79 35.5 4.8 34.4 5.8 32.1 6.7 28.8 7.2 29.5 7.2 6.9 2.2 4.3 2.4 3.3 2.7 7.2 6.6 6.4 4 63.8 7.7 62.5 9.2 64.4 10.3 66.9 11.6 58.8 11.7 28.2 7.4 32.1 9.1 29.8 9.8 27.1 11.3 37.6 11.5 8.1 4.2 5.4 4.0 5.9 4.8 6.0 4.1 3.6 2.8 62.4 13.2 72.5 12.6 78.3 17.4 73.3 17.8 83.0 11.1 22.1 10.8 21.3 11.2 19.4 17.3 26.7 17.8 12.1 9.7 15.6 11.7 6.1 6.8 2.3 3.6 0.0 0.0 4.9 6.0 Patterns of Tobacco Use 117 Surgeon General's Report Table 49. Percentage of adult African American ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic % +crt % +CI % +CI % +Cl Total 15.5 1.7 14.2 1.7 20.6 1.5 19.7 2.4 Gender Men 16.1 2.2 15.5 2.2 22.2 2.0 21.7 3.6 Women 14.5 2.7 12.3 2.4 18.4 2.1 17.4 2.9 Age (years) 18-34 8.3 2.0 7.2 1.8 12.8 1.8 13.0 3.9 35-54 16.7 2.6 14.0 2.4 21.1 2.0 16.9 3.3 >55 29.3 5.2 32.4 5.4 37.4 3.6 38.1 5.8 Education® Less than high school NA NA 17.5 2.3 23.2 2.1 23.3 3.5 High school 18.23 2.1 11.2 3.5 19.4 3.7 17.4 4.7 Some college NA NA 12.8 6.5 24.2 6.8 33.2 11.8 College 13.24 5.7 19.9 8.6 33.9 9.9 20.4 9.9 1985 1987 1988 1990 Characteristic % +CI % +Cl % tCI % HCI Total 31.3 2.4 31.1 2.4 32.5 2.1 39.0 2.6 Gender Men 34.4 3.6 32.9 3.6 34.9 3.1 39.5 3.4 Women 27.9 3.3 29.0 2.7 29.7 3.0 38.4 3.5 Age (years) 18-34 21.1 3.5 18.3 3.1 19.2 3.1 24.8 3.9 35-54 30.6 3.7 31.2 3.7 34.9 3.7 39.1 3.8 255 48.5 4.6 50.1 4.5 48.3 4.1 58.3 4.6 Education® Less than high school 32.8 3.6 34.2 3.7 35.8 3.4 40.4 4.4 High school 30.8 44 27.0 3.7 27.6 3.5 35.7 3.9 Some college 36.6 6.6 35.8 55 37.3 5.8 43.8 6.5 College 37.4 8.7 49.9 8.2 50.4 8.3 51.4 8.2 *Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic African Americans; these data exclude those African Americans who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are those who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking. *The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year old age category were statistically adjusted to produce estimates that approximate those for African Americans aged 18-34 years old. 118 Chapter 2 Tobacco Use Among ULS. Racial/Ethnic Minority Groups 1976" 1977" 1978 1979 1980 1983 G il G% +l % +Cl G% +l % +Cl % itl 24.3 2.5 227 25 26.2 41 26.7 2.7 275 3.4 28.0 2.9 26.7 34 264 44 28.5 64 287 3.8 292 49 32.0 4.3 216 37 18.7 3.0 23.6 48 24.4 37 255 4.9 23.4 37 13.8 31 143 3.1 17.9 5.6 18.4 4.0 16.9 47 18.8 3.9 240 47 23.0 42 27.3 6.0 26.5 4.9 31.1 72 277 «648 43.4 6.1 37.4 62 41.6 10.8 428 6.1 41.7 10.0 446 64 30.0 3.5 269 844 297 61 33.1 48 34.7. 73 32.4 51 23.2 49 20.9 49 23.4 59 254 42 21.3 93 954 53 23.7 95 26.7 83 27.9 13.2 32.7 10.6 37.2 12.9 32.3 9.0 23.9 13.5 25.3 10.9 20.0 16.2 268 9.5 41.9 12.7 36.4 11.8 1991 1992 1993 1994 1995 % «CI G% itl % +Cl % HCI % +CI 334 26 36.4 3.3 37.8 34 34.7 3.5 36.1 3.9 34.2 3.6 40.1 5.2 37.9 48 34.1 5.3 35.9 53 32.4 3.2 31.9 40 376 48 35.3 43 36.4 53 17.2 3.6 239 72 233 58 16.7 5.6 22.7 62 31.8 3.5 31.3 45 355 5.1 34.1 5.3 32.1 59 564 52 574 5.4 56.0 6.7 53.8 62 55.6 6.1 35.8 45 38.9 5.6 41.2 6.1 34.5 5.6 39.3 59 294 34 335 58 33.3 54 32.3 6.2 30.8 63 33.0 5.5 37.7 7.6 40.3 7.7 37.6 87 370 92 51.2 91 43.9 118 55.1 12.2 50.3 13.0 51.7 113 495% confidence interval. SIncludes persons aged 25 years and older. Levels presented for 1965 are for persons who had a high scho some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. ol education or less and persons who attended Patterns of Tobacco Use 119 Surgeon General's Report Table 50. Percentage of African American women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic % +cit %e +Cl %o +Cl % +CI Total 42.9 2.9 42.6 2.9 38.6 3.1 41.1 3.5 Education§ Less than high school NA NA 48.1 4.7 45.4 4.6 47.1 7.7 High school 45.04 4.0 45.9 6.7 38.9 5.4 45.6 6.4 Some college NA NA 49.6 11.7 36.6 10.4 25.6 12.6 College 44.74 9.6 42.9 10.9 41.2 9.2 52.7 13.3 1985 1987 1988 1990 Characteristic % +C! % +C! % +CI % aCI Total 34.0 2.8 31.4 2.5 29.8 2.4 22.7 2.1 Education Less than high school 54.3 6.8 49.1 6.0 47.2 6.1 38.2 6.8 High school 36.9 49 35.8 43 33.2 4.1 30.7 4.3 Some college 34.0 7.1 32.4 5.6 28.9 5.0 21.2 4.1 College 21.3 7.3 19.7 6.5 20.2 6.0 14.9 5.8 “Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic African Americans; these data exclude those African Americans who indicated they were of Hispanic origin. For 1965-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 120 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1976" 1977" 1978 1979 1980 1983 % +Cl % +CI % +Cl % +Cl % +Cl % tcl 38.8 42 41.7 4.0 36.4 63 35.2 3.0 346 54 34.3 3.4 453 7.1 44.0 9.0 41.5 10.3 43.2 89 35.7. 12.9 496 89 391 73 493 7.6 36.4 7.7 34.5 68 40.0 10.0 36.5 62 46.0 9.6 41.4 105 53.0 15.3 33.2 97 30.5 11.8 293 84 35.5 15.4 36.6 15.1 45.9 19.2 36.2 10.3 31.0 174 225 92 1991 1992 1993 1994 1995 % +I % +CI % +Cl % +l % +Cl 28.1 2.4 2745 29 23.1 2.9 229 18 23.8 3.9 504 61 45.9 10.0 45.6 9.4 43.6 94 49.6 123 32.4 4.0 298 5.2 30.2 5.5 26.1 5.2 30.6 69 315 5.6 26.1 67 26.3 65 274 82 24.9 7.6 19.8 6.6 18.5 8.2 8.2 6.0 8.0 5.7 13.6 79 The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates that approximate those for African American women aged 18-44 years. 495% confidence interval. Includes persons aged 25 years and older. ALevels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Patterns of Tobacco Use 121 Surgeon General's Report Appendix 5. Validation of the Retrospective Assessment of Smoking Prevalence Because the method of computing smoking prevalences retrospectively is inherent in the birth co- hort analyses described in this chapter, comparability of these estimates with accepted cross-sectional estimates was examined. At least two factors contrib- ute to the observed difference between retrospective and cross-sectional estimates of smoking prevalence: how a former smoker is defined and differences in mor- tality between smokers and nonsmokers (differential mortality). Retrospective estimates will be greater than cross-sectional ones because they are based on the age at which a smoker quits once and for all. However, cross- sectional estimates, using the accepted definition of a former smoker (a person who has ever smoked 100 cigarettes but does not smoke now), classify ever smok- ers who are not currently smoking as quitters, even though many will relapse several times before finally quitting. Differential mortality results in retrospective estimates smaller than cross-sectional ones because smokers are less likely than others to survive and re- port their smoking history. This factor affects only the older birth cohorts (Harris 1983). Retrospective estimates of smoking prevalence were assessed by comparing them with smoking prevalence estimates from the NHISs from 1965 through 1988 and from Gallup surveys from 1944 through 1988. The NHIS and Gallup surveys both sample adults only; thus, for the comparison, retro- spective prevalences computed for each year included only respondents aged 18 years and older in that cal- endar year. Sample sizes for the birth cohorts in- cluded in this analysis varied widely (Table 51) (NCHS, public use data tapes, 1978, 1979, 1980, 1982-1984 [HHANES], and 1987 and 1988 combined). When this methodology was used to estimate smoking prevalences retrospectively for the national Table 51. Sample sizes for birth cohorts, by gender, race/ethnicity, and education,* National Health Interview Surveys, 1978-1980, 1987 and 1988 combined, and Hispanic Health and Nutrition Examination Survey, 1982-1984 Men Women African American Hispanic African American Hispanic Birth Cohort HS HS HS HS 1908-1917 401 96 142 33 601 185 229 30 1918-1927 494 222 267 aul 683 444 376 113 1928-1937 370 387 387 178 331 638 508 233 1938-1947 292 622 266 226 457 1,013 392 277 1948-1957 277 1,066 322 375 555 2,006 417 462 1958-1967" 175 755 180 255 415 1,510 224 319 *Education was identified as either <12 years of school completed ( Michigan, ° eexe Minnesota, and a Wisconsin 20 eee Oklahoma Arizona and New Mexico T T | I 1968-1972 1973-1977 Years | ] 1978-1982 I T I I | 1983-1987 *Rates presented here were determined using midpoint population estimates for each 5-year time interval and were adjusted to the 1970 U.S. standard population. Source: Valway 1992. Health Service (IHS) areas (Arizona and New Mexico had low rates of lung cancer deaths) (Valway 1992), Lung cancer death rates among American Indians and Alaska Natives have been rising in most IHS areas (Fig- ures 2 and 3) (Valway 1992); national death rates from malignant diseases of the respiratory system have also been increasing (Table 1). Lung cancer death rates vary by IHS area. Spe- cifically, American Indians in the Southwest have had the lowest lung cancer death rates, whereas American Indians in Alaska, North Dakota, South Dakota, and Montana have had rates nearly as high as those in the general U.S. population (Table 3, Figures 2 and 3) (Valway 1992). These differences are associated with variations in smoking among American Indians and Alaska Natives (Centers for Disease Control [CDC] 1987; Welty et al. 1993). In an analysis of data from the 1985-1988 Behavioral Risk Factor Surveillance System (BRFSS) on 1,055 American Indians, Sugarman and colleagues (1992) determined smoking prevalence for three groups of states that contained three specific IHS 144 Chapter 3 areas. In this study, the Plains states (lowa, Minne- sota, Montana, Nebraska, North Dakota, South Dakota, and Wisconsin) contained the Aberdeen, Bemidji, and Billings IHS areas; the West Coast states (California, Idaho, and Washington) contained the Portland and California IHS areas; and the Southwest states (Arizona, New Mexico, and Utah) contained the Al- buquerque, Navajo, Tucson, and Phoenix [HS areas. Cigarette smoking prevalence rates were highest in the Plains states (48.4 percent for men and 57.3 percent for women), intermediate in the West Coast states (25.2 percent for men and 31.6 percent for women), and low- est in the Southwestern states (18.1 percent for men and 14.7 percent for women). These general geo- graphic patterns of smoking prevalence paralleled patterns of lung cancer mortality (Table 3) (Valway 1992). The smoking prevalence estimates from the 1985-1988 BRFSS analyses may be imprecise because of relatively small samples. However, other analyses (American Indians and Alaska Natives, in Chapter 2; Welty et al. 1995) show similar patterns. Another Tobacco Use Among U.S. Racial/Ethnic Minority Groups Figure 3. Age-adjusted lung cancer death rates among American Indian and Alaska Native women in selected states compared with rates among all U.S. women, 1968-1987" 80 704 Rate per 100,000 wwe = Alaska North Dakota, ='=+* South Dakota, and Montana Michigan, seme Ninnesota, and Wisconsin =aese Al) U.S. women e—= Oklahoma Arizona and New Mexico I l 1968-1972 1973-1977 Years T T 1978-1982 ] 1 1983-1987 *Rates presented here were determined using midpoint population estimates for each 5-year time interval and were adjusted to the 1970 U.S. standard population. Source: Valway 1992. potential limitation is that American Indians living in the California and Portland IHS areas may be more likely than American Indians from other IHS areas to be misclassified on death certificates as being of other racial/ethnic categories (Valway 1992), suggesting that death rates for American Indians may be underesti- mated in these areas (Sorlie et al. 1992). Lanier and colleagues (1996) recently reported on lung cancer incidence rates for Alaska Native men and women. Lung cancer incidence was higher for Alaska Natives than it was for the general U.S. population. In addition, lung cancer was the most common inci- dent cancer among men and the third most common incident cancer among women (after breast cancer and cancer of the colon/rectum). Lung cancer incidence increased substantially among Alaska Native men (by 93 percent) and women (by 241 percent) between 1969-1973 and 1989-1993. The authors concluded, “Reduction in tobacco use would result in the greatest decreases in cancer rates in this population” (p. 751). Asian Americans and Pacific Islanders Two issues should always be kept in mind when interpreting data about the health consequences of cigarette smoking among Asian Americans and Pacific Islanders: the diversity of this group and the paucity of data. The Asian American and Pacific Islander population of the United States includes approxi- mately 32 national and racial /ethnic groups and nearly 500 languages and dialects. Although many of these persons were born in the United States, many others are recent immigrants (see Chapters 1 and 2); yet the national data do not indicate these distinctions. Envi- ronmental exposures experienced in Asia, such as women’s exposure to smoke from cooking fuels, may influence lung cancer occurrence among recent immi- grants (Coultas et al. 1994). From 1980 through 1995, age-adjusted death rate for malignant neoplasms of the respiratory system (primarily deaths from lung cancer) among Asian Health Consequences 145 Surgeon General’s Report Table 3. Death rates for lung cancer among American Indians and Alaska Natives, by Indian Health Service (IHS) area, 1984-1988 Men Women Areas N Rate* N Rate* US., all ethnicities 74.2 27.3 Nine IHS areas*t 307 38.54 203 27.2 All 12 IHS areas 562 40.14 296 21.44 Aberdeen 63 68.7 4] 45.0+ Alaska 80 75.5 62 68.54 Albuquerque 12 18.8! 5 7.8" Bemidji 41 63.4% 24 = 40.78 Billings 360 65.3 33.65.74 Californiat 33 33.24 8 6.64 Nashville 24 41.81 15 25.1 Navajo 25 11.4 7 4.0 Oklahomat 167 46.0! 55 14.0# Phoenix 20 17.2+ 13 11.53 Portlandt 55 40.5+ 30 23.4 Tucson 6 25.94 3 «13.5% *Per 100,000, age-adjusted to the 1970 U.S. standard population. Rates based on a small number of deaths should be interpreted with caution. *The California, Oklahoma, and Portland IHS areas appear to have a problem with underreporting Indian ethnicity on death certificates; therefore, a separate total is presented for the nine other IHS areas, excluding these three areas. tDenotes a rate significantly different from the rate for the overall U.S. population. Source: Valway 1992. American and Pacific Islander men remained fairly constant; this death rate for Asian American and Pa- cific Islander women increased slightly between 1980 and 1995 but was substantially lower than for men (Table 1) (NCHS 1997). Trends should be interpreted with caution because the large numbers of immigrants from Asia and the Pacific Islands that came to the United States during that time may have influenced both disease prevalence in and the age structure of this group. During 1992-1994, the age-adjusted death rate for lung cancer was 27.9 per 100,000 for Asian Ameri- can and Pacific Islander men and 11.4 per 100,000 for women (Table 2). These rates were slightly higher than those for Hispanics and slightly lower than those for American Indians and Alaska Natives. In 1993, the four leading causes of cancer death among Asian 146 9 Chapter 3 Americans and Pacific Islanders were lung cancer (22.3 percent of all cancer deaths), cancer of the colon and rectum (10.4 percent), cancer of the liver and intrahe- patic bile duct (8.6 percent), and stomach cancer (7.7 percent) (Parker et al. 1997). Data on lung cancer for more specific subgroups have been published in several reports (Baquet et al. 1986; Ross et al. 1991; Zane et al. 1994; NCI 1996b). The most recent data are from NCI’s SEER program and provide information for 1988-1992. This report includes incidence data from the nine areas included in the annual SEER reports (e.g., Kosary et al. 1995) and from Los Angeles, San Jose/ Monterey, and the Alaska Area Native Health Service. Data on Hispan- ics are predominantly from Los Angeles, New Mexico, San Francisco, and San Jose/Monterey. Most Hispan- ics represented in SEER are Mexican Americans. Data on Asian Americans and Pacific Islanders are mainly from Los Angeles, Hawaii, San Francisco /Oakland, San Jose/Monterey, and Seattle/Puget Sound. Data on American Indians are from New Mexico; data from the Alaska Native Area Health Service provide infor- mation on Alaska Natives (NCI 1996b). During 1988-1992, the age-adjusted (to the 1970 U.S. standard population) incidence per 100,000 popu- lation of lung cancer for men was 89.0 for Hawaiians, 70.9 for Vietnamese, 53.2 for Koreans, 52.6 for Filipi- nos, 52.1 for Chinese, and 43.0 for Japanese. For com- parison purposes, the lung cancer incidence rates were 117.0 for African American men, 76.0 for white men, and 41.8 for Hispanic men. For women, the lung can- cer incidence rates were 43.1 for Hawaiians, 31.2 for Vietnamese, 25.3 for Chinese, 17.5 for Filipinos, 16.0 for Koreans, and 15.2 for Japanese. In comparison, the lung cancer incidence rates were 44.2 for African American women, 41.5 for white women, and 19.5 for Hispanic women. Age-adjusted lung cancer death rates during 1988-1992 were, per 100,000 men, 88.9 for Hawaiians, 40.1 for Chinese, 32.4 for Japanese, and 29.8 for Filipi- nos; mortality estimates were not available for Kore- ans and Vietnamese of either gender. In comparison, the lung cancer death rates were 105.6 for African American men, 72.6 for white men, and 32.4 for His- panic men. For women, the lung cancer death rates were 44.1 for Hawaiians, 18.5 for Chinese, 12.9 for Japa- nese, and 10.0 for Filipinos. In comparison, the lung cancer death rates were 31.9 for white women, 31.5 for African American women, and 10.8 for Hispanic women (NCI 1996b). The lung cancer rates reflect gen- der differences in smoking rates among Asian Ameri- can and Pacific Islander populations, as indicated by 1978-1995 data from the NHISs (see Chapter 2). Several studies have identified high rates of lung cancer among Native Hawaiians. Data on lung cancer among Pacific Islanders from the Hawaii Tumor Regis- try indicate that Native Hawaiians have the highest lung cancer incidence rates among the islands’ other racial/ethnic groups, including Japanese, Filipinos, and Chinese (Kolonel 1980; Hinds et al. 1981). Using medi- cal records of lung cancer patients and data from a population-based survey, Hinds and colleagues (1981) assessed the risk of developing lung cancer associated with smoking among women in Hawaii. The risk for developing lung cancer among women who had ever smoked compared with those who had never smoked was substantially greater among Native Hawaiian women (tenfold higher) than among Japanese women (fivefold higher) and Chinese women (twofold higher). In a comparison of the risks of smoking among Native Hawaiians, Filipinos, Japanese, and Chinese in Hawaii, Le Marchand and colleagues (1992) found that Native Hawaiian men had the highest risk and that white and Filipino women had higher risks than Native Hawai- ian women. The pattern of variation of smoking’s effect on lung cancer was statistically significant for men. These differences persisted after variables for beta-carotene and cholesterol intake were included in the statistical model. The observation that the risk of lung cancer related to smoking may vary among sub- groups requires further elucidation. Ina cohort study of 7,961 Japanese American men who were living in Hawaii, the incidence of lung cancer was 11.4 times higher in current smokers than in persons who had never smoked; the risk for former smokers was 3.1 times higher than for never smokers (Chyou et al. 1993). Hispanics According to NCHS data from 1985 through 1995, the age-adjusted death rate for malignant neoplasms of the respiratory system (primarily deaths from lung cancer) among Hispanic men was about three times higher than that for Hispanic women (Table 1) (NCHS 1997). Trends should be interpreted with caution, be- cause only 17 states and the District of Columbia con- tributed death certificate data on Hispanics for 1985; by 1990, however, 47 states and the District of Colum- bia, covering 99.6 percent of the U.S. Hispanic popu- lation, contributed relevant data (Table 1) (NCHS 1997). From 1992 through 1994, the age-adjusted death rate for cancer of the trachea, bronchus, and lung (gener- ally referred to as lung cancer) was 23.1 per 100,000 for Hispanic men and 7.7 per 100,000 for Hispanic women (Table 2). Overall, lung cancer is the leading cause of cancer death among Hispanics. Among those Tobacco Use Among U.S. Racial/Ethnic Minority Groups who died of cancer in 1993, the four leading causes of death were lung cancer (17.9 percent), cancer of the colon and rectum (9.6 percent), cancer of the female breast (8.2 percent), and cancer of the liver and other biliary organs (6.0 percent) (Parker et al. 1997). Among Hispanic women, however, breast cancer mortality exceeds that of lung cancer (NCI 1996b). National mortality data for 1992-1994 (Table 4) also indicate that rates of lung cancer per 100,000 were higher among Cuban men (33.7) than among Mexican American (28.3) and Puerto Rican men (21.9). Among women, little variation is evident across His- panic subgroups (Table 4). An earlier nationwide analysis limited to foreign-born Cubans, Mexicans, and Puerto Ricans provided similar results for 1979-1981 (Rosenwaike 1987). Some regional data suggest that rates of lung cancer among Hispanics increased rapidly. For ex- ample, New Mexico mortality data for 1958-1982 indicate that lung cancer death rates increased for suc- cessive birth cohorts of Hispanics (Samet et al. 1988b). Between 1958-1962 and 1978-1982, lung cancer death rates per 100,000 increased from 10.1 to 28.8 among Hispanic men and from 4.8 to 11.2 among Hispanic women (Samet et al. 1988b). However, lung cancer death rates among Hispanics remained below those of the general U.S. population. Moreover, be- tween 1969-1971 and 1979-1981, lung cancer incidence rates doubled for persons with Spanish surnames (not necessarily all persons were Hispanic) residing in the Denver, Colorado, area (Savitz 1986). National and regional vital statistics have shown that patterns of lung cancer incidence differ among Hispanics and whites throughout the United States (NCHS 1994). Much of the information available on lung cancer incidence has relied on the SEER Program, which for many years included only one subgroup of Hispanics—those residing in New Mexico. Since the 1950s, descriptive studies of death have documented differing patterns of lung cancer among Hispanics and whites in the western and southwestern United States. In California, during the 1950s and 1960s, age-specific death rates from lung cancer among older Mexican-born women were two to three times the rates among California women of all ages (Buechley et al. 1957: Buell et al. 1968). Lung cancer death rates for women in Texas and New Mexico during the 1960s and 1970s showed a similar pattern of age-specific rates (Lee et al. 1976; Samet et al. 1980, 1988b), although Hispanic women in the West and Southwest have had lower over- all lung cancer death rates than white women (Savitz 1986; Martin and Suarez 1987; Samet et al. 1988b; Bernstein and Ross 1991). Health Consequences 147 Surgeon General's Report Table 4. Age-adjusted death rates* for selected smoking-related causes of death among Mexican Americans, Puerto Rican Americans, and Cuban Americans, United States, 1992-1994 Mexican Puerto Rican Cuban Disease category UCD-9 code)* Men Women Men Women Men Women Cancer Lip, oral cavity, pharynx (140-149) 2.0 0.4 5.5 0.9 3.3 0.7 Esophagus (150) 2.7 0.3 6.1 1.1 2.7 0.4 Stomach (151) 6.8 3.5 7.7 3.9 3.1 1.3 Pancreas (157) 54 43 5.0 3.6 5.0 4.1 Larynx (161) 11 0.1 2.6 0.3 2.2 0.1 Trachea, bronchus, lung (162) 21.9 8.0 28.3 9.6 33.7 8.9 Cervix uteri (180) NA 3.7 NA 3.7 NA 1.6 Bladder (188) 1.4 0.5 2.1 1.0 3.5 0.5 Kidney, other, unspecified urinary organs (189) 3.7 1.6 1.9 1.0 2.7 1.0 Cardiovascular diseases Coronary heart disease (410-414) 82.3 44.2 118.6 67.3 95.2 42.4 Cerebrovascular disease (430-438) 25.5 18.9 27.3 16.5 17.1 11.5 Respiratory diseases Bronchitis, emphysema (491-492) 2.2 0.9 3.2 1.3 3.3 1.0 Chronic airway obstruction, not elsewhere classified (496) 7.6 3.7 10.5 5.3 9.1 3.1 *Per 100,000, age-adjusted to the 1940 U.S. standard population. Death rates are not available from New Hampshire for 1992 and from Oklahoma for 1992-1994. Due to limitations in the data, the population estimates for Oklahoma and New Hampshire were not subtracted from the denominator. Based on the 1990 Census, the number of persons of Hispanic origin from New Hampshire and Oklahoma represented about 0.04 percent of the U.S. Hispanic population. ‘International Classification of Diseases, Ninth Revision, World Health Organization 1977. NA = data not available. Sources: National Center for Health Statistics, public use data tapes, 1992-1994; U.S. Bureau of the Census 1997. In 1982 and 1983, lung cancer rates among Hispanic men and women in Florida also were lower than the rates among whites (Trapido et al. 1990a,b). More recent data (1981-1989) from Dade County, Florida, again show the incidence of lung cancer to be lower among Hispanic men than among white men and lower among Hispanic women than white women (Trapido et al. 1994a,b). Similarly, Mexican and Puerto Rican immigrants in Illinois have had lower standard- ized lung cancer death rates than whites (Mallin and Anderson 1988). In addition, lung cancer incidence and death rates have been much lower among 148° Chapter 3 Hispanic men than among white men in New Mex- ico (Samet et al. 1980), Texas (Lee et al. 1976), Califor- nia (Menck et al. 1975; Bernstein and Ross 1991), Connecticut (Polednak 1993), and Colorado (Savitz 1986). Mortality data indicate that Puerto Ricans living on Long Island, New York, had slightly lower death rates for lung cancer than Puerto Ricans living elsewhere in the United States (except Puerto Rico) (Polednak 1991). However, Puerto Rican men and women residing on Long Island had lung cancer death rates that were three to four times the rates among Puerto Rico residents. These lower rates of lung cancer among Hispan- ics appear to reflect differences in smoking between Hispanics and whites. The results of a 1980-1982 case-control study of lung cancer cases among Hispan- ics and whites residing in New Mexico indicate that the risks (adjusted for gender and age) across catego- ries of smoking consumption among both groups were comparable (Table 5) (Humble et al. 1985). This find- ing suggests that the reduced rates of lung cancer deaths among Hispanics are attributable to their lower cigarette consumption (number of cigarettes smoked daily) and not to some other correlate of Hispanic race / ethnicity. In a mortality study conducted in Texas be- tween 1970 and 1979 using age-standardized death rates, Holck and colleagues (1982) found that Mexi- can American women had stable lung cancer death rates (approximately 30 per 100,000), whereas white women had increasing rates of death from lung cancer. The lower lung cancer rates for Mexican American women were consistent with their lower prevalence of smoking (18.5 percent of Mexican Ameri- can women vs. 31.6 percent of white women). The elevated rates of lung cancer death among older Hispanic women in the West and Southwest have been attributed to a possible pattern of early initiation of smoking among women born in Mexico before 1900 as well as the custom of cooking indoors with an open fire (Buell et al. 1968; Lee et al. 1976). The findings of a 1980-1982 case-control study in New Mexico indicate that older Hispanic women smoked hand-rolled ciga- rettes, which may have contributed to the high lung cancer death rate among older Mexican American women (Humble et al. 1985). Other Cancers Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 5. Odds ratios for the risk of lung cancer, by gender, race/ethnicity, and smoking status, case-control] study, New Mexico,* 1980-1982 Men Smoking status Hispanic White Former smokers 8.0" 7.2 (1.9-42.2% — (3.0-17.6) Current smokers 11.6 9.2 <20 cigarettes per day (2.7-61.5) (3.3-25.8) >20 cigarettes per day 26.1 24.7 (5.6-146.6) — (10.0-59.9) Women Hispanic White Former smokers 6.3° 6.5 (1.5-27.8) (2.8-15.4) Current smokers 18.5 19,2 <20 cigarettes per day (4.9-72.4) (6.5-60.8) >20 cigarettes per day 36.9 16.0 (7.6-217.1) (6.7-36.3) *Mantel-Haenszel estimates of exposure odds ratios were calculated for two age strata: <65 years of age and >65 years of age. Odds ratios are relative to persons who never smoked. tp <0.01. 195% Cornfield confidence limits; unless otherwise indicated, p <0.0001. Source: Adapted from Humble et al. 1985. Cigarette smoking causes cancers of the lung, larynx, mouth, esophagus, and bladder; is a contrib- uting factor for cancers of the pancreas, kidney, and cervix; and is associated with cancer of the stomach (USDHHS 1989b, 1990). Cigarette smoking is also sus- pected of contributing to colon cancer (Giovanucci et al. 1994), liver cancer (Doll et al. 1994), and acute myeloid leukemia (Siegel 1993). Little information is available on cigarette smoking as a risk factor for these cancers among members of racial/ethnic minority groups. In the annual Cancer Statistics Review of the SEER Program, cancer incidence and death rates are reported for African Americans and whites (Kosary et al. 1995). A special 1986 report provides more detailed information on African Americans and other ethnic groups for 1978-1981 (Baquet et al. 1986). A more re- cent report provides detailed information on several ethnic groups for 1988-1992 (NCI 1996b). Other population-based cancer registries are also beginning to contribute relevant information. Several recently published sources of information on cancer among American Indians include an THS Health Consequences 149 Surgeon General's Report report, which describes regional! differences in cancer deaths among American Indians in the United States for 1984-1988 and time trends for 1968-1987 (Valway 1992); two reports from the Alaska Area Native Health Service (Lanier et al. 1993, 1996), which describe can- cer incidence in the state’s Eskimo, Aleut, and Indian populations; and an NCI monograph that documents the status of the evidence on cancer and the need for additional research regarding cancer among American Indians and Alaska Natives (Burhansstipanov and Dresser 1993). Table 6. Age-adjusted incidence and death rates* for selected smoking-related cancers, by race/ethnicity and gender, National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program, 1988-1992 American Primary cancer site African Alaska Indian (ICD-9 code)' American Native (New Mexico) Chinese Filipino All sites Incidence rate,s men 560° 372 196 282 274 Incidence rate, women 326 348 180 213 224 Death rate,! men 319 225 123 139 105 Death rate, women 168 179 99 86 63 Cervix uteri (180) Incidence rate, women 13.2 15.8 99 7.3 9.6 Death rate, women 6.7 _ - 2.6 2.4 Esophagus (150) Incidence rate, men 15.0 ~ - 5.3 2.9 Incidence rate, women 4.4 - - - — Death rate, men 14.8 - - 4.2 2.2 Death rate, women 3.7 - - - - Kidney and renal pelvis (189.0-189.1) Incidence rate, men 12.8 - 15.6 4.6 5.8 Incidence rate, women 6.0 - - 2.3 2.8 Death rate, men 5.1 - - 1.3 1.9 Death rate, women 2.2 - - 0.9 7 Larynx (161) Incidence rate, men 12.7 - - 2.8 2.4 Incidence rate, women 2.5 - - - - Death rate, men 5.6 - - 0.9 - Death rate, women 0.9 - - - - Lung and bronchus (162.2-162.9) Incidence rate, men 117.0 81.1 14.4 52.1 52.6 Incidence rate, women 44.2 50.6 - 25,3 17.5 Death rate, men 105.6 69.4 - 40.1 29.8 Death rate, women 31.5 45.3 - 18.5 10.0 *Rates per 100,000, age-adjusted to the 1970 U.S. standard population. ‘U.S. Department of Health and Human Services 1989a. tIncludes persons of other ethnic groups who designated themselves as of Hispanic origin. SA] incidence data are from five states: Connecticut, Hawaii, lowa, New Mexico, and Utah; from six metropolitan areas: Atlanta (including 10 rural counties), Detroit, Los Angeles, San Francisco /Oakland, San Jose / Monterey, and Seattle /Puget Sound; and from the Alaska Area Native Health Service. 150 Chapter 3 Death and incidence data both indicate marked heterogeneity of cancer occurrence among racial/ ethnic groups in the United States, and this heteroge- neity extends to the cancer sites associated with ciga- rette smoking. For example, SEER data indicate that African Americans have higher incidence and death rates Tobacco Use Among U.S. Racial/Ethnic Minority Groups than whites for a number of smoking-related cancer sites, including the oral cavity and pharynx, esophagus, cer- vix uteri, larynx, stomach, pancreas, and lung (Table 6; Figure 4) (Kosary et al. 1995; NCI 1996b). When the ra- tios of African American to white incidence and death rates exceed 1.0 in Figure 4, then African Americans Hawaiian Japanese Korean Vietnamese White Hispanict 340 322 266 326 469 319 321 241 180 273 346 243 239 133 NA NA 213 129 168 88 NA NA 140 85 9.3 53.8 15.2 43.0 8.7 16.2 - 15 NA NA 2.5 3.4 9.4 5.6 - - 5.4 4.4 7 - - - 17 0.9 - 4.8 NA NA 5.3 3.4 - 0.9 NA NA 1.2 0.7 9.8 7.3 6.3 - 11.9 10.0 - 2.3 7 - 5.9 5.5 - 2.4 NA NA 5.0 3.7 - 0.8 NA NA 2.3 1.7 - 2.5 - - 7.5 5.1 - - - - 15 0.7 - - NA NA 2.3 1.9 ~ - NA NA 0.5 0.2 89.0 43.0 53.2 70.9 76.0 41.8 43.1 15.2 16.0 31.2 41.5 19.5 88.9 32.4 NA NA 72.6 32.4 44.1 12.9 NA NA 31.9 10.8 Estimates for all cancer sites are rounded to the nearest integer. National Center for Health Statistics, public use data tapes, 1988-1992, is the source for all death rates in this table. Death rates are U.S. mortality rates. **A dash means that the rate was not calculated for fewer than 25 cases. NA = data not available. Source: National Cancer Institute 1996b; National Center for Health Statistics, public use data tapes, 1988-1992. Health Consequences 151 Surgeon General's Report Table 6. Continued American Primary cancer site African Alaska Indian (ICD-9 code)’ American Native (New Mexico) Chinese Filipino Oral cavity excluding nasopharynx (140.0-146.9; 148.0-149.9) Incidence rate, men 20.44 - - 5.3 5.4 Incidence rate, women 5.8 — - 2.3 53 Death rate, men 8.7 - - 1.6 1.2 Death rate, women 2.1 - - 0.7 13 Pancreas (157) Incidence rate, men 14.0 - - 8.0 6.5 Incidence rate, women 11.5 - - 49 6.0 Death rate,* men 14.4 - - 6.7 4.5 Death rate, women 10.4 - - 5.1 3.5 Stomach (151) Incidence rate, men 17.9 27.2 - 15.7 8.5 Incidence rate, women 7.6 - - 8.3 5.3 Death rate, men 13.6 - - 10.5 3.6 Death rate, women 5.6 - - 4.8 2.5 Urinary bladder (188) Incidence rate, men 15.2 - - 13.0 8.3 Incidence rate, women 5.8 - - 3.7 2.1 Death rate, men 4.8 - - 2.0 1.2 Death rate, women 2.4 - - 1.0 - *Rates per 100,000, age-adjusted to the 1970 U.S. standard population. *U.S, Department of Health and Human Services 1989a. ‘Includes persons of other ethnic groups who designated themselves as of Hispanic origin. SA]l incidence data are from five states: Connecticut, Hawaii, lowa, New Mexico, and Utah; from six metropolitan areas: Atlanta (including 10 rural counties), Detroit, Los Angeles, San Francisco / Oakland, San Jose/Monterey, and Seattle / Puget Sound; and from the Alaska Area Native Health Service. experience excess morbidity and mortality from the can- cers shown. Also, SEER data for 1988-1992 show that whites have higher rates of some cancers than Hispan- ics, Asian Americans, Pacific Islanders, American In- dians, and Alaska Natives (Table 6) (NCI 1996b). US. mortality data for 1984-1988 show that American In- dians have a lower mortality rate from lung cancer than the general U.S. population but a higher mortality rate from cervical cancer (Table 7) (Valway 1992). Cervical Cancer In a case-control Los Angeles County study of invasive cervical cancer that included 98 English- speaking case-control pairs and 102 Spanish-speaking 152 Chapter 3 pairs, Peters and colleagues (1986) found that the over- all risk of such cancer was increased by cigarette smok- ing. The cervical cancer risk related to smoking was comparable in the two groups. Ina more recent study of the risk factors for cervical dysplasia among Hispanic and white women in New Mexico (Becker et al. 1994a,b), cigarette smoking was significantly asso- ciated with high-grade cervical dysplasia among white women but not among Hispanic women; however, this difference in risk was not statistically significant. In addition, in a recent pilot study of American Indian women in the Albuquerque IHS area, Becker and colleagues (1993) found that cigarette smoking was associated with cervical dysplasia; however, the results were not statistically significant. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Hawaiian Japanese Korean Vietnamese White Hispanic! 11.7 7.0 - 11.6 14.6 8.9 - 3.3 - - 5.8 2.7 2.4 NA NA 3.8 2.7 - 0.8 NA NA 15 0.7 10.9 8.7 - - 9.8 8.0 8.7 7.3 7.6 - 7.4 6.9 12.8 8.5 NA NA 9.7 7.1 9.1 6.7 NA NA 6.9 5.2 20.5 30.5 48.9 25.8 10.2 15.3 13.0 15.3 19.1 25.8 4.4 8.0 14.4 17.4 NA NA 6.1 8.4 12.8 9.3 NA NA 2.8 4.2 - 13.7 10.4 - 31.7 15.8 - 4.1 - - 7.8 4.3 - 2.0 NA NA 5.8 2.8 - 1.2 NA NA 17 0.9 Estimates for all cancer sites are rounded to the nearest integer. National Center for Health Statistics, public use data tapes, 1988-1992, is the source for all death rates in this table. Death rates are U.S. mortality rates. ** A dash means that the rate was not calculated for fewer than 25 cases. NA = data not available. Source: National Cancer Institute 1996b; National Center for Health Statistics, public use data tapes, 1988-1992. Esophageal Cancer Esophageal cancer incidence and death rates in the United States are highest among African Ameri- cans (Tables 2 and 6) (NCI 1996b). To assess potential causes of the high rates of death from esophageal can- cer found among African American men, Pottern and colleagues (1981) conducted a case-contro] study in Washington, D.C. After adjusting the data for alcohol consumption, they found that the relative risk of esophageal cancer among smokers was only margin- ally higher than among nonsmokers. In a more recent study, the risk for African American men of develop- ing squamous cell carcinoma of the esophagus was significantly elevated for smokers, even after adjust- ing statistically for age, geographic area, alcohol consumption, and income (Brown et al. 1994). Smoking mentholated cigarettes may also be a cause of the high and rising esophageal cancer rates among African Americans. Ina case-control study of data from the American Health Foundation’s ongoing tobacco study, Hebert and Kabat (1 989) failed to show a consistent effect of smoking mentholated cigarettes on the risk of esophageal cancer among African Ameri- cans. Better designed studies are needed to adequately address this hypothesis. Oral Cancer Tobacco use and alcohol use are the predominant risk factors for cancers of the oral cavity and pharynx (commonly referred to as oral cancer) (USDHHS5 1989b). African Americans have the highest oral Health Consequences 153 Surgeon General's Report Figure 4. rate for all ages, by cancer site 3.575 3.04 2.5974 2.04 1.57 Incidence 1.04 SEER®* cancer incidence and U.S. death rates, 1988-1992, ratio of African American rate to white 0.5 7 0.0 Death rate Cancer Site *National Cancer Institute’s Surveillance, Epidemiology, and End Results Program; rates are age-adjusted to the 1970 U.S. standard population. *Not otherwise specified. Source: Kosary et al. 1995. cancer incidence and death rates in the United States (Tables 2 and 6) (NCI 1996b). Using underlying cause- of-death data compiled by NCHS and U.S. census population enumerations and intercensal population estimates, investigators found that from 1950 to 1990, the death rate for cancers of the oral cavity and phar- ynx (age-adjusted to the 1970 age distribution of the U.S. population) decreased for white men from 6.6 to 4.2 per 100,000 population. However, for African 154 Chapter 3 American men, the death rate increased from 4.8 in 1950 to 11.0 in 1980 and subsequently decreased slightly, to 9.8 in 1990. From 1980 through 1990, the rate for African American men was approximately twice as high as that for white men. The death rate for cancers of the oral cavity and pharynx for African American women exceeded the rate for white women for nearly all of the 41-year period. The death rate increased slightly for white women, from 1.5 to 1.6, Surgeon General's Report Table 8. Odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of oral cancer associated with cigarette smoking, by race/ethnicity and smoking status, 1984-1985* African American White Smoking status ORt tcl ORt Cl Never smoked 1.0 1.0 No. of cigarettes per day* 1-19 1.2 0.5-2.6 1.2 0.8-1.7 20-39 2.1 1044 2.2 1.6-2.9 240 2.8 1.0-7.7 2.8 2.04.0 Years of cigarette smoking 1-19 0.9 0.3-2.4 0.6 0.4-1.0 20-39 1.6 0.7-3.3 19 1.3-2.5 240 2.9 1.2-7.2 3.3. 2.3-4.6 Age at smoking initiation (years) <17 1.8 0.8-3.9 2.0 1.4-2.7 17-24 17 0.8-3.8 1.9 1.4-2.6 225 1.2 0.4-3.6 2.2 14-3.5 Years since stopped smoking, O (never quit) 2.3 11-47 3.6 2.6-48 1-9 1.1 0.4-3.1 1.1 0.7-1.6 10-19 0.1 0.0-1.3 1.1 0.7-1.6 220 0.3 0.1-1.7 0.6 0.3-0.9 *Data from four population-based cancer registries in Los Angeles County and Santa Clara and San Mateo Counties near San Francisco-Oakland, metropolitan Atlanta, and the state of New Jersey. *ORs are adjusted for alcohol consumption, gender, age, study location, and respondent status and are rela- tive to persons who never smoked. tUsual number of cigarettes smoked daily when the persons smoked. Source: Day et al. 1993. 156 Chapter 3 Urinary Bladder Cancer The incidence of urinary bladder cancer in the United States is highest for whites (Table 6) (NCI 1996b). Among men, mortality is highest for whites; among women, mortality is highest for African Ameri- cans (Tables 2 and 6) (NCI 1996b). Differences in blad- der cancer risk associated with cigarette smoking for African Americans and whites have been examined in several case-control studies (Table 9), including the ongoing study conducted by the American Health Foundation (Harris et al. 1990), a population-based study conducted in the Detroit metropolitan area (Burns and Swanson 1991), and a population-based study carried out through SEER registries in 1978 (Hartge et al. 1993). In the American Health Founda- tion study, investigators found that although cigarette smoking was a significant risk factor for bladder can- cer among both whites and African Americans, the data suggested a steeper exposure-response relation- ship among whites (with significant increased risk beginning at exposures of 20 pack-years) than among African American men (with increased risk beginning only after 60 pack-years). However, in a multivariate analysis of the data for men, the risk of bladder cancer did not differ by race. The other two studies showed similar findings for both whites and African Ameri- cans in the association between cigarette smoking and bladder cancer. Ina smaller case-control study in Or- ange County, California, no significant interactions were found between smoking and race/ethnicity among whites, Hispanics, Asian Americans, or Pacific Islanders (Anton-Culver et al. 1993). Thus, informa- tion currently available suggests that smoking in- creases the risk of bladder cancer in a similar fashion among both whites and African Americans. In a co- hort study of 7,995 Japanese American men who were living in Hawaii, the risk of bladder cancer was 2.9 times higher in current smokers than in nonsmokers (Chyou et al. 1993). Aromatic amines, such as 4-aminobiphenyl, are considered causative chemical agents in cigarette smoke-induced bladder cancer (Bartsch et al. 1993). As with other potential carcinogens in tobacco smoke, aromatic amines require metabolic activation before interacting with DNA (Miller and Miller 1981). Acom- peting chemical pathway (ie., acetylation) exists and serves as a detoxification mechanism. Genotyping studies have characterized several variant alleles of the N-acetyltransferase gene, which can result in differ- ent rates of chemical acetylation. People who are slow acetylators have increased risk for bladder cancer (Hein 1988). Bell and colleagues (1993) determined Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 9. Odds ratios for the risk of urinary bladder cancer associated with smoking, by gender, race/ ethnicity, and smoking status Men Women Reference, study type, Smoking African African and year status American White American White Harris et al. 1990 Never 1.0 1.0 1.0 1.0 Multicenter, hospital-based, Former 1.6 2.1 1.3 1973-1985 Current 2.0 3.2 3.9% 3.2 Burns and Swanson 1991 Never 1.0 1.0 1.0 1.0 Detroit, population-based Ever 3.0 2.3 3.8 2.4 Pack-years < 30 1.9 1.5 3.1 1.7 30-59.9 4.0 2.6 3.8 2.9 60~89.9 4.7 2.7 5.0 3.5 > 90 4.8 3.0 5.2 2.7 Hartge et al. 1993 Never 1.0 1.0 1.0 1.0 SEER’ registries, Former population-based, 1978 Cigarettes smoked < 20 per day 1.6 13 3.6 2.0 2 20 per day 1.8 19 5.0 1.3 Current Cigarettes smoked < 20 per day 2.2 2.1 1.7 2.0 2 20 per day 4.5 3.0 2.1 3.1 *Ever smokers. *National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. that 41 percent of African Americans and 55 percent of whites were slow acetylators. A phenotyping study also found the highest percentage of slow acetylators among whites (54 percent), compared with African Americans (34 percent) and Asians (14 percent) (Yu et al. 1994). In the 1994 study by Yu and colleagues, slow acetylators had higher levels of 3- and 4-aminobiphenyl-hemoglobin adducts, regardless of race and level of smoking (Yu et al. 1994). For African Americans, Asians, and whites, however, the levels of 3- and 4-aminobiphenyl-hemoglobin adducts in- creased proportionately more for cigarette smokers compared with nonsmokers than for slow acetylators compared to rapid acetylators. In a subsequent study by Yu and colleagues (1995), the slow acetylation phenotype combined with the null genotype of the gene (GSTM1) for a phase II detoxification enzyme (glutathione S-transferase) resulted in higher levels of 3- and 4-aminobiphenyl-hemoglobin adducts than did lower risk profiles (i.e., rapid acetylator and/or at least one functional GSTM1 gene allele). The highest risk profile was seen in 27 percent of whites, 15 percent of African Americans, and 3 percent of Asians. Several studies show that the highest levels of risk are experienced by smokers, because high levels of exposure to tobacco smoke overwhelm the various phenotypic traits. The differences in risks for various detoxification and activation pathways appear to be most significant among persons who did not smoke or who smoked at very low levels (Yu et al. 1994, 1995; Landi et al. 1996). Health Consequences 157 Surgeon General’s Report Chronic Obstructive Pulmonary Disease In addition to causing lung cancer, tobacco smok- ing also causes several non-malignant diseases of the lung and increases the frequency of respiratory symptoms and illnesses (USDHHS 1989b, 1990). Chronic obstructive pulmonary disease (COPD) is a clinical term applied to persons with a permanent airflow obstruction associated with significant impair- ment (Samet 1989; USDHHS 1989b). Cigarette smok- ers with COPD have impaired breathing as a result of emphysema (air space enlargement and destruction) and damage to the airways (USDHHS 1984). These smokers also may have chronic bronchitis, which is the term used by epidemiologists and clinicians for chronic sputum production. Longitudinal studies show that the development of COPD follows sustained excessive loss of ventila- tory function of the lung caused by cigarette smoking (USDHHS 1984, 1990). The rate at which ventilatory function declines tends to increase with the amount smoked and to revert to the rate associated with aging after smoking cessation (USDHHS 1990). The fre- quency of chronic bronchitis is similarly related to smoking pattern. African Americans Data from several national surveys have been used to compare the prevalence of COPD among Afri- can Americans and whites. McWhorter and colleagues (1989) used data from the 1971-1975 National Health and Nutrition Examination Survey (NHANES I) and the 1982-1984 NHANES I Epidemiologic Follow-up Study (NHEFS) to determine the prevalence of COPD among 14,404 adults aged 25-74 years. African Ameri- can race/ethnicity was associated with a lower risk for having COPD; 6.2 percent of whites and 3.2 per- cent of African Americans had COPD. In the 1990 NHIS, the prevalence of self-reported chronic bronchitis was 55.2 per 1,000 African Ameri- cans aged 45-64 years and 42.7 per 1,000 African Americans aged 65 years and older (USDHHS 1991). The prevalence of self-reported emphysema was 3.6 per 1,000 middle-aged African Americans and 41.5 per 1,000 older African Americans. Compared with Afri- can Americans, whites in both age groups reported higher prevalences of chronic bronchitis (59.7 for those aged 45-64 years and 73.8 for those aged 65 years and older) and emphysema (13.8 for those aged 45-64 years 158 Chapter 3 and 46.1 for those aged 65 years and older). However, self-reports of chronic bronchitis and emphysema, without further validation, are probably subject to sub- stantial misclassification. African Americans are also less likely than whites to die of COPD (Evans et al. 1987; NCHS 1991). Evans and colleagues (1987) found that in 1982, the age- adjusted COPD death rate was 16.6 per 100,000 whites and 12.8 per 100,000 African Americans. Data for 1986— 1988 also show lower death rates from COPD among African Americans than among whites (Desenclos and Hahn 1992). More recent data (Table 2) show that Af- rican American men have higher death rates (17.6) for chronic airway obstruction than men in the other three racial/ethnic minority groups, although their rates are lower than rates among white men (20.4). The same pattern is also evident for deaths due to bronchitis and emphysema. The rate of COPD mortality is unexpect- edly low among African Americans, given their high prevalence of smoking and related high lung cancer rates. The reasons for this discrepancy remain to be explored. However, whites are more likely than Afri- can Americans to have ever smoked and to be former smokers (see Table 37 in Chapter 2). Mannino and colleagues (1997) have observed that death rates from obstructive lung disease relate to rates of ever smok- ing. These authors suggest that the differences in the race- and gender-specific relative rankings for obstruc- tive lung disease and lung cancer may be because long-term former smokers are more likely to develop obstructive lung disease than lung cancer. American Indians and Alaska Natives Little information is available on the occurrence of COPD among American Indians and Alaska Natives. In a 1987 survey of approximately 6,500 American Indians and Alaska Natives aged 19 years and older, 2.4 percent of men and 1.4 percent of women reported having emphysema, compared with 2.7 per- cent of men and 2.3 percent of women in the general U.S. population (Johnson and Taylor 1991), Rhoades (1990) studied hospitalization and death rates for COPD in American Indians and Alaska Natives. Although the death rates for COPD were lower than from other competing causes, such as chronic liver disease, diabetes, and injuries, the hospitalization rates for COPD exceeded those for cancer and tuberculosis. Additionally, hospitalization rates and death rates for COPD varied widely between geographic regions. The contribution of COPD to hospitalization rates ranged from 1.6 percent in the Navajo IHS area to 5.1 percent in the Bemidji area; COPD death rates per 100,000 ranged from 1.7 in the Albuquerque area to 10.3 in the Billings area (Rhoades 1990). Between 1992 and 1994, COPD death rates among American Indian men were approximately two-thirds the rates among whites (Table 2). Data from the Alaska area indicate that from 1979 through 1986, COPD death rates per 100,000 were 31.6 for Alaska Native men, compared with 40.3 for white men in Alaska and 38.3 for men in the United States as a whole (Coultas et al. 1994), The COPD death rates per 100,000 were 22.3 for Alaska Native women, compared with 34.8 for white women in Alaska and 18.6 for women in the United States as a whole. Similarly, death rates for COPD in New Mexico (Samet et al. 1988b) reflect the nationwide pattern of lower rates of death among American Indians compared with whites and are con- sistent with the lower smoking prevalence among tribes in the southwestern United States (Sugarman et al. 1992). The high rates of COPD among Alaska Natives are probably related to the fact that rates of smoking among Alaska Natives are higher than rates among American Indians elsewhere, particularly in the Southwest. Asian Americans and Pacific Islanders Information on COPD morbidity and death among Asian Americans and Pacific Islanders is sparse. National mortality data indicate that the prevalence of deaths from bronchitis and emphysema is lower in this group than among African Americans and whites (Table 2); the death rate from chronic airways obstruc- tion is lowest for Asian Americans and Pacific Island- ers. Data from California show that from 1986 through 1987, the overall prevalence of COPD deaths among “Asian and other” persons was lower than among whites but varied widely for specific Asian American and Pacific Islander subgroups (Asian American Health Forum, Inc. 1990). One of the oldest studies of Asian Americans— the Honolulu Heart Study, conducted in 1965—provides valuable age-related information on smoking and lung function among Japanese Americans. Of the 6,346 Japanese American men aged 46-68 years who under- went spirometric testing, 48 percent were current ciga- rette smokers, 25 percent were former smokers, and 27 percent had never smoked (Marcus et al. 1988). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Airflow obstruction was found in 11.7 percent of the participants. The prevalence of airflow obstruction increased with age and with the amount smoked. For most age and smoking categories, the prevalence of airflow obstruction was lower among Japanese Ameri- can men than among white men from Connecticut participating in the same study (Beck et al. 1981). In another recent analysis of data from the Ho- nolulu Heart Program, Japanese American men who continued to smoke showed steeper rates of decline in forced expiratory volume after one second (FEV,), a measure of pulmonary function, compared with never smokers. Among continuing smokers, FEV, decline was significantly associated with duration of smok- ing. Additionally, the rate of decline in FEV, among former smokers became more like that of persons who had never smoked (Burchfiel et al. 1995), consistent with previous reports on the benefits of quitting smok- ing (USDHHS 1990). In another analysis of data from the same study, Sharp and colleagues (1994) found that a diet composed of large amounts of fish may protect the lungs against damage from cigarette smoking. However, fish consumption was not associated with pulmonary function at higher levels of cigarette smok- ing (>30 cigarettes /day). Hispanics In the 1982-1984 Hispanic Health and Nutrition Examination Survey (HHANES), Puerto Ricans (2.9 percent) had a higher prevalence of reported chronic bronchitis than Mexican Americans (1.7 percent) or Cuban Americans (1.7 percent) (Bang et al. 1990). Chronic airflow obstruction (assessed using spirom- etry) was present in less than 1 percent of Hispanic adults surveyed in a New Mexico community (Samet et al. 1988a). Similarly, investigators who surveyed Mexican Americans in Tucson, Arizona, found a rela- tively low prevalence of physician-diagnosed COPD or related diagnoses (Di Pede et al. 1991). COPD has been reported to occur less frequently among Hispanics than among whites. Surveys in New Mexico have shown, for example, that physician- diagnosed chronic bronchitis or emphysema is less common among Hispanics than among whites (Samet et al. 1982, 1988a). Death rates from chronic obstruc- tive lung diseases and allied conditions are also lower among Hispanics than among whites (Tables 2 and 4). Mortality data for New Mexico indicate that between 1958 and 1982, Hispanic men had a lower death rate from COPD than white men; however, from 1958 through 1982, the death rate from COPD rose Health Consequences 159 Surgeon Generals Repert steeply among Hispanic men from 5.0 per 100,000 in 1958-1962 to 30.1 per 100,000 in 1978-1982 (Samet et al. 1988b). During this same time, COPD death rates in- creased among Hispanic women but remained compa- rable to rates among white women (Samet et al. 1988b). Little information is available on the risk of COPD among Hispanic smokers. In a 1979 respira- tory disease survey of Hispanic and white residents of New Mexico’s Bernalillo County, Samet and colleagues (1982) found that race/ethnicity was not a significant predictor of current or previous physician- diagnosed chronic bronchitis and emphysema and that no significant interaction existed between race/ ethnicity and cigarette smoking. Hispanic ethnicity also was not a significant predictor of the symptoms of chronic cough, chronic phlegm, or persistent wheeze. Similarly, the results of a survey of Hispanics Coronary Heart Disease and whites in Tucson indicated that race/ethnicity was nota significant determinant of respiratory symptoms, after survey data were adjusted for cigarette smoking (Di Pede et al. 1991). However, a recent cross-sectional study of urban pregnant women indicated that the prevalence of either doctor-diagnosed asthma or per- sistent wheeze without asthma was lower among a het- erogenous Hispanic population than among white women of similar socioeconomic background (these data were adjusted for cigarette smoking status, fam- ily history of asthma, educational level, household exposure to pets, and level of lung function). The au- thors did not conclude that their data provided evi- dence of biological protection from wheeze syndromes. An almost fivefold excess risk of persistent wheeze was detected in the total population of urban women who are current smokers (David et al. 1996). In 1994, cardiovascular diseases, comprising a diverse group of disorders including coronary heart disease (CHD), hypertension, stroke, and rheumatic heart disease, caused approximately 940,000 deaths in the United States (NCHS 1996a). The occurrence of specific cardiovascular diseases and their risk factors varies widely among the different racial/ethnic mi- nority groups. Of the cardiovascular diseases, CHD is the single largest cause of death; it results in approxi- mately 480,000 deaths annually in the United States. This section of the report focuses on CHD, which is also termed coronary artery disease or ischemic heart disease (IHD). Coronary artery disease results from atheroscle- rasis of coronary arteries. Anatomical lesions become evident in young adults and are usually clinically manifest in the fifth through seventh decades as angina pectoris, myocardial infarction, and sudden cardiac death (Enos et al. 1986; Strong 1986). In this chapter, these clinical manifestations of coronary artery disease are collectively termed CHD. Numerous non-modifiable and modifiable risk factors contribute to the development of CHD. The non-modifiable factors include aging, gender (men have greater risk), and family history of CHD. The major risk factors that are potentially modifiable include hypertension, cigarette smoking, obesity, hypercholesterolemia, diabetes mellitus, and physical 160 Chapter 3 inactivity (Smith and Pratt 1993). The 1983 Surgeon General's report on smoking and health concluded that “Cigarette smoking should be considered the most important of the known modifiable risk factors for coronary heart disease in the United States” (USDHHS 1983, p. iv). African Americans The first population-based epidemiological in- vestigations of cardiovascular diseases in the United States that included substantia] numbers of African American and white participants began in 1960 in Evans County, Georgia, and Charleston, South Caro- lina (Saunders 1991). Since 1960, follow-up data for these cohorts and a number of other epidemiological studies have provided information on the combined effects of race/ethnicity and various risk factors for cardiovascular disease. Consistent with findings for the general population, cigarette smoking increased risk of death from CHD among African Americans (Hames et al. 1993; Keil et al. 1995). Tyroler and colleagues (1984) examined deaths from CHD among the Evans County men, who were followed from 1960 through 1980, and found that the overall rate of death from CHD was lower among Af- rican Americans than among whites, with a ratio of 0.86. For current and former smokers, the probability of dying from all causes and from CHD was higher among whites with a low-socioeconomic status (on the basis of occupation, education, and source of income of the head of household) than among their African American counterparts. However, the analysis did not control for the number of cigarettes smoked, and the data were limited because of the small number of CHD deaths (31) among African Americans. In the Charleston Heart Study of CHD death rates between 1960 and 1990, Keil and colleagues (1993) found that the age-adjusted, African American- to-white death rate ratios were 0.90 for men and 1.2 for women. After controlling for age and other car- diac risk factors, the researchers found that smoking was associated with a slightly higher risk of dving of CHD among African American men than among white men. White women had a slightly higher risk of dying of CHD than did African American women. These racial/ethnic group differences were not tested for statistical significance, however. Other investigations that provide information on the risks for CHD and the modification of the effects of smoking, by race/ethnicity, include the Cancer Pre- vention Study I (CPS-[) (Garfinkel 1984), the NHEFS (Cooper and Ford 1992), the National Mortality Followback Survey (NMFS) (DeStefano and Newman 1993), and the ongoing study of Kaiser Permanente enrollees (Friedman et al. 1997). As part of the CPS-1, death patterns in the original cohort of one million people were described for 1959-1972. The observed- to-expected death rate ratios from CHD among Afri- can Americans and whites followed the same pattern as nationwide vital statistics described previously. Overall, the African American-to-white ratios of CHD deaths were 0.78 for men and 1.07 for women. Strati- fied analyses, by gender, of any effects that the amount of cigarettes smoked might have on CHD deaths showed little difference between African Americans and whites. Participants in the NHANES I, conducted be- tween 1971 and 1975, were reexamined between 1982 and 1984 as part of the NHEFS (Cooper and Ford 1992). Of the 12,599 participants in the follow-up survey, 10,741 were white and 1,858 were African American. The study showed that cumulative incidence rates of fatal CHD were higher among African Americans (6.2 percent of men and 3.7 percent of women) than among whites (5.6 percent of men and 2.6 percent of women). In contrast, cumulative incidence rates of nonfatal CHD were higher among whites (7.0 percent of men and 4.7 percent of women) than among African Ameri- cans (5.0 percent of men and 3.9 percent of women). The risk of new CHD events associated with cigarette Tobacco Use Among U.S. Racial/Ethnic Minority Groups smoking was similar among whites and African Ameri- cans. These results, however, are limited by the small number of new CHD events among African Ameri- cans and the low proportion (approximately 50 per- cent) of respondents for whom smoking information was collected at baseline. In a case-control study of CHD deaths among African Americans and whites, DeStefano and Newman (1993) used data from the 1986 NMFS to iden- tify case subjects (n = 803) and 1988 data from the BRFSS to identify control subjects (n = 25,398). When they compared the risk of death among smokers vs. persons who have never smoked (men aged 25-44 vears and women aged 25-54 years), the investigators found that among persons without diabetes, African American smokers had a lower relative risk for CHD death than white smokers. However, the 95 percent confidence intervals associated with these odds ratios overlapped each other—an indication that the differ- ence in risk was not statistically significant. In the Kaiser study, the risk of death from CHD has varied among African Americans and whites, but small num- bers limit interpretation of these findings (Friedman et al. 1997). American Indians and Alaska Natives Most of the available data on CHD among Ameri- can Indians and Alaska Natives have originated from studies of selected tribes, as reviewed by Young (1994). Investigations of heart disease in southwestern Ameri- can Indians and Alaska Natives conducted several decades ago showed a low prevalence of CHD rela- tive to the U.S. population and other racial/ethnic groups (Welty and Coulehan 1993). In a descriptive study of CHD deaths occurring from 1948 through 1952 among the Navajos, Smith (1957) found that the standardized death rate ratios for CHD among the Navajos compared with whites were 0.10 for men and 0.12 for women. Since then, numerous other regional investigations of CHD deaths and the incidence of CHD in other tribes of the United States and Canada have been reported. Overall, for studies conducted in the 1950s and 1960s, the ratios of CHD death rates among American Indians and Alaska Natives com- pared with nationwide rates have ranged from 0.1 to 0.5. An analysis of death statistics from the NCHS showed that crude CHD death rates for individuals classified as American Indians, Eskimos, or Aleuts declined from 100 per 100,000 in 1969-1971 to 67 per 100,000 for the years 1979-1981 (Gillum 1988). A re- view of New Mexico’s vital statistics for 1958-1982 indicates that for American Indian men, CHD death Health Consequences 161 Surgeon General's Report rates peaked at 101.7 per 100,000 between 1968 and 1972 and fell to 76.6 per 100,000 between 1978 and 1982 (Becker et al. 1988). For American Indian women, the CHD death rate peaked at 63.0 per 100,000 between 1963 and 1967 and declined to a low of 28.3 per 100,000 between 1978 and 1982. In a recent analysis of mortality data for 1992- 1994 (Table 2), the rate of death due to CHD was lower among American Indian and Alaska Native men (100.4) and women (45.9) than among white men (132.5) and women (62.9). The ratio of CHD death rates among American Indians and Alaska Natives com- pared with whites was .76 for men and .73 for women. The fact that these ratios are higher than ratios from earlier studies suggests that CHD deaths among American Indians and Alaska Natives may be increas- ing (Welty and Coulehan 1993; Young 1994). Risk factors for cardiovascular disease were in- vestigated recently in a large multi-tribal study of American Indians. The results showed that mean lev- els of total, low density lipoprotein, and high density lipoprotein cholesterol were lower in American Indi- ans than in the U.S. general population. Prevalence of hypertension, non-insulin dependent diabetes melli- tus, and obesity were very high, but varied consider- ably among tribes and geographic regions (Welty et al. 1995). Asecond study found that levels of serum cholesterol were lower in American Indian smokers who attended a stop smoking clinic than in African American and white smokers from population-based samples (Folsom et al. 1993). However, fibrinogen lev- els and the prevalence of abdominal obesity were higher in American Indian smokers than in African Americans and whites. The IHS is another source of nationwide and re- gional health statistics on CHD deaths. Because the mortality data in IHS reports combine all cardiovas- cular diseases under “diseases of the heart” (IHS 1994b), this information cannot be compared directly with CHD data from other sources. Between 1989 and 1991, diseases of the heart accounted for 21.9 percent of deaths in all IHS areas, with a crude death rate of 115.1 per 100,000 (IHS 1994b). These data indicate cardiovascular diseases were the leading cause of death among American Indians. However, because Indian race/ethnicity was underreported on death cer- tificates in several IHS areas, including California and Oklahoma as well as Portland, Oregon, this death rate may be incorrect. Death rates from heart diseases vary widely among people in the 12 [HS areas. From 1989 through 1991, the rate of death from heart diseases per 100,000 was lowest in the Albuquerque area (88.0) and high- 162. Chapter 3 est in the Aberdeen area (249.0) (IHS 1994a). These wide variations in deaths from diseases of the heart parallel the wide variations in the prevalence of ciga- rette smoking among the various tribes (Sugarman et al. 1992; Coultas et al. 1994) (see also Chapter 2). For example, in a 1985-1988 survey of adult American In- dians in the southwestern United States, 18.1 percent of men and 14.7 percent of women reported current smoking, compared with 48.4 percent of men and 57.3 percent of women in the Plains states (Sugarman et al. 1992), Data to assess the influence of tobacco use on the risk of cardiovascular disease among American Indians are extremely limited. One study has shown that cigarette smoking increases the risk for CHD among American Indians, after adjustment for other risk factors (Howard et al. 1995). In fact, most studies presented in this section describe cardiovascular dis- ease morbidity and mortality without ever assessing the influence of tobacco use. Nevertheless, cardiovas- cular disease is the leading cause of death among American Indians and Alaska Natives (NCHS 1996b), and tobacco use is an important risk factor for this disease. More studies are needed to evaluate the in- dependent effect of tobacco use on the risk of cardio- vascular disease among American Indians and Alaska Natives. Asian Americans and Pacific Islanders Limited data are available on risk factors and CHD among Asian Americans and Pacific Islanders in the United States (Yu 1991). A recent study of na- tionwide mortality indicated that Asian Americans and Pacific Islanders have lower rates of death from CHD than whites (Table 2). In an analysis of 1980 death rates in Los Angeles County, Frerichs and colleagues (1984) found that the - age- and gender-adjusted death rates for cardiovascu- lar diseases varied widely among Asian Americans and Pacific Islanders. Koreans had the lowest rate per 100,000 (82), and Japanese had the highest rate (162). These rates were substantially lower than the overall rate for the county population, with rate ratios of 0.26 for Koreans and 0.52 for Japanese. Specific data on CHD deaths and cigarette smoking prevalence were not available. In another study, Reed and colleagues (1983) used death records from Hawaii to describe age-adjusted, gender-specific, and racial- and ethnic-specific rates of CHD deaths occurring from 1940 through 1978. For all racial/ethnic minority groups, CHD death rates were higher among men than among women. Death rates and the temporal trends in deaths varied widely between the different groups, with the highest death rates among Native Hawaiians and the lowest among Japanese. Filipino men had the greatest increase in CHD death rates, surpassing the rates for whites in 1978. Although most of the other groups had declines in CHD death rates between 1960 and 1970, CHD death rates for Native Hawaiian men remained level. In 1965, three cohorts of Japanese men were as- sembled in Japan, Honolulu, and San Francisco to in- vestigate the differences in CHD deaths observed among Japanese men living in the three locales (Worth et al. 1975; Yano et al. 1988). From 1965 through 1972, Worth and colleagues (1975) found that age-specific death rates were highest among the San Francisco men, intermediate among those living in Honolulu, and low- est among those living in Japan. For example, among men 60-64 years of age, the annual CHD death rates per 1,000 were 4.9 in San Francisco, 3.9 in Honolulu, and 2.1 in Japan. Mortality data for 1965-1980 indi- cate that the age-adjusted CHD death rate ratio for men in Honolulu compared with men in Japan was 1.4 (Yano et al. 1988). The age-adjusted mean levels of most CHD risk factors, including cigarette smoking (measured in cigarette-years), were also higher among Honolulu men. After adjusting for these risk factors, the rate ratio for CHD declined to 1.17, indicating that more than half of the elevated CHD death rate was due to the higher mean levels of CHD risk factors among Honolulu men. In the Honolulu Heart Program cohort, com- posed of 7,705 Japanese men 45-68 years of age living in Hawaii who had no evidence of CHD at enrollment between 1965 and 1968, numerous analyses were con- ducted to further examine predictors of CHD incidence and death (Reed et al. 1982, 1987; Yano et al. 1984, Benfante et al. 1991). A higher level of acculturation was found to be associated with CHD risk factors and incidence during the 1971-1979 follow-up (Reed et al. 1982). Men who were primarily Japanese in culture smoked an average of seven cigarettes per day, whereas men who were more acculturated smoked an average of 11 cigarettes per day. A similar pattern was seen for total CHD incidence, which was highest among the men who were more acculturated (62 per 1,000) and lowest among the men who were primarily Japanese in culture (35 per 1,000). Yano and coworkers (1984) conducted detailed analyses of the relationship between risk factors and the incidence of CHD during a 10-year period, begin- ning after the enrollment period (1965-1968). Systolic blood pressure, number of cigarettes smoked, and cho- lesterol level were all independently associated with Tobacco Use Among US, Racial/Ethnic Minority Groups the occurrence of all CHD events. Alcohol consump- tion was found to be a protective factor. Subsequent analyses of 20-year follow-up data from the same study showed that cigarette smoking was independently associated, in a dose-response manner, with increased risk of CHD (fatal or nonfatal) and aortic aneurysm (Goldberg et al. 1995). The risk for angina was elevated in persons who smoked more than 20 cigarettes per day. Another analysis suggested that high levels of fish intake might limit the increased risk among heavy smokers, although these findings should be consid- ered preliminary (Rodriguez et al. 1996). In addition, cigarette smoking was found to be independently associated with increased prevalence of myocardial lesions in Japanese men with minimal evidence of coro- nary atherosclerosis at autopsy (Burchfiel et al. 1996). Hispanics Because of incomplete data, the NCHS reported data from 1985 death certificates on decedents of His- panic origin for only 17 states and the District of Columbia (NCHS 1996b). By 1990, data for 47 states and the District of Columbia were reported. The NCHS estimated that the 1990 reporting area encompassed 99.6 percent of the U.S. Hispanic population (NCHS 1996b). In 1993 and 1994, only Oklahoma did not pro- vide information on Hispanic origin (NCHS 1996a,b). Between 1992 and 1994, the overall rate of death from CHD in the United States was lower among His- panics than among whites (Table 2). Among the vari- ous Hispanic subgroups, Puerto Rican men had the highest death rates per 100,000 (118.6); similarly, CHD death rates among Puerto Rican women (67.3) were higher than among Mexican (44.2) and Hispanic (42.4) women. Nationwide death rates among Hispanics and whites have been estimated by using data collected by the U.S. Bureau of the Census as part of the Cur- rent Population Survey (CPS) (Sorlie et al. 1993). Baseline interview data were obtained between 1973 and 1985 from approximately 40,000 Hispanics and 660,000 non-Hispanics aged 25 years and older. Death rates for these two groups were ascertained up to nine years after the initial interview through the National Death Index. Age-adjusted death rate ratios for CHD were lower among Hispanics than among non- Hispanics (0.60 for men and 0.75 for women). Further details for the different Hispanic subgroups were not provided. In addition to nationwide data on the occurrence of CHD among Hispanics, regional studies have been conducted in California (Schoen and Nelson 1981; Health Consequences 163 Surgeon General's Report Frerichs et al. 1984), Colorado (Rewers et al. 1993), New Mexico (Buechley et al. 1979; Becker et al. 1988), and Texas (Stern and Gaskill 1978; Stern et al. 1987; Mitchell et al. 1991; Goff et al. 1993). In general, these investi- gations have consistently shown that Hispanic men have lower CHD death rates than white men, although the Colorado study found little evidence for lower CHD death rates among Hispanics without diabetes (Rewers et al. 1993). The prevalence of angina was also found to be lower among Hispanics than among whites in a re- view of data from a sample of Mexican Americans participating in the 1982-1984 HHANES and of whites surveyed in the 1976-1980 NHANES II (LaCroix et al. 1989). Prevalence rates based on self-reports were 2.8 percent among Mexican American men and 3.9 per- cent among white men, and they were 5.4 percent among Mexican American women and 6.3 percent among white women. As with African Americans, no significant differences were observed in the distribu- tion of cardiovascular disease risk factors among Mexi- can Americans with and without self-reported angina. The results of this survey were limited by the lack of smoking-specific analyses for Mexican Americans. Several investigators also have examined the car- diovascular disease risk factor profiles of Hispanics (Mitchell et al. 1991; Shea et al. 1991; Winkleby et al. 1993). Shea and colleagues (1991) analyzed 1989 BRFSS data on 636 Hispanics, most of whom were Puerto Ricans, Dominicans, and Cubans living in New York City. Although the overall risk factor profile was high among these Hispanic subgroups, the prevalence of current cigarette smoking varied by level of education. Mitchell and colleagues (1991) obtained information Cerebrovascular Disease on cardiovascular disease risk factors from 5,148 subjects, including 3,281 Mexican Americans, who participated in the San Antonio Heart Study from 1979 through 1988. The overall risk profiles were higher among Mexican Americans. For men of all ages, the prevalence of current smoking was higher among Mexican American men (36.7 percent) than among white men (30.4 percent). For women of all ages, how- ever, the prevalence of current smoking was lower among Mexican American women (21.0 percent) than among white women (26.8 percent). For both men and women, the number of cigarettes smoked per day was consistently lower among Mexican Americans than among whites. More recently, Winkleby and col- leagues (1993) examined the cardiovascular disease risk profiles of 756 Hispanics and 756 whites partici- pating in California surveys from 1979 through 1990. Hispanics and whites were matched by age, gender, educational level, city of residence, and time of sur- vey. Whites had a higher prevalence of smoking (34.2 percent) than Hispanics (24.0 percent), and they smoked more cigarettes per day (19.7) than Hispanics (11.4). Few investigators have compared the risk of smoking-related CHD between Hispanics and mem- bers of other racial/ethnic groups. Mitchell and co- workers (1991) determined the 1979-1988 prevalence of myocardial infarction among 3,281 Mexican Ameri- cans and 1,867 whites who participated in the San Antonio Heart Study. On the basis of either electro- cardiograms or self-reports, the risk of myocardial in- farction among Mexican Americans compared with whites was 24 percent lower for men but 40 percent higher for women. Race/ethnicity did not appear to modify the risk for myocardial infarction. Cerebrovascular disease is a major cause of mortality and morbidity in the United States every year. In 1994, a total of 153,306 deaths in the United States were caused by cerebrovascular disease (NCHS 1996a). Stroke, the major form of cerebrovascular disease, results from an interruption of the arterial blood sup- ply to the central nervous system, primarily the brain. Most commonly, the interruption of the arterial blood supply results from an occlusion of an artery in the brain by a thrombus, which may have resulted from atherosclerosis or blood clots froma diseased heart. A 164 Chapter 3 less common mechanism for development of stroke is rupture of a blood vessel in the brain. Other diag- noses under the general rubric of cerebrovascular disease include transient cerebral ischemia and cere- bral arteriosclerosis. As for CHD, risk factors for stroke may be divided into non-modifiable and modifiable charac- teristics. The non-modifiable factors include aging, gender, and family history of stroke. The major risk factors that are potentially modifiable include hyper- tension, hypercholesterolemia, diabetes mellitus, ciga- rette smoking, and heart disease (USDHHS 1989b). African Americans The rate of death from cerebrovascular disease in the United States is higher among African Ameri- cans than other racial /ethnic groups and whites (Table 2). For 1992-1994, the rate of death (per 100,000 popu- lation) from cerebrovascular disease was twice as high among African American men (53.1) as among white men (26.3) and almost twice as high among African American women (40.6) as among white women (22.6). Similar patterns have been observed in studies of persons belonging to health plans. Klatsky and cal- leagues (1991) determined the incidence of hospital- ization for cerebrovascular disease among 74,096 whites and 33,041 African Americans who were mem- bers of a prepaid health plan in northern California from 1978 through 1984. The relative risks for hospi- talization for hemorrhagic cerebrovascular disease, cerebral thrombosis, and nonspecific cerebrovascular disease were higher among African Americans than among whites. Because hypertension is the strongest risk factor for stroke, the high prevalence of hyperten- sion among African Americans partially explains this pattern (Braithwaite and Taylor 1992). Despite lim- ited data on the link between smoking and stroke among African Americans, the high rate of cigarette smoking among African Americans (see Chapter 2) clearly appears to have played a significant role in el- evating the risks of stroke in this population (USDHHS 1983). American Indians and Alaska Natives In recent years, age-adjusted death rates for cere- brovascular disease were slightly lower among Ameri- can Indian and Alaska Native men and women than among white men and women (Table 2). For example, from 1992-1994, the age-adjusted death rate per 100,000 population for cerebrovascular disease was 23.9 for American Indian and Alaska Native men, 26.3 for white men, 21.1 for American Indian and Alaska Native women, and 22.6 for white women. Young’s (1994) recent review of the literature in- dicates that few investigations have focused on cere- brovascular disease among American Indians or Alaska Natives. Middaugh (1990) found little differ- ence between the death rate from cerebrovascular dis- ease among Alaska Natives and persons of other race/ ethnicities, with death rate ratios of 1.13 for men and 1.03 for women. Ina review of 1958-1987 vital statis- tics data from New Mexico, Kattapong and Becker (1993) observed lower rates of death from cerebrovas- cular disease among American Indians than among Tobacco Use Among U.S. Racial/Ethnic Minority Groups Hispanics and whites. For American Indian men, cere- brovascular disease death rates per 100,000 peaked at 70.1 between 1968 and 1972 and fell to 31.3 between 1983 and 1987. Cerebrovascular disease death rates for American Indian women also peaked at 55.7 between 1968 and 1972 and declined to a low of 19.3 between 1983 and 1987. Asian Americans and Pacific Islanders From 1992 through 1994, the age-adjusted death rate per 100,000 population for cerebrovascular dis- ease was 29.3 for Asian American and Pacific Islander men, 26.3 for white men, 22.4 for Asian American and Pacific Islander women, and 22.6 for white women (Table 2). In a study of stroke deaths occurring between 1965 and 1972 among Japanese men living in Japan, Honolulu, and San Francisco, age-specific stroke death rates were highest among men living in Japan (Worth et al. 1975). Among men 60-64 years of age, annual death rates per 1,000 men were 5.4 in Japan, compared with 2.5 in San Francisco and 1.1 in Honolulu. For CHD, however, the death rates in Japan were lower than rates in Honolulu and San Francisco. Data from the Honolulu Heart Program suggest that other risk or protective factors associated with a Japanese diet, such as high alcohol intake and low intake of food from animal sources, may play important roles in the de- velopment of stroke and CHD in Honolulu and Japan, along with smoking, older age, high systolic blood pressure, and high serum cholesterol and glucose lev- els (Reed 1990). In a study of 1980 death rates among Asian Americans in Los Angeles, Frerichs and colleagues (1984) found that Koreans had the lowest age- and gender-adjusted death rate for cerebrovascular disease (48 per 100,000) and that Japanese had the highest rate (80 per 100,000). When the investigators compared the average age- and gender-adjusted death rates for these Asian Americans with rates for the entire county, the mortality ratio was 1.07 for Japanese and 0.65 for Koreans. Cigarette smoking was found to be an indepen- dent risk factor for stroke among men of Japanese ancestry who participated in the Honolulu Heart Program (Abbott et al. 1986). For all types of stroke, the estimated relative risk of smoking, adjusted for age and other major risk factors, was 2.5. This risk de- creased to 1.5 among men who quit smoking during the six-year follow-up period and increased to 3.5 among men who continued to smoke, indicating that cigarette smoking is a cause of stroke in Japanese men. Health Consequences 165 Surgeon General’s Report as A subsequent analysis of participants in the Honolulu Heart Program indicated that cigarette smoking sig- nificantly increased the risk for thromboembolic stroke (Goldberg et al. 1995). Hispanics Studies about stroke among Hispanics have fo- cused on the magnitude of this outcome in relation to other racial/ethnic groups. Between 1986 and 1988, the overall rate of death from cerebrovascular disease was lower among Hispanics than among whites in the United States (Desenclos and Hahn 1992). When cere- brovascular disease death rates for Hispanics and whites were compared, the mortality ratio for Hispanic men was 0.89, and the ratio for Hispanic women was 0.84. Of the different Hispanic subgroups, Mexican Americans had the highest death rates from cere- brovascular disease. Sorlie and colleagues (1993) had similar observations when they estimated death rates using census data collected between 1973 and 1985. Age-adjusted death rate ratios for cerebrovascular dis- ease were lower among Hispanics than among whites (0.60 for men and 0.76 for women). No details were provided for the different Hispanic subgroups. In more recent years, age-adjusted death rates for cere- brovascular disease were slightly lower among His- panic men and women than among white men and women. For example, from 1992-1994, the age- adjusted death rate per 100,000 population for cere- brovascular disease was 22.7 for Hispanic men, 26.3 for white men, 16.7 for Hispanic women, and 22.6 for white women (Table 2). Regional studies in California (Frerichs et al. 1984), New Mexico (Kattapong and Becker 1993), and Texas (Stern and Gaskill 1978) provide further evidence that Hispanics have a lower risk of death from cerebrovascular disease than do whites and African Smoking and Pregnancy Americans. Frerichs and colleagues (1984) compared 1980 death rates among the different racial/ethnic groups in Los Angeles County. The age- and gender- adjusted cerebrovascular disease death rates per 100,000 were 64 for Hispanics compared with 76 for whites (death rate ratio, 0.84) and 94 for African Americans (death rate ratio, 0.68). After reviewing New Mexico vital statistics data for 1958-1987, Kattapong and Becker (1993) described time trends in deaths from cerebrovascular disease among Hispanics, whites, and American Indians. Ex- cept for the period 1983-1987, Hispanic men had lower death rates than white men. From 1983 to 1987, the ratio of death rates among Hispanic men (45.8 per 100,000) compared with the rate among white men (36.1 per 100,000) was 1.27. For women, the pattern of death rates was less consistent. From 1958 through 1972, Hispanic women had higher death rates than white women; between 1973 and 1982, they had lower rates; and from 1983 through 1987, Hispanic women had slightly higher death rates (43.1 per 100,000) than white women (39.3 per 100,000). Stern and Gaskill (1978) examined temporal trends in stroke deaths from 1970 through 1976 among Hispanics and whites living in Bexar County, Texas, which includes San Antonio. Stroke deaths were gen- erally lower among Hispanic women, but no signifi- cant difference was observed between the rates among men of either racial/ethnic group. Furthermore, no temporal trends in stroke deaths were evident for either gender or racial/ethnic group. Cigarette smoking probably explains some of the risk of stroke among Hispanics. However, data to as- sess the strength of this relationship are not available. Because the data presented here suggest that stroke is a leading cause of morbidity and death among His- panics (NCHS 1993), future studies should examine the specific role that cigarette smoking plays. Smoking has long been known to be associated with poor outcomes for the infants of mothers who smoke. Mean infant birth weight and low birth weight (LBW) (<2,500 grams or <5.5 pounds) are often stud- ied as measures of fetal morbidity because birth weight is easy to measure. LBW can result either from preterm delivery (<37 weeks’ gestation) or from intrauterine 166 Chapter 3 growth retardation, but the distinction may be diffi- cult to make. Smoking has been associated with an average decrease in birth weight of about 200 grams as well as LBW, preterm birth, perinatal mortality, and infant mortality (USDHHS 1980, 1989b; Malloy et al. 1988; English and Eskenazi 1992). Evidence that the relationship between smoking and poor infant outcomes is causal has been strength- ened by recent studies that used biomarkers of tobacco exposure, such as saliva and serum cotinine (Bardy et al. 1993; Li et al. 1993; English et al. 1994). Bardy and colleagues (1993) demonstrated a dose-response rela- tionship between serum cotinine and decreased ges- tational age, decreased birth weight, and decreased crown-heel length. The exact mechanisms whereby smoke exposure affects the fetus are poorly understood. Carbon mon- oxide, which impairs oxygen delivery to the fetus, and nicotine, which impairs placental blood flow, have been implicated as the causative substances in tobacco smoke (USDHHS 1980). The infant outcomes most often studied have been LBW and infant mortality. Sudden infant death syndrome (SIDS) is an important component of infant mortality because it is the most common cause of death among infants older than one month of age. Available data show that LBW, infant mortality, and SIDS occur differentially in different racial/ethnic groups in the United States (Table 10) (Kleinman 1990; NCHS 1994). In general, whites have lower rates of these conditions and other racial/ethnic groups tend to have higher rates, but considerable variation exists. Several studies have reported different effects of smoking on LBW, infant mortality, and SIDS across racial/ethnic minority groups. This section focuses only on those studies that have investigated potential racial/ethnic group differences in the rela- tionship between smoking and infant outcomes. Studies of Low Birth Weight Nearly 25 years ago, the possibility was raised that smoking might have a differential effect on repro- ductive outcomes in different racial/ethnic groups (Lubs 1973). In a study of all singleton live births at Yale-New Haven Hospital in 1972, Lubs reported a dif- ference in the effect of maternal smoking on LBW among 783 African American and 3,415 white women. Astrong dose-response relationship was observed be- tween the number of cigarettes smoked during preg- nancy and infant LBW (defined as <2,500 grams for whites and <2,350 grams for African Americans). Among African American women, smoking 20 or more cigarettes per day was associated with a threefold in- crease in LBW, compared with only a twofold increase among white women. These racial/ethnic group dif- ferences were not explained by differences in age, prepregnancy weight, education, or marital status. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Several more recent studies also provide evidence for the possibility of a differential effect of smoking on LBW among white and African American women. English and colleagues (1994) used interview data from the Child Health and Development Studies, conducted from 1959 through 1966 in California. Stored serum samples were analyzed for cotinine, and the levels were compared with self-reported cigarette consump- tion and infant birth weight for 374 African American and 829 white pregnant smokers separately. African American pregnant smokers were found to have higher serum cotinine levels than white pregnant smokers after the data were controlled for smoking dose and demographic confounders. No racial/ ethnic minority group difference was found in the rate of decrease in mean birth weight per given amount of cotinine in the serum of women who smoked. These data suggest that cigarette smoking may have a greater effect on birth weight among African Americans than among whites because higher cotinine levels are present in African American women than in white women who smoke the same amount; the higher cotinine levels may result from a greater intake of to- bacco smoke per cigarette by African American women than by white women. Li and colleagues (1993) found a differential ef- fect of smoking reduction during pregnancy on infant birth weights among African American and white women. Study subjects were 803 participants in an experimental trial of smoking cessation for pregnant women in Alabama; self-reported smoking was vali- dated with saliva cotinine. Reduction was defined as a minimum drop in saliva cotinine values between the baseline (early pregnancy) visit and the late pregnancy visit. Smoking reduction increased the birth weight of infants of both African American and white women, but racial/ethnic group differences were present. Among white women, a reduction in smoking in- creased infant birth weight regardless of the baseline cotinine value. However, among African American women with high baseline cotinine values, a reduc- tion in smoking had no effect on infant birth weights. The authors suggested that high levels of cigarette smoking (as detected by high cotinine levels) early in pregnancy may have irreversible effects on African American infants. Another recent study reported a differential ef- fect of smoking on LBW (<2,500 grams) among multi- parous African American and white women, but in the opposite direction (Neggers et al. 1994). Among Afri- can American women, the investigators found no sig- nificant difference in birth weight between smokers Health Consequences 167 Surgeon General's Report Table 10. Rates of selected infant outcomes, by mother’s race/ethnicity,* United States African a fien an d Asian American and Pacific Islander Reference Outcome/years American Alaska Native Total Chinese Japanese Filipino Other NCHS, public Low-birth-weight use data tapes, (<2,500 grams) 19928 rate per 100 live births, 1992 13.4 6.6 5.2 7.9 74 6.9 NCHS Infant mortality 19948 rate per 1,000 live births, 1987 17.8 13.0 7.3 6.2 6.6 6.6 7.9 Kleinman 1990 Sudden infant death syndrome rate per 1,000 live births, 1983-1984 2.41 0.95 NA NA NA NA *The categories African American and white include persons of Hispanic and non-Hispanic origin. Conversely, persons of Hispanic origin may be included in other categories as well. *Reported for selected states only; reporting areas for Hispanic origin vary by year. and nonsmokers, whereas among white women, the infants of smokers weighed significantly less than those of nonsmokers. However, no information was available on the number or type of cigarettes smoked or the biomarker of exposure; these results were ad- justed only for the mother’s parity, age, height, and alcohol consumption as well as the infant's gender and gestational age at birth. In addition, the study was not designed to study the relationship between smok- ing and LBW but to determine whether the relation- ship between maternal triceps skinfold thickness and infant birth weight was modified by smoking and race/ethnicity. Two studies have reported that smoking is re- lated to an elevated risk of LBW among both African American and white women, but neither study found significant racial/ethnic group differences. Ina popu- lation-based, case-control study of African American and white women delivering singleton infants with- out congenital anomalies in a large urban county of California, the Alameda County Low Birth Weight Study Group (1990) found that the risk of LBW associ- ated with regular smoking throughout pregnancy was 3.0 (95 percent confidence interval [CI], 1.7-5.3) for white women and 3.6 (95 percent CI, 2.4-5.6) for 168 Chapter 3 African American women (adjusted for age, parity, prepregnancy weight, socioeconomic status, alcohol use, prior LBW birth, and prenatal care). Unfortu- nately, the authors were unable to adjust the data for the number of cigarettes smoked. Castro and colleagues (1993) reported a study of maternal smoking and substance abuse during preg- nancy and found similar associations between smok- ing during pregnancy and small size for gestational age (birth weight of less than the 10th percentile for gestational age) for African American and white women (odds ratio [OR] for African American women, 2.0 [95 percent CI, 1.3-3.1]; OR for white women, 2.4 [95 percent CI, 1.7-3.0]). These results were adjusted for maternal age, parity, marital status, in- surance status, alcohol use, marijuana use, and other drug use; however, no information was available on the number of cigarettes smoked or the biomarker of exposure. Few studies have examined the relationship be- tween smoking and LBW among Hispanic popula- tions. Cohen and colleagues (1993) analyzed birth weight data on 19,571 Hispanic infants and 206,973 white infants (those whose mothers did not indicate they were of Hispanic origin) born in Massachusetts Tobacco Use Among U.S. Racial/Ethnic Minority Groups Hispanic’ Mexican Central and Total American Puerto Rican Cuban South American Other! White 6.4 6.0 8.8 6.0 5.6 7.5 5.9 8.2 8.0 99 7.1 7.8 8.7 8.2 NA 0.84 1.38 0.83 0.53 1.52 1.21 tIncludes persons of unknown Hispanic origin. “Data calculated to one significant digit. NA = data not available. between 1987 and 1989 and found that the incidence of LBW ranged froma high of 73 per 1,000 Puerto Rican infants to a low of 32.2 per 1,000 Cuban infants. The crude percentage of LBW was higher for smokers than for nonsmokers in each racial/ethnic group; however, multivariate adjusted risks were not presented for racial/ethnic groups separately. Several studies have demonstrated associations between smoking and LBW in specific racial/ethnic minority groups, including Puerto Ricans (Becerra and Smith 1988), Mexican Americans (Wolff et al. 1993), North American Indians (Godel et al. 1992), and Afri- can Americans (Jacobson et al. 1994; Johnson et al. 1994). In each instance, smoking was shown to be re- lated to lower birth weight; however, these studies did not provide data on other racial/ethnic groups, which might have allowed comparisons. The percentage of LBW (<2,500 grams) in the United States in 1993 was higher overall for smok- ers (11.8 percent) than for nonsmokers (6.6 percent) (NCHS 1996b). Although a higher percentage of white mothers (16.8) smoked during pregnancy than did African American mothers (12.7), African American women had a higher percentage (13.3) of LBW live births than white women (6.0) did in 1993. Age- and racial /ethnic-specific analyses of population data may be more revealing. Land and Stockbauer (1993), for example, found that the teenage-specific LBW rate for African Americans in Missouri dropped by 13.6 percent from 1978-1990, concomitant with a drop in cigarette smoking prevalence among young African American mothers. Analyses of individual data sta- tistically controlled for confounding factors such as preterm deliveries and maternal parity, weight, and access to health care (USDHHS 1989a) would be pref- erable. The studies of individuals that are reported in this section provide more useful data than do popula- tion-based ecological comparisons on the relationship between cigarette smoking and the increased occur- rence of LBW in various racial/ethnic groups. Studies of Infant Mortality and Sudden Infant Death Syndrome Only one study has examined the risks of smok- ing associated with overall fetal and infant mortality in specific racial/ethnic groups (Kleinman et al. 1988). The authors used data from Missouri live birth, fetal death, and infant death certificates for births during Health Consequences 169 Surgeon General's Report Table 11. Risk of sudden infant death syndrome associated with smoking, by race/ethnicity, selected studies, United States African American Asian American and Pacific Islander American Indian and Alaska Native Reference Exposure/years OR* OR CI OR Cl Li and Daling Active smoking 19914 1984-1989 3.1 1,7-5.9 1.4 0.9-2.4 2.7 1.1-6.6 Schoendorf Passive exposure and Kiely 1988 1.8 1.0-3.0 NA NA NA NA 19928 Combined exposure 1988 3.1 2.3-4.2 NA NA NA NA Klonoff-Cohen Passive exposure et al.4 1995 1989-1992 5.0 1.1-22.8 NA NA NA NA *OR = odds ratio. tC] = 95% confidence interval. tLi and Daling assessed the risk, by mother’s ethnicity, associated with active maternal smoking during pregnancy; ORs are adjusted for maternal age, marital status, prenatal care, parity, and birth weight. ’Schoendorf and Kiely assessed the risk, by mother’s ethnicity, associated with (1) passive smoking (maternal smoking after birth but not during pregnancy) and (2) combined exposure (maternal smoking during pregnancy and after birth); ORs are adjusted for maternal age, education, and marital status. 4Klonoff-Cohen et al. assessed the risk, by infant’s ethnicity, associated with total passive smoke exposure from all adults (mother, father, live-in adults, and day-care providers); ORs are adjusted for birth weight, routine sleep position, medical conditions at birth, breast-feeding, prenatal care, and maternal smoking during pregnancy. NA = data not available. 1979-1983 to examine the risk of mortality associated with smoking during pregnancy. They found no sig- nificant variation in the effects of smoking on African American and white women, with adjusted ORs rang- ing from 1.3 to 1.6, depending on parity and the amount smoked. Three studies have examined the effects of smok- ing on SIDS in specific racial/ethnic minority groups (Table 11) (Li and Daling 1991; Schoendorf and Kiely 1992; Klonoff-Cohen et al. 1995). Li and Daling (1991) used data from Washington State birth records from 1984 through 1989, linked with infant death records. After adjusting the data for maternal age, marital sta- tus, prenatal care, parity, and birth weight, they found a statistically significant increased risk of SIDS associ- ated with maternal smoking during pregnancy in all racial/ethnic groups except American Indians (Table 170 Chapter 3 11). The ORs were not significantly different between groups, except between African Americans and Ameri- can Indians. No information was available on the num- ber of cigarettes smoked or the biomarker of exposure. Schoendorf and Kiely (1992) used data from the 1988 National Maternal and Infant Health Survey to study the association between SIDS and maternal smoking (either passive [only after birth] or combined [during pregnancy and after birth]) among infants of normal birth weight. They found similar increased risks of SIDS among African American and white in- fants exposed to maternal smoking (Table 11), after adjusting the data for maternal age, education, and marital status. Although white mothers reported heavier smoking than African American mothers, the authors did not adjust their findings for the number of cigarettes smoked. Hispanic White OR Cl OR CI 5.5 1.4-22.0 2.2 1.8-2.6 NA NA 3.1 2.34.2 NA NA 1.8 1.0-3.0 2.6 0.9-7.3 3.4 1.6-7.2 Klonoff-Cohen and colleagues (1995) conducted a 1989-1992 case-control study of passive smoking and SIDS in five counties in southern California. The OR for SIDS associated with all types of passive smoke exposure combined was 3.50 (95 percent CI, 1.81-6.75), after adjustment for birth weight, routine sleep posi- tion, medical conditions at birth, breast-feeding, pre- natal care, and maternal smoking during pregnancy. The evidence suggested a dose-response relationship, with an increased risk of SIDS associated with in- creased passive exposure to smoke. The authors also stratified the data by racial/ethnic group and found similar effects across groups (Table 11), although the results were not adjusted for the number of cigarettes smoked. Health Problems Affecting Pregnant Women Smoking is related to a variety of health prob- lems affecting pregnant women, ranging from ectopic pregnancy to abruptio placentae (USDHHS 1980; Rosenberg 1987), but race- and ethnic-specific data are not generally available. In addition to exploring smoking’s effects on fetuses and infants, future re- search should focus on the race- and ethnic-specific effects of smoking on the pregnant woman herself. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Implications The question of whether race- and ethnic-specific differences exist in the relationship between smoking and infant outcomes has not been satisfactorily resolved. Many intriguing questions have been raised, but investigators have not yet determined the exact nature of such differences or what factors mediate them. Comparative studies have been hampered by inconsistent and inadequate measurement of exposure. For example, few investigators have fully explored is- sues of dose of smoking such as the number of ciga- rettes smoked or the levels of biomarkers, although the amount of smoking during pregnancy does differ among racial/ethnic minority groups (see Chapter 2). Moreover, even though the timing of smoking during pregnancy may play a critical role in the development of LBW (Lieberman et al. 1994), few studies of LBW have separately assessed the effects of smoking dur- ing each trimester of pregnancy. Patterns of quitting and reducing smoking during pregnancy may in fact differ by race/ethnicity. Racial/ethnic group differences in nicotine me- tabolism may also be important (Wagenknecht et al. 1990; English et al. 1994). African American pregnant smokers appear to have higher serum cotinine levels than white pregnant smokers when the data are con- trolled for nicotine dose (English et al. 1994). Thus, fetal exposure may be higher among African Ameri- cans than among whites for a given number of ciga- rettes smoked. Racial/ethnic group differences in oxygen- carrying capacity may also play a role in mediating the effects of smoking. In 1973, Lubs suggested that the increased effects of smoking on birth weight among Af- rican American women might in part be explained by higher rates of sickle cell trait or glucose-6-phosphate dehydrogenase (G6PD) deficiency, which impair oxy- gen-carrying capacity (Lubs 1973). No published re- ports have examined Lubs’s hypothesis. In addition, anemia, which is more prevalent among African Ameri- can women, may be a risk factor for preterm delivery (Hogue and Yip 1989). Future studies of smoking and pregnancy outcomes should consider racial/ethnic group differ- ences in the timing of smoking during pregnancy, nicotine metabolism, and factors that affect oxygen- carrying capacity, such as sickle cell trait, G6PD defi- ciency, and anemia. Health Cousequences 171 Surgeon General’s Report Summary of Health Consequences from Active Cigarette Smoking Attempts to predict racial- and ethnic-specific rates of disease incidence and mortality from racial- and ethnic-specific cigarette smoking prevalences are of limited value, because other factors can also influence disease rates. When studies of individuals are con- ducted, the data lead to the conclusion that cigarette smoking is a major cause of disease and death in each of the four U.S. racial/ethnic minority groups studied in this report. These studies reveal few major differ- ences in the risk ratios for various diseases. Limited epidemiological and biological data suggest that Afri- can Americans may be at an especially high level of risk forlung cancer. Although further research could clarify the nature of the interrelationships between cigarette smoking, other risk factors, potential modi- fying factors, racial/ethnic group membership, and various disease outcomes, it is clear that reducing to- bacco use in each of the nation’s racial/ethnic groups will reduce the incidence and mortality from several of the nation’s leading causes of death and is a major public health goal to pursue. Effects of Exposure to Environmental Tobacco Smoke Environmental tobacco smoke (ETS) is the mix- ture of sidestream smoke and exhaled mainstream smoke that is produced by active smokers and then involuntarily inhaled by nonsmokers. Over the past decade, the adverse effects of ETS have been reported in the literature. The 1986 Surgeon General's report on smoking and health (USDHHS 1986a) concluded that the inhalation of ETS (labeled “involuntary smok- ing” in that report) is a cause of diseases, including lung cancer, in healthy nonsmokers and that the chil- dren of parents who smoke are more likely than the children of nonsmoking parents to have respiratory infections, respiratory symptoms, and abnormal matu- ration of lung function. Similar conclusions were also reached in 1986 by a committee of the National Re- search Council (1986). More recently, the U.S. Envi- ronmental Protection Agency (1992) assessed the risks associated with ETS, and the results reaffirmed that ETS is carcinogenic and that it exacerbates and may even cause childhood asthma. To date, racial/ethnic group differences in the adverse effects of ETS have not been investigated, although a number of studies have investigated racial/ethnic group differences in the level of exposure to ETS and in people’s reactions to ETS. Overpeck and Moss (1991) examined patterns of exposure to ETS among children five vears of age and younger included in the 1988 NHIS and found that exposure varied by race/ethnicity and socioeconomic status (Table 12). African American children were the most likely to be exposed to ETS, whereas Hispanic 172 Chapter 3 children were the least likely to be exposed to ETS. Moreover, in the CARDIA (Coronary Artery Risk De- velopment in [Young] Adults) study, the prevalence of exposure to ETS was significantly higher among African Americans (32 percent) than among whites (24 percent) (Wagenknecht et al. 1993). Overall, 28 per- cent of individuals 18-30 years of age were exposed to ETS, as detected by a serum cotinine level of 2-13 ng/mL. Adult survey data from the 1992 California Tobacco Survey show that Hispanics (21.3 percent) were most likely to report working around a cigarette smoker within the two weeks before the survey (Pierce et al. 1994). Asian Americans (13.2 percent) and Afri- can Americans (12.8 percent) reported being exposed to ETS at work in lower proportions than whites (17.9 percent). Data from the 1988 NHIS (CDC 1992) show that 40.3 percent of employed adults reported that cigarette smoking was allowed in their place of employment. The percentages of persons who reported experiencing discomfort caused by ETS ex- posure at work did not differ significantly by racial / ethnic group. Ina 1992-1993 study of U.S. adults who worked indoors, Asian Americans and Pacific Island- ers (51.4 percent) were the most likely and African Americans (43.3 percent) were the least likely to work under a completely smoke-free ETS policy (Gerlach et al. 1997). Since most studies suggest that differences exist in the ETS exposure of various racial/ethnic groups, studies to monitor the health effects of this exposure are needed. Table 12. Exposure to household smoke among children 5 years of age and yo distribution, by level of exposure since birth and selected characteristics, Tobacco Use Among U.S. Racial/Ethnic Minority Groups Percentage distribution” unger and percentage United States, 1988 Exposed since birth Number of Current Former children Not exposed smokerin smoker in Characteristic (in thousands)’ Total since birth Total? household household All children® 19,019 100.0 51.1 (0.9) 48.9 (0.9) 42.4 (0.9) 6.1 (0.4) Ethnicity African American 2,759 100.0 41.5 (2.4) 58.5 (24) 51.3 (24) 6.7 (1.2) White 15,575 100.0 51.9 (1.0) 48.1 (1.0) 41.6 (1.0) 6.1 (0.4) Hispanic origin Non-Hispanic 16,923 100.0 50.4 (1.0) 49.6 (1.0) 43.2 (1.0) 6.0 (0.4) Hispanic 2,096 100.0 56.4 (2.6) 43.6 (2.6) 35.8 (2.5) 6.9 (1.2) Mexican American 1,006 100.0 60.7 (4.1) 39.3 (4.1) 31.8 (3.8) 6.5 (1.5) Annual household income <$10,000 2,685 100.0 33.4 (2.1) 66.6 (2.1) 57.7 (2.3) 8.7 (1.1) $10,000-$24,999 5,436 100.0 44.3 (1.5) 55.7 (1.5) 48.8 (1.6) 6.3 (0.7) $25,000-$39,999 4,871 100.0 55.9 (1.7) 44.1 (1.7) 38.3 (1.6) 5.4 (0.7) >$40,000 4,149 100.0 65.7 (1.8) 34.3 (1.8) 29.5 (1.5) 4.6 (0.9) Poverty status* In poverty 3,376 100.0 36.4 (2.1) 63.6 (2.1) 55.7 (2.3) 7.6 (1.0) Not in poverty 14,582 100.0 54.8 (1.0) 45.2 (1.0) 39.2 (1.0) 5.6 (0.4) Mother’s education <12 years 3,279 100.0 33.3 (2.2) 66.7 (2.2) 61.2 (2.1) 5.1 (0.8) 12 years 8,014 100.0 44.5 (1.4) 55.5 (1.4) 47.9 (1.4) 7.3 (0.6) >12 years 7,505 100.0 66.3 (1.2) 33.7 1.2) 27.6 (1.1) 5.4 (0.6) Place of residence Metropolitan statistical area 14,550 100.0 51.5 (1.0) 48.5 (1.0) 42.2 (1.1) 5.9 (0.4) Central city 5,994 100.0 49.4 (1.4) 50.6 (1.4) 43.6 (1.5) 6.3. (0.6) Not central city 8,556 100.0 529 (1.4) 47.1 (14) 41.1 G4) 5.6 (0.6) Not metropolitan statistical area 4,469 100.0 49,7 (1.9) 50.3 (1.9) 43.1 (1.7) 6.8 (0.8) *Figures in parentheses are standard errors of estimates. texcludes children whose exposure status is unknown. Includes children exposed since birth whose period of expo SIncludes all other ethnicities, unknown household income, un and unknown assessed health status. “Poverty status determined in the National Health Interview household income by using 1987 poverty levels defined b Source: Adapted from Overpeck and Moss 1991. sure is unknown. known poverty status, unknown education of mother, Health Consequences Survey by family size, number of children, and y the U.S. Bureau of the Census. 173 Surgeon General's Report Effects of Smokeless Tobacco Use Smokeless tobacco refers to moist oral snuff, dry oral and nasal snuff, and chewing tobacco. Smokeless tobacco is commonly used by youths, particularly those in rural areas, and it is highly addictive (USDHHS 1986b; Boyd and Glover 1989). Among the adverse health effects of smokeless tobacco use are oral cancer, oral leukoplakia (white mouth lesions that may be precancerous), gingival recession, periodontal dis- eases, elevated blood pressure, and increased risk for cardiovascular disease (NCI 1992; USDHHS 1994; Bolinder et al. 1994). Few studies have examined the adverse health effects of smokeless tobacco use in racial/ethnic minority populations, and the research that has been conducted has been limited in several ways: (1) popu- lation-based, case-control studies rarely have sufficient numbers of racial/ethnic group members to allow group-specific analyses for groups other than African Americans (Blot et al. 1988; Day et al. 1993); (2) be- cause the use of smokeless tobacco and associated health effects are relatively rare in most racial/ethnic groups, the feasibility of conducting prospective in- vestigations is limited; and (3) smokeless tobacco us- ers often report current or past use of other substances, such as cigarettes and alcohol, that are risk factors for health effects also associated with smokeless tobacco use, such as oral cancer (Blot et al. 1988; Mattson and Winn 1989). These multiple risk factors complicate or preclude analysis of the independent effects of smoke- less tobacco use. The valid data that are available, however, indi- cate that for men, the prevalence of smokeless tobacco use is highest among American Indians, Alaska Natives, and whites; for women, the prevalence is highest among American Indians, Alaska Natives, and African Americans (CDC 1993c). Data for 1989-1991 show that rates of death from cancers of the lip, oral cavity, and pharynx have been higher among African American men (7.8 per 100,000) than among Puerto Rican men (3.9 per 100,000), Asian American and Pa- cific Islander men (3.4 per 100,000), and white men (3.2 per 100,000) (Table 2) (NCHS, public use data tapes, 1989-1991; U.S. Bureau of the Census 1993). In a case-control study, Winn and colleagues (1981) examined the estimated relative risk of oral and pharyngeal cancer associated with snuff-dipping among African American and white women in the southern United States. Although the relative risk was 174 Chapter 3 higher among white women (4.2) than among African American women (1.5), white women had dipped snuff for significantly longer periods and had con- sumed more snuff per week than African American women had. The relative risk for cancers of the gum and buccal mucosa increased with longer duration of snuff use, but this analysis was not conducted sepa- rately for African Americans and for whites. A few studies of the health effects associated with smokeless tobacco use have been conducted among American Indian and Alaska Native populations. Ina study of Navajo youths aged 14-19 years in New Mexico (Wolfe and Carlos 1987), 64 percent of the teen- agers used smokeless tobacco products. Oral] leuko- plakia was found in 26 percent of smokeless tobacco users, representing a ninefold increase in risk when these youths were compared with those who did not use smokeless tobacco. The estimated relative risk of leukoplakia increased with duration and frequency of smokeless tobacco use. The investigators observed no apparent differences between users and nonusers of smokeless tobacco regarding gingival bleeding, calcu- lus accumulation, or the extent or severity of gingival recession or loss of periodontal attachment. In a survey of students in grades 7-12 attending schools on the Rosebud Sioux Reservation in South Dakota, more than one-third of the students reported regularly using smokeless tobacco (CDC 1988). Of these regular users, 37 percent had oral lesions (iLe., any white or red wrinkled area in the mouth or buccal mucosa). The students with oral lesions had used smokeless tobacco for a mean of 3.4 years, 6.6 times per day, and they had held each dip or chew for an average of 40 minutes. Students who used smokeless tobacco but did not have lesions had used the product for a mean of 2.3 years, 2.9 times per day, and they had held each dip or chew for an average of 30 min- utes. This suggests a possible relationship between duration and intensity of smokeless tobacco use and the occurrence of oral lesions. The prevalence of oral lesions among nonusers of smokeless tobacco was not reported. The 1986-1987 National Survey of Oral Health in US. School Children conducted oral clinical exami- nations on 17,027 children aged 12-17 years who provided information on their use of various tobacco products (Tomar et al. 1997). Smokeless tobacco lesions (defined by the authors as slight to heavy wrinkling of the oral mucosa) were more common among white (2.0 percent) than among African Ameri- can (0.2 percent) or Hispanic (0.8 percent) school chil- dren. In white males, the strongest correlates of le- sions were, in order, current snuff use and current Tobacco Use Among ULS. Racial/Ethnic Minority Groups chewing tobacco use. Lesions were more common with increasing duration and frequency of smokeless tobacco use. Because of small sample sizes, analyses were not conducted on data for other racial/ethnic groups. Nicotine Addiction and Racial/Ethnic Differences Most smokers have difficulty quitting because they are addicted to nicotine (USDHHS 1988). Anun- derstanding of the role of nicotine addiction in deter- mining smoking behavior could help clarify racial/ ethnic differences in tobacco use and facilitate smok- ing cessation treatment. Nicotine addiction was reviewed extensively in the 1988 Surgeon General's report on smoking and health (USDHHS 1988). Con- cepts of addiction also have been reviewed in subse- quent Surgeon General’s reports (USDHHS 1989%b, 1994). However, relatively little research has been con- ducted on racial/ethnic minority differences in nico- tine addiction. This section provides a brief review of nicotine addiction and discusses the limited data on racial/ethnic differences and nicotine addiction. Nature of Addiction In the broadest sense, addiction (often used in- terchangeably with dependence) indicates a loss of control over drug-taking behavior. The World Health Organization describes drug dependence as “a behav- ioral pattern in which the use of a given psychoactive drug is given a sharply higher priority over other be- haviors which once had a significantly higher value” (Edwards et al. 1982). In other words, drug use con- trols one’s behavior to an extent considered detrimen- tal to the individual or to society. The criteria for drug dependence, described in the 1988 Surgeon General’s report on smoking and health (Table 13) (USDHHS 1988), include highly con- trolled or compulsive use of a drug, the use of a drug that produces psychoactive effects, and evidence that drug-taking behavior is reinforced by the effects of the drug. Other criteria for drug dependence have been developed by the American Psychiatric Association [APA] (1994) for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV™) (Table 14). These criteria are quite specific and useful in diagnosing drug dependence in individual patients. Pharmacologic Factors in Nicotine Addiction Nicotine addiction, like all drug addictions, is a complex process involving the interplay of pharma- cology, learned or conditioned factors, personality, social setting, and genetics (USDHHS 1988, 1994; Benowitz 1992a). The pharmacologic reasons for drug use include an enhancement of one’s mood or func- tioning. Drugs produce such effects either directly or by relieving withdrawal symptoms. The pharmaco- logic factors involved in nicotine addiction work in several ways. For example, positive effects reported after smoking tobacco include pleasure, arousal, and relaxation as well as improved attention, reaction time, and performance of certain tasks. In addition, ciga- rette smoking has been cited as effective in relieving aversive emotional states, including reducing anxiety or stress, relieving hunger and preventing weight gain, and relieving nicotine withdrawal symptoms (Table 15) (Benowitz 1992a). The pharmacology of nicotine addiction can be discussed in relation to several processes: (1) absorp- tion, distribution, and elimination of nicotine in the body (pharmacokinetics); (2) pharmacologic effects of nicotine on target organs (pharmacodynamics), and (3) translation of pharmacologic effects into behavior. These processes are reviewed in the following sections, and racial/ethnic differences are discussed when information is available. Absorption, Distribution, and Elimination of Nicotine in the Body Nicotine from tobacco smoke is absorbed rapidly across the lungs’ alveolar membranes and into the sys- temic circulation (Benowitz 1990). Following absorp- tion from the lung, concentrations of nicotine in the blood rise quickly and peak at the completion of smoking. Concentrations of nicotine in arterial blood leaving the lungs and heart are several times higher than those measured in venous blood (Henningfield Health Consequences — 175 Surgeon General's Report Table 13. Criteria for drug dependence Primary criteria Highly controlled or compulsive use Psychoactive effects Drug-reinforced behavior Additional criteria Addictive behavior often involves— stereotypic patterns of use use despite harmful effects relapse following abstinence recurrent drug cravings Dependence-producing drugs often produce— tolerance physical dependence pleasant (euphoric) effects Source: Adapted from U.S. Department of Health and Human Services 1988. et al. 1993). Within 10 to 19 seconds after the start ofa puff, nicotine is delivered to the brain. Rapid delivery of high concentrations of nicotine to the brain provides the possibility for rapid behavioral reinforcement from smoking and allows the smoker to control the concen- tration of nicotine in the brain and, hence, to modu- late the pharmacologic effects of nicotine. In contrast, the absorption of nicotine from smokeless tobacco is gradual, with blood levels peak- ing at the end of chewing tobacco or using snuff (Benowitz et al. 1988). Buccal-oral absorption results in a gradual increase in concentrations of nicotine in the brain, with relatively little arterial-venous disequi- librium. This pattern of absorption may provide a less intense pharmacologic reinforcement than that pro- duced by smoke inhalation but is sufficient to produce addiction. The level of nicotine in the body is determined by the balance of nicotine intake from tobacco and the rate of nicotine elimination from the body. Nicotine is eliminated primarily by hepatic metabolism, with a small amount (5-10 percent) excreted unchanged in the urine. The primary metabolite of nicotine is cotinine, which has been used as a measure of nicotine exposure (Benowitz 1996). Keenan and colleagues (1994, 1995) recently published preliminary data consistent with the hypothesis that cotinine has some 176 Chapter 3 psychoactive properties. These effects do not appear to be mediated by nicotine receptor agonism, but could play some role in nicotine addiction. The rate of me- tabolizing nicotine varies considerably from person to person (Benowitz et al. 1982). A person who metabo- lizes nicotine slowly would not need to take in as much nicotine to achieve a particular level of nicotine in the body as a person who metabolizes nicotine more rap- idly. The level of nicotine in the body appears to be positively correlated with the degree of nicotine de- pendence and negatively correlated with the likelihood of successful cessation therapy (USDHHS 1988, Pomerleau et al. 1990; Sutherland et al. 1992). Theoretically, racial/ethnic differences in the ab- sorption, distribution, or elimination of nicotine could influence the likelihood of developing nicotine depen- dence (see Racial/Ethnic Differences in Nicotine Me- tabolites later in this chapter for further discussion of this topic). Pharmacodynamics of Nicotine Nicotine acts on nicotinic cholinergic receptors in the brain and other organs of the body, enhancing the release of neurotransmitters such as acetylcholine, norepinephrine, dopamine, beta-endorphin, and sero- tonin (USDHHS 1988). The physiologic consequences of nicotine intake include behavioral arousal and sym- pathetic neural activation (Table 15) (Benowitz 1992a). The release of specific neurotransmitters has been speculatively linked to the various reinforcing effects of nicotine (Pomerleau and Pomerleau 1984). For ex- ample, the enhanced release of dopamine and norepi- nephrine may be associated with pleasure as well as appetite suppression, the latter of which may contrib- ute to lower body weight. The release of acetylcho- line may be associated with improved performance of behavioral tasks and improved memory, whereas the release of beta-endorphin may be associated with re- duced anxiety and tension. Although smokers give different explanations for smoking, most agree that smoking produces arousal, particularly with the first few cigarettes of the day, and paradoxically, smoking can also be calming or relax- ing, especially in stressful situations (Pomerleau and Pomerleau 1984; Benowitz 1992a). Consistent with reports of arousal, the smoking of cigarettes or the administration of nicotine is followed by electroencephalographic desynchronization, with an upward shift in the brain’s dominant alpha frequency and decreased total alpha and theta power (Pickworth et al. 1989). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 14. American Psychiatric Association diagnostic criteria for substance dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following consequences, occurring at any time in the same 12-month period: Tolerance, as defined by either— need for markedly increased amounts of the substance to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount of the substance. Withdrawal, as manifested by either— the characteristic withdrawal syndrome* for the substance or the same (or a closely related) substance being taken to relieve or avoid withdrawal symptoms. Consumption of the substance in larger amounts or ov er a longer period than was intended. Having a persistent desire to cut down or control substance use or unsuccessfully trying to do so. Spending a great deal of time in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects. Giving up or reducing important social, occupational, or recreational activities because of substance use. Continuing to use the substance, despite the knowledge that one has a persistent or recurrent physical or psychological problem likely caused or exacerbated by recognition of cocaine-induced depression or continued worsened by alcohol consumption). the substance (e.g., current cocaine use despite drinking despite recognition that an ulcer was “The characteristic withdrawal syndrome for nicotine refers to the daily use of nicotine for at least several weeks and abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by four or more of the following signs: dysphoric or depressed mood; insomnia; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; increased appetite or weight gain. Source: Adapted from American Psychiatric Association 1994. Several researchers have studied the effects of cigarette smoking and nicotine administration on the behavior of smokers who have abstained from tobacco use (abstinent smokers) (USDHHS 1988; Hughes et al. 1990; Warburton 1990; Le Houezec and Benowitz 1991; Heishman et al. 1994). Many of these studies have shown that nicotine restores tobacco-abstinence- related deficits in attention and short-term memory and decreases reaction time (Peeke and Peeke 1984; USDHHS 1988; Snyder et al. 1989; Snyder and Henningfield 1989; Warburton 1990; Levin 1992: Pritchard et al. 1992). Nicotine also may increase a person's vigilance in performing repetitive tasks and increase selective attention in abstinent smokers. The effects of nicotine on the cognitive functioning of non- smokers have not been clearly identified (USDHHS 1988; Heishman et al. 1994). Smokers commonly re- port pleasure, mental stimulation, and reduction of stress after smoking a cigarette (McKennell 1970; Russell et al. 1974). Cigarette smoking and nicotine also have sym- pathomimetic action, producing brief increases in blood pressure, heart rate, and cardiac output with cutaneous vasoconstriction (Benowitz 1988). Nicotine causes muscle relaxation by stimulating discharge of the Renshaw cells and pulmonary afferent nerves, which inhibit motor neuron activity and relax certain muscles. However, not all muscles are relaxed; increased electromyographic activity and tonicity of the large upper-back muscles (trapezius) have been observed after smoking (Fagerstr6m and Gotestam 1977). Health Consequences 177 Surgeon General's Report Table 15. Human pharmacology of nicotine Primary effects* Withdrawal symptoms Pleasure Arousal, enhanced vigilance Improved task performance Relief of anxiety Reduced hunger Body weight reduction Electroencephalogram desynchronization Increased circulating levels of catecholamines, vasopressin, growth hormone, adreno- corticotropic hormone (ACTH), cortisol, prolactin, beta-endorphin Increased metabolic rate Lipolysis, increased free fatty acids Heart rate acceleration Cutaneous and coronary vasoconstriction Increased cardiac output Increased blood pressure Skeletal muscle relaxation Irritability, restlessness Drowsiness Difficulty concentrating, impaired task performance Anxiety Hunger Weight gain Sleep disturbance Cravings or strong urges for nicotine Decreased catecholamine excretiont Heart rate slowing* *Some of these effects are related in part to relief of withdrawal symptoms. ‘May represent a return to baseline rather than true withdrawal. Source: Benowitz 1992a. Genetic differences in the number of nicotinic receptors and pharmacologic responses to nicotine have been well demonstrated in animals (Marks et al. 1991). Genetic differences in pharmacologic responses to nicotine could underlie different susceptibilities to nicotine addiction, as appears to be the case for cer- tain types of alcohol addiction (Hughes 1986; Cloninger 1987; Carmelli et al. 1992). Genetic suscep- tibility may vary by ancestry of origin (for example, sickle cell disease and African American ancestry). Genetic differences in nicotine responsiveness associ- ated with ancestry of origin remain to be explored. Tolerance, Withdrawal, and Addictive Tobacco Use With prolonged or repeated exposure to nicotine, neurologic changes (neuroadaptation) occur. In ani- mals, chronic nicotine exposure results in an increased number of nicotinic receptors in the brain (Marks et al. 1985). During the course of these changes, the 178 Chapter 3 smoker develops more brain nicotinic receptors and an increased tolerance to the various effects of nico- tine. For example, previous studies have shown that at autopsy, the number of nicotinic receptors was greater in the brains of cigarette smokers than in those of nonsmokers (Benwell et al. 1988). Smokers develop substantial tolerance to the behavioral arousal and cardiovascular effects of nicotine in the course of a single day (Benowitz et al. 1989b). They can regain sensitivity to the effects of nicotine, at least in part, after overnight abstinence from smoking. As a consequence of these neurologic changes, nicotine withdrawal symptoms appear when nicotine use is abruptly stopped (Table 16) (Hughes and Hatsukami 1992). Withdrawal symptoms include rest- lessness, irritability, anxiety, drowsiness, impatience, confusion, impaired concentration, and depression (Hughes et al. 1990). Some abstaining smokers gain weight, and others have impaired performance measures, such as reaction time. Many abstaining Table 16. Incidence” of nicotine withdrawal symptoms, United States Clinic Self- attendees quitters Symptom (%) (%) Anxiety 87 49 Irritability 80 38 Difficulty concentrating 73 43 Restlessness 71 46 Hunger 67 53 Craving 62 37 Nocturnal awakenings 24 39 Depression NA 31 *Percentage of subjects with postcessation ratings greater than precessation ratings 2 days after they quit smoking. NA = data not available. Sources: Hughes 1992; Hughes and Hatsukami 1992. Adapted from Hughes and Hatsukami 1992. smokers have a strong craving to smoke a cigarette. Most of the withdrawal symptoms reach maximal in- tensity 24 to 48 hours after cessation and gradually diminish in intensity within three to four weeks (Gross and Stitzer 1989; Hughes et al. 1990), although some individuals experience longer lasting symptoms (USDHHS 1988). These symptoms, which also appear after quitting the use of smokeless tobacco (CDC 1994) or nicotine gum, are relieved following the adminis- tration of nicotine—a strong indication that the with- drawal symptoms are related to the effects of nicotine. The degree of nicotine dependence is determined in part by the level of nicotine that accumulates in smokers. In general, the level of accumulated nicotine is proportional to the number of cigarettes smoked per day. Consistent with the concept of a daily tolerance- withdrawal cycle, a short duration of time between awakening and smoking the first cigarette is associ- ated with a high degree of nicotine dependence (Heatherton et al. 1989). This presumably reflects an effort to relieve nicotine withdrawal symptoms. These two factors—the number of cigarettes smoked per day and the amount of time from awakening to smoking the first cigarette—are commonly used to assess the severity of nicotine dependence (Fagerstrém and Schneider 1989). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Level of Addiction Assessments of the level of nicotine addiction help predict responses to nicotine and serve as a potential guideline for therapeutic approaches to smoking cessation. The professionals who design strat- egies to prevent tobacco use and treat persons with nicotine addiction need to understand the high level of addiction among cigarette smokers and to appreci- ate the group-specific cultural characteristics of the be- havior and smokers’ individual reasons for initiating, continuing, and quitting tobacco use (Krasnegor 1979; Grunberg and Acri 1991). The most widely used in- dexes of addiction levels are the number of cigarettes smoked per day, the serum nicotine or cotinine level, the Fagerstrom dependence questionnaire (Fagerstrom and Schneider 1989), and the diagnostic criteria of the DSM-IV™ (APA 1994). The Fagerstrém dependence questionnaire incorporates questions about the num- ber of cigarettes smoked per day, the time between awakening and smoking the first cigarette of the day, as well as episodes in which the smoker lost control of smoking behavior (such as smoking at inappropriate times or in inappropriate places). The prevalence of smoking cessation—and conversely, the number of unsuccessful quit attempts—also reflects the level of addiction, at least in part. The brand of cigarette smoked might be expected to correlate with a person’s level of dependence because high-yield cigarettes nominally deliver more nicotine per cigarette. How- ever, in large surveys of smokers, only a modest rela- tionship was found between yield (measured by a smoking machine) and levels of nicotine or cotinine in the body (Benowitz et al. 1986; Coultas et al. 1993). This is because people smoke differently than ma- chines that are set to a standardized testing protocol— that is, they are able to take more frequent or deeper puffs, to smoke each cigarette more completely, to smoke more cigarettes per day, and to block ventila- tion holes in the cigarettes (Henningfield et al. 1994; NCI 1996a). Racial/Ethnic Differences in Nicotine Metabolites Evidence suggests that African Americans have higher cotinine levels per reported number of ciga- rettes smoked per day than whites (Wagenknecht et al. 1990; English et al. 1994; Clark et al. 1996a) (Figure 5). In Figure 5, the racial/ethnic minority group com- parisons among those who smoked 25 or more ciga- rettes per day may be somewhat biased, because the average daily consumption for whites was substantially higher than that for African Americans and Mexican Health Consequences 179 Surgeon General's Report Figure 5. Serum cotinine levels by number of cigarettes smoked daily for African Americans, Mexican Americans, and whites, National Health and Nutrition Examination Survey, United States, 1988-1991 350- a African 300-4 American Mexican ize ‘ 250-| American a CL] White Sp 200-4 rs E BS 2 iS ‘2 150- BS 5 x 7 i 100- RS 50~ 0 _ HR <1 1-<8 8—<15 15-<25 Average number of cigarettes smoked per day (past 5 days) Note: N = 2,136. Source: National Center for Health Statistics, public use data tape, 1997. Americans. Clark and colleagues (1996b) found no evidence that underreporting of daily cigarette con- sumption occurred more often in African American than in white smokers. One possible explanation for the higher cotinine level among African Americans is that African Ameri- cans may absorb more nicotine from their cigarettes than whites (Benowitz et al. 1995). Greater absorp- tion could result from several factors, including group- specific patterns of smoking behavior (i.e., more and deeper puffs per cigarette or longer retention of tobacco smoke in the lungs) (Benowitz et al. 1995). Addition- ally, menthol in cigarettes may facilitate absorption of cigarette smoke constituents (Jarvik et al. 1994; McCarthy et al. 1995; Clark et al. 1996a). However, the fact that African Americans smoke menthol ciga- rettes more commonly than whites do explains only a small percentage of their higher levels of cigarette 180 Chapter 3 smoke constituents (Wagenknecht et al. 1992; Ahijevych et al. 1996; Clark et al. 1996a). Racial/ethnic differences in nicotine metabolism could influence the development of nicotine addiction. Several researchers have suggested that African Ameri- cans might metabolize cotinine differently than whites (Pattishall et al. 1985; Wagenknecht et al. 1990; English et al. 1994; Benowitz et al. 1995). Results of studies of nonsmokers support this hypothesis (Pattishall et al. 1985; Wagenknecht et al. 1993; Crawford et al. 1994; Knight et al. 1996; Pirkle et al. 1996). Most of these investigations (Pattishall et al. 1985; Crawford et al. 1994; Knight et al. 1996; Pirkle et al. 1996) reported that African Americans had higher cotinine levels than whites, even after ETS exposure and other factors were taken into account. These findings may be limited by the fact that no measures of tobacco smoke or nicotine concentrations in the air were obtained. Based on a preliminary report of data for 40 Af- rican Americans and 39 white controls matched for age, gender, and cigarette consumption, Benowitz and col- leagues (1995) reported that the disposition kinetics of nicotine were similar for both groups. For example, the percentage conversion of nicotine to cotinine was similar across groups. However, the clearance of cotinine was significantly lower for African Americans than for whites. Additionally, the average estimated intake of nicotine per cigarette smoked was 1.41 mg in African Americans and 1.09 mg in whites. This differ- ence is of borderline statistical significance (p = 0.07) (Benowitz et al. 1995). African Americans took in 28 percent more nicotine per cigarette than would have been expected based on FTC yields; whites took in 9 percent more nicotine per cigarette than would have been expected based on FTC yields (Pérez-Stable et al., unpublished data). Investigators have also found cotinine levels in African Americans that were higher than expected for the number of cigarettes smoked. Ahijevych and Wewers (1993) found an average salivary cotinine level of 402 ng/mL in African American women who smoked an average of 15 cigarettes per day. This level is much higher than the expected level found in other persons who smoked the same number of cigarettes. Clark and colleagues (1996b) reported that African American smokers smoked longer cigarettes and more of each cigarette than white smokers. However, be- cause they smoked fewer cigarettes each day, African Americans smoked fewer total daily millimeters of cigarettes. Among young adults in the CARDIA study, African Americans (48 percent) were more likely than whites (36 percent) to report that a substantial amount of their cigarette burned without their smoking it (Wagenknecht et al. 1992). Also, in a study of 33 Afri- can American and white women, Ahijevych and colleagues (1996) did not find a racial/ethnic differ- ence in total puff volume (per cigarette). Pérez-Stable and colleagues (1990) reported that among Mexican Americans who were part of the 1982-1984 HHANES, cotinine levels were unexpect- edly high in smokers reporting low levels of cigarette consumption. Higher-than-expected cotinine levels may reflect underreporting of smoking by Hispanics, but the possibility also exists that Hispanics absorb or metabolize nicotine differently than whites (Henningfield et al. 1990). However, recent data from NHANES III (Figure 5) indicate that, among persons who smoked at least one cigarette daily, Mexican American smokers had lower serum cotinine levels in each consumption category than African American and white smokers. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Racial/Ethnic Differences in Self-Reported Nicotine Dependence The use of questionnaires to systematically in- vestigate racial/ethnic differences in nicotine depen- dence has been limited. Data from the 1987 NHIS (Table 17) show that African Americans were more likely than whites and Hispanics to report smoking their first cigarette of the day within 10 minutes of awakening, although these differences tended to dis- appear among those who reported smoking 25 or more cigarettes per day (NCHS, public use data tapes, 1987). Telephone survey data on smoking, collected as part of the Community Intervention Trial (COMMIT) for Smoking Cessation, also indicate that African Ameri- cans were more likely than whites to smoke within 10 minutes of awakening (an indicator of nicotine depen- dence [USDHHS 1988]), even after the researchers con- trolled for the number of cigarettes smoked per day (Royce et al. 1993). Conversely, Andreski and Breslau (1993) conducted a study that used the dependence criteria of the DSM-III™ and found that, compared with African Americans, greater proportions of whites had symptoms of nicotine dependence. The research- ers randomly selected 1,200 adults aged 21-30 years from the members of a health maintenance organiza- tion in southeast Michigan. Overall, 22.6 percent of the whites who smoked met the criteria for nicotine dependence, compared with 9.3 percent of the Afri- can Americans who smoked. Nicotine dependence was found to have a significant association with psychological distress, as measured by the Brief Symp- tom Inventory for smokers in both groups. Poor physical health was also associated with nicotine de- pendence, and this relationship was stronger among African Americans than among whites. Kandel and colleagues (1997) used questions from the 1991, 1992, and 1993 (combined) National Household Surveys on Drug Abuse (NHSDAs) to de- velop a proxy measure of DSM-IV™ (APA 1994) de- pendence on various substances (including nicotine). Respondents were asked, for example, if they felt un- able to reduce their use when they tried to cut down, experienced withdrawal symptoms (described in this survey as feeling sick because they stopped or cut down), felt that they needed or were dependent on the substance, and felt the need for larger amounts to obtain the same effect. This study used responses from 87,915 persons aged 12 years and older. Among per- sons who smoked during the previous year, whites were more likely than African Americans, Hispanics, and other racial/ethnic minority group members to be rated as dependent on nicotine. The authors Health Consequences 181 Surgeon General's Report Table 17. Percentage of adult smokers" who reported that they smoked their first cigarette within 10 minutes and within 30 minutes of awakening, by race/ethnicity and number of cigarettes smoked per day, National Health Interview Survey, United States, 1987 African Americans Hispanics Whites Characteristic % +cr* % +CI % +CI 1-14 cigarettes <10 minutes 21.9 4.9 11.3 5.3 11.1 2.1 <30 minutes 39.2 5.5 26.2 7.3 27.1 3.0 15-24 cigarettes $10 minutes 51.7 8.4 32.7 10.3 36.9 2.4 $30 minutes 77.6 5.9 61.3 10.3 68.4 2.5 225 cigarettes £10 minutes 69.0 18.0 63.3 17.2 61.9 3.0 $30 minutes 95.6 3.6 93.4 8.2 88.8 1.8 ‘Persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. *95% confidence interval. Source: National Center for Health Statistics, public use data tapes, 1987. acknowledged that their study was limited somewhat because the NHSDA indicators of dependence were not based on diagnostic interviews designed specifi- cally to assess DSM-IV™ criteria. Nevertheless, the finding that whites were more likely to exhibit indica- tors of dependence than African Americans was con- sistent with that of Andreski and Breslau (1993). Fur- ther research is needed to resolve the apparent dis- crepancy for African Americans between studies that are based on the number of minutes to the first ciga- rette of the day and those that are based on DSM-III or DSM-IV™ criteria for dependence. Navarro (1996) used population-based data from the 1990 California Tobacco Survey on white (n = 70,997) and Hispanic (n = 28,000) adults. Her analy- ses indicated that whites were significantly more likely than Hispanics to smoke ona daily basis and to smoke at least 15 cigarettes each day. Furthermore, among the daily smokers, whites were more likely than Hispanics to smoke a cigarette within 30 minutes of awakening. Among Hispanics, those who were less acculturated (i.e., who came from households where the language spoken in the household was not English) were significantly less likely than those who were more acculturated (i.e., who came from households where English was the language spoken) to be daily smokers and to smoke at least 15 cigarettes each day. Among 182 Chapter 3 Hispanics who were daily smokers, the percentage who smoked within 30 minutes of awakening did not differ significantly by level of acculturation. Smoking to maintain a lower body weight is be- lieved to contribute to tobacco dependence. In a sur- vey of high school students in Memphis, Tennessee, Camp and colleagues (1993) found that more whites than African Americans believed that cigarette smok- ing could help them control their body weight. Among the high school students who smoked, 39 percent of white females and 12 percent of white males reported smoking to control their body weight, compared with none of the African American students. A few studies have analyzed the perceptions that members of racial/ethnic groups have regarding the addictive nature of tobacco. In a San Francisco area study of 2,835 primary care patients who smoked, Vander Martin and colleagues (1990) found that whites smoked more cigarettes per day and were more likely to consider themselves addicted to cigarettes than Af- rican American, Asian American, and Hispanic smok- ers. Smoking within 15 minutes of awakening was least likely among Hispanic smokers but equally com- mon among smokers in the other groups. In addition, African Americans and Hispanics were less likely than the others to believe that quitting smoking would lead to weight gain. Most Americans of all races and ethnicities real- ize that cigarette smoking is addictive. In a survey of 2,092 adults in St. Louis and Kansas City, Missouri, Brownson and colleagues (1992) found that a similar number of whites (90.3 percent) and African Ameri- cans (88.5 percent) believed cigarette smoking was addictive. Results from the 1992-1993 CPS (see Chap- ter 5, Research and Development Limitations) showed that most members of the four racial/ethnic groups as well as whites agreed with the statements that ciga- rette smoking was an addiction or both a habit and an addiction (Table 18) (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992- 1993). Minor differences across gender were observed, although smokers were somewhat less likely to agree with the statements. Approximately 5 percent of the Asian American and Hispanic smokers indicated that cigarette smoking was neither a habit nor an addic- tion, compared with 1.9 percent of white smokers. Racial/Ethnic Differences in Quitting Smoking Because nicotine is addictive, highly addicted smokers have great difficulty in quitting. Differences in quitting can be used as another measure of the level of dependence. Some studies have found that although a similar percentage of whites and African Americans have ever been smokers, the percentage of former smokers has been greater among whites (26.4 percent) than among African Americans (17.2 percent) (Novotny et al. 1988) (see also Chapter 2). Data for 1989 from the BRFSS indicate that the standardized prevalence of smoking cessation was 47 percent among whites vs. 39.1 percent among African Americans (prevalence of cessation was defined as the percent- age of ever smokers who were former smokers) (CDC 1990). Similar findings were reported by Kabat and Wynder (1987), Hahn and colleagues (1990), and Geronimus and colleagues (1993). The 1991 NHIS Health Promotion and Disease Prevention supplement collected data on smokers who had quit for at least one day at the time of survey and for at least one month in the previous year (CDC 1993b). Hispanics (52.1 percent) and African Americans (48.7 percent) were more likely than whites (40.3 percent) to have quit smoking for one day. However, data on abstinence from smoking in the previous year showed that His- panics (16.3 percent) and whites (14.0 percent) were more likely than African Americans (7.9 percent) to have quit smoking for one month or longer. Thus, African Americans were less likely than whites to Tobacco Use Among U.S. Racial/Ethnic Minority Groups maintain abstinence. This effect remained after the findings were controlled for socioeconomic status. In an unadjusted analysis of data from the Current Popu- lation Survey NCI Supplement, a similar pattern was observed, although the differences between Afri- can Americans and whites were slight (see Table 2 and African Americans, Quitting Behavior in Chapter 2). The lower smoking cessation rates among Afri- can Americans do not appear to result from a lack of desire to quit (Royce et al. 1993). In the COMMIT tele- phone survey, 46.0 percent of African American women and 44.4 percent of African American men stated that they wanted to quit smoking “a lot,” com- pared with 35.0 percent of white women and 33.3 per- cent of white men. Thus, the lower prevalence of cessation among African Americans may be related to factors other than the desire to quit, such as the absence of culturally appropriate smoking cessation interventions, difficulties in accessing community resources for quitting smoking, and possibly a higher level of nicotine dependence as indicated by compara- tively higher levels of cotinine when the data are con- trolled for the number of cigarettes smoked. Addiction to Smokeless Tobacco Considerable nicotine is absorbed from smoke- less tobacco. An average systemic dose of nicotine is 3.6 mg for snuff, 4.6 mg for chewing tobacco, and 1.8 mg for cigarettes (Benowitz et al. 1988). Blood nic- otine concentrations throughout the day are similar among smokers and those who use smokeless tobacco (Benowitz et al. 1989a). Plasma cotinine levels in regu- lar smokeless tobacco users are often similar to the lev- els in cigarette smokers (Holm et al. 1992). Abstinence from smokeless tobacco use results in signs and symp- toms of nicotine deprivation that are similar to those seen in smokers after they stop smoking (Hatsukami et al. 1987; CDC 1994). These symptoms are reversed by the use of tobacco or administration of nicotine gum. Ina study of Swedish oral snuff users, many of the participants considered themselves addicted to snuff, and they reported having as much difficulty giv- ing up smokeless tobacco use as was reported by ciga- rette smokers trying to quit smoking (Holm et al. 1992). Evidence also suggests that when regular snuff users are deprived of snuff, they will smoke cigarettes to satisfy their need for nicotine (Benowitz 1992b). How- ever, no data are available on racial or ethnic differ- ences in the level of addiction to smokeless tobacco. Health Consequences 183 Surgeon General's Report Table 18. Percentage of men and women who considered smoking a habit or addiction,* overall and by smoking status, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic %t x+cIt % +Cl % +cl % +Cl % +CI Overall Habit 31.7 0.7 19.6 2.6 23.9 1.4 25.1 0.8 17.8 0.2 Addiction 19.8 0.6 19.6 2.6 17.8 1.2 26.3 0.8 21.9 0.2 Both 41.3 0.7 54.6 3.3 46.4 1.6 38.4 0.9 57.0 0.3 Men Habit 32.3 1.1 19.5 3.9 25.5 2.0 26.4 1.2 19.3 0.3 Addiction 20.4 0.9 21.4 4.0 18.4 1.8 26.7 1.2 22.0 0.3 Both 39,5 1.1 52.6 4.9 45.8 2.3 36.7 1.3 55.2 0.4 Women Habit 31.3 0.9 19.6 3.5 22.5 1.9 24.0 1.0 16.5 0.3 Addiction 19.5 0.8 18.1 3.4 17.2 1.7 25.9 1.1 21.9 0.3 Both 42.5 0.9 56.2 4A 46.9 2.2 39.8 1.2 58.6 0.4 Nonsmokers Habit 29.8 0.8 18.3 3.3 21.7 1.4 23.5 0.8 16.4 0.2 Addiction 20.4 0.7 21.1 3.5 18.9 1.4 27.1 0.9 23.0 0.3 Both 42.9 0.8 54.6 4.2 47.5 1.8 39.4 1.0 57.7 0.3 Men Habit 30.3 1.3 19.8 5.3 22.2 2.2 24.6 1.3 18.0 0.4 Addiction 20.5 1.1 22.4 5.5 20.2 2.1 27.9 1.4 22.8 0.4 Both 41.6 1.4 51.4 6.6 48.1 2.6 38.0 1.5 56.1 0.5 Women Habit 29.6 1.0 17.3 4.2 21.3 1.9 22.7 1.1 15.0 0.3 Addiction 20.3 0.9 20.2 4.5 17.8 1.8 26.5 1.1 23.1 0.4 Both 43.7 1.1 56.8 55 47.0 2.4 40.4 1.3 59.0 0.4 Smokers Habit 36.6 1.4 21.5 4.4 36.0 3.9 32.7 2.0 22.1 0.5 Addiction 18.6 1.1 17.5 4.0 12.3 2.7 22.6 1.7 18.9 0.4 Both 37.2 1.4 54.4 5.3 40.9 4.0 34.1 2.0 55.2 0.6 Men Habit 36.4 2.0 19.4 5.9 36.6 4.7 32.3 2.5 22.9 0.7 Addiction 20.2 1.7 20.5 6.1 12.6 3.2 23.3 2.3 19.7 0.6 Both 35.1 2.0 53.6 75 38.3 4.7 32.8 2.5 53.0 0.8 Women Habit 36.7 1.9 23.7 6.4 34.6 7.1 33.2 3.1 21.2 0.7 Addiction 17.2 1.5 14.4 5.3 11.5 4.8 21.4 2.7 18.1 0.6 Both 39.0 1.9 55.2 7.5 47.0 75 36.1 3.2 57.3 0.8 *In response to the question, “Do you think smoking is a habit, an addiction, neither, or both?” ‘Percentages in this table do not include all categories of responses and thus may not equal 100%. 195% confidence interval. Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes, 1992-1993, 184 Chapter 3 Conclusions Tobacco Use Among U.S. Racial/Ethnic Minority Groups 1. Cigarette smoking is a major cause of disease and death in each of the four racial/ethnic groups stud- ied in this report. African Americans currently bear the greatest health burden. Differences in the magnitude of disease risk are directly related to differences in patterns of smoking. 2. Although lung cancer incidence and death rates vary widely among the nation’s racial/ethnic groups, lung cancer is the leading cause of cancer death for each of the racial/ethnic groups studied in this report. Before 1990, death rates from malig- nant neoplasms of the respiratory system increased among African American, Hispanic, and American Indian and Alaska Native men and women. From 1990 through 1995 death rates from respiratory can- cers decreased substantially among African Ameri- can men, leveled off among African American women, decreased slightly among Hispanic men and women, and increased among American Indian and Alaska Native men and women. 3. Rates of tobacco-related cancers (other than lung cancer) vary widely among members of racial/ ethnic groups, and they are particularly high among African American men. 4. The effect of cigarette smoking (as reflected by biomarkers of tobacco exposure) on infant birth weight appears to be the same in African American and white women. As reported in previous Sur- geon General's reports, cigarette smoking increases the risk of delivering a low-birth-weight infant. Appendix. Methodological Issues 5. Nosignificant racial/ethnic group differences have been consistently demonstrated in the relationship between smoking and infant mortality or sudden infant death syndrome (SIDS); cigarette smoking has been associated with increased risk of SIDS and remains a probable cause of infant mortality. 6. Future research is needed and should focus on how tobacco use affects coronary heart disease, stroke, cancer, chronic obstructive pulmonary disease, and other respiratory diseases among members of racial/ethnic groups. Studies also are needed to determine how the health effects of smokeless to- bacco use and exposure to environmental tobacco smoke vary across racial/ethnic minority groups. 7. Persons of all racial/ethnic backgrounds are vul- nerable to becoming addicted to nicotine, and no consistent differences exist in the overall severity of addiction or symptoms of addiction across racial/ethnic groups. 8. Levels of serum cotinine (a biomarker of tobacco exposure) are higher in African American smok- ers than in white smokers for similar levels of daily cigarette consumption. Further research is needed to clarify the relationship between smoking prac- tices and serum cotinine levels in U.S. racial/ ethnic groups. Variables such as group-specific patterns of smoking behavior (e.g., number of puffs per cigarette, retention time of tobacco smoke in the lungs), rates of nicotine metabolism, and brand mentholation could be explored. It is important to review some methodological issues involved in collecting the data discussed in this chapter. These methodological problems affect the quality of the data and the type of conclusions that can be reached from studies conducted to date. Also, because cigarette smoking tends to be associated with other lifestyle risk factors that impact on health (e.g., Wingard et al. 1982; Vickers et al. 1990; Pérez- Stable et al. 1994), there is a need to control their co-occurrence in order to better understand the health effects of tobacco use. Classification of Smoking Status In investigating the health effects of smoking cigarettes and using other tobacco products, research- ers typically obtain information from the subjects or surrogate respondents on the use of such products. Questionnaires usually cover cigarette smoking sta- tus (i.e., never, former, and current smoker), number of years of smoking and age at initiation of smoking, number of cigarettes smoked per day, and use of other tobacco products (e.g., pipes, cigars, and smokeless Health Consequences 185 Surgeon General's Report tobacco). However, this information may not be fully valid, resulting in misclassification of exposure to ciga- rette smoking. A previous report of the Surgeon Gen- eral reviewed the classification of cigarette smoking status and the consequences of misclassification (USDHHS 1990). Misclassification of smoking information merits consideration in investigating tobacco use among racial/ethnic populations, because of the potential for bias in comparing the effects of smoking across racial / ethnic groups. To date, such bias has not been identi- fied, although several studies show that Hispanics may underreport cigarette smoking. In a population-based survey in New Mexico, Coultas and colleagues (1988) compared self-reports of smoking against salivary cotinine level (a product of nicotine that has been used as a measure of exposure to nicotine) and end-tidal car- bon monoxide concentration. Based on the question- naire results, the age-standardized prevalence rates of current smoking were 30.9 and 27.1 percent for His- panic men and women, respectively. After adjusting for cotinine and carbon monoxide levels, these percent- ages were 39.1 and 33.2. The rate of misclassification was greater in self-reported former smokers than in never smokers, but self-reported never smokers also had levels of cotinine and carbon monoxide indicative of active smoking. Using information from the Hispanic Health and Nutrition Examination Survey (HHANES), Pérez- Stable and colleagues (1992) documented the misclassification of smoking status through compari- sons of self-reports with serum cotinine levels. Among 65 Mexican American former smokers participating in the HHANES in 1982 through 1983, 7 (10.8 percent) had a cotinine level indicative of active smoking; among 124 reported never smokers, 5 (4 percent) were probably active smokers based on their cotinine lev- els. In a number of surveys, Hispanics, particularly Latino groups in the southwestern and western United States, have been found to smoke about one-half pack of cigarettes per day, compared with non-Hispanic whites who typically report smoking one pack per day (Coultas et al. 1994). Pérez-Stable and colleagues (1992) used data from 547 Mexican American participants in the HHANES to examine underreporting of cigarette consumption using the ratio of serum cotinine to self-reports of the number of cigarettes smoked per day as the “gold standard.” This study found that among Mexican Americans, 20.4 percent of men and 24.7 percent of women who were self-reported smokers underreported smoking between one and nine cigarettes per day. Self-reported Mexican Ameri- can smokers who reported smoking greater numbers of cigarettes per day underreported less frequently. 186 Chapter 3 An analysis of the data from the Coronary Artery Risk Development in (Young) Adults Study (CARDIA) showed that there were higher rates of misclassification in terms of self-reported nonsmok- ers who had serum cotinine levels of at least 14 ng/ mL among African Americans (5.7 percent) than among non-Hispanic whites (2.8 percent) (Wagen- knecht et al. 1992). Alternative explanations for underreporting, such as more efficient smoking and differences in cotinine metabolism, could not be excluded. Two additional studies examined the relation- ship between ancestry of origin and levels of biochemi- cal markers in smokers. In a study of participants in CARDIA, African American smokers demonstrated higher cotinine levels than non-Hispanic white smok- ers after controlling for several dimensions of cigarette- smoking behavior (Wagenknecht et al. 1990). Lactose intolerance, which elevates breath hydrogen concen- tration, may increase the apparent level of expired air carbon monoxide, a readily measured marker of ac- tive smoking (McNeill et al. 1990). Lactose intolerance is common in a number of racial/ethnic groups, in- cluding Asian Americans and African Americans. Classification of Race/Ethnicity The data included in this chapter are derived from diverse sources, including vital statistics, cancer registries, and epidemiological studies on smoking. Race/ethnicity has been classified in these studies us- ing various techniques, including designation on death certificate, classification according to cancer registry protocols, self-reports, birthplace, language use, and surname. The validity of each of these approaches is undoubtedly imperfect; moreover, validity varies across regions and over time. However, comprehen- sive assessments of the validity of racial/ethnic mi- nority classification in various types of health data have not been reported. The limited information available indicates some potential for misclassification. For example, Frost and colleagues (1992) compared the classification of “Native American,” as recorded by the Seattle-Puget Sound registry of the Surveillance, Epidemiology, and End Results (GEER) Program against an Indian Health Service (IHS) registry of patients eligible for services. A substantial portion of patients with invasive cancer in the IHS registry were not similarly classified by the Seattle-Puget Sound cancer registry. Similarly, an injury registry for the state of Oregon under- counted those with injuries (Sugarman et al. 1993). Using data from the National Longitudinal Mortality Study, Sorlie and colleagues (1992) compared demographic characteristics reported on the CPS of the U.S. Bureau of the Census with those characteristics reported on the death certificates for persons who died (during a seven-year follow-up period). Among 216 persons identified as American Indians or Alaska Natives by the CPS, only 159 (73.6 percent) were so classified on the death certificate. Similarly, the con- cordance rate for 272 persons classified by the CPS as Asian Americans or Pacific Islanders was 82.4 percent. Such disagreement suggests that current estimates of mortality rates for selected racial/ethnic groups are underestimated. However, in New Mexico, the classi- fication of “American Indian” by the New Mexico Tu- mor Registry, also a participant in the SEER Program, closely corresponded with the classification by the state’s Bureau of Vital Statistics (Eidson et al. 1994). Another study in New Mexico also showed a high concordance between self-reported Hispanic race/ethnicity and the designation by the Bureau of Vital Statistics (Samet et al. 1988b). In the report by Sorlie and colleagues (1993), 10.3 percent (n = 62) of persons identified as Hispanics by the CPS were not classified as Hispanics on the death certificate. Sur- names also have been used to classify Hispanic ethnicity, using either surname lists developed by the U.S. Bureau of the Census or name recognition algo- rithms (Howard et al. 1983; Wiggins and Samet 1993). Although studies in parts of the southwestern United States have shown a generally high validity for sur- name-based approaches for identifying Hispanic ethnicity, the sensitivity and specificity of the various Census Bureau lists have varied over time, and data from the Southwest cannot be readily generalized to other locales. In addition, surname lists tend to ex- clude women who marry non-Hispanic whites and who take their husband’s last name and to exclude as well their children when given the father’s non- Hispanic last name (Marin and Marin 1991). These studies suggest that the validity of classi- fication of race/ethnicity is likely to vary across loca- tions and possibly by type of data. In interpreting health data for racial /ethnic populations, consideration should be given to the potential for misclassification of race/ethnicity and the consequences of any result- ing bias. Classification of Health Outcomes Comparisons of disease occurrence among racial/ethnic groups also may be biased by differen- tial patterns of disease diagnosis and labeling by race and ethnicity. Such differences may have multiple causes that reflect the complex sequence that begins with the development of symptoms and signs and ex- tends to the labeling of an illness by a clinician or the statement of cause-of-death on a death certificate. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Health beliefs and knowledge, ability to access and pay for medical care, the quality of care available, and differential patterns of care by race/ethnicity may all affect diagnoses of illnesses. A full review of these top- ics is beyond the scope of this report, but several ex- amples are offered to illustrate the potential for differ- ential patterns of classification of health outcomes by race/ethnicity. Becker and colleagues (1990) examined the assign- ment of underlying cause of death to the category “symptoms, signs, and ill-defined conditions” in the Manual of the International Classification of Diseases, Inju- ries and Causes of Death ICD). In the nation, the crude death rate for this non-specific category has paralleled the mortality rate in this category for African Ameri- cans. Becker and colleagues (1990) analyzed vital statis- tics data for New Mexico for 1958 through 1982 and calculated mortality rates for “symptoms, signs, and ill-defined conditions” by racial/ethnic group. The state mortality rates for Hispanics, non-Hispanic whites, and American Indians for this category ex- ceeded the nationwide rates. Among the racial/ethnic minority groups in New Mexico, American Indians had particularly high mortality rates; for men, 8.4 percent of American Indian deaths were in this category ver- sus 5.9 percent of Hispanic deaths and 5.0 percent of non-Hispanic white deaths. Similarly, mortality rates for cancers of ill-defined and unknown primary sites tend to be much higher in American Indians in several areas of the country than for all racial/ethnic groups combined (Valway 1992). Recent comparisons of the evaluation and man- agement of chest pain and coronary artery disease in African Americans and non-Hispanic whites further illustrate the potential for bias by race/ethnicity in di- agnostic classification. In a study of patients present- ing to an emergency room with chest pain, African Americans were less likely to be admitted and less likely to be sent to a coronary care unit once they were admitted (Johnson et al. 1993). The study also found that African Americans were as likely as non-Hispanic whites to have cardiac catheterization. In contrast, other studies, using Department of Veterans’ Affairs, Medicare, and other large data bases, have shown that African Americans are less likely than non-Hispanic whites to have cardiac catheterization and invasive interventions for coronary artery disease (Wenneker and Epstein 1989; Udvarhelyi et al. 1992; Ayanian et al. 1993; Franks et al. 1993; Whittle et al. 1993; Peterson et al. 1994). 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Chapter 4 Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups Introduction 207 Historical Context of Tobacco 208 African Americans 208 American Indians and Alaska Natives 209 Asian Americans and Pacific Islanders 211 Hispanics 212 Economic Influences 213 Tobacco Industry Support for Racial/Ethnic Minority Communities 213 Employment Opportunities 213 Advertising Revenues 214 Funding of Community Agencies and Organizations 215 Support for Education 217 Support for Political, Civic, and Community Campaigns 217 Support for Cultural Activities 218 Support for Sports Events 219 Advertising and Promotion 220 Magazine Advertisements 221 Outdoor Advertisements 221 In-Store Promotions 222 Racial/Ethnic Symbols, Names, and Events 222 Targeted Products 223 Psychosocial Determinants 225 Initiation and Early Use of Tobacco 225 African Americans 226 American Indians and Alaska Natives 227 Asian Americans and PacificIslanders 227 Hispanics 228 Multiple Group Studies 229 Prevalence of Risk Factors for Cigarette Use 229 Factors Associated with Initiation of Cigarette Use 231 Factors Associated with Initiation of Smokeless Tobacco Use 232 Summary, Initiation and Early Use of Tobacco 233 Tobacco Use Among Adults 233 African Americans 233 American Indians and Alaska Natives 233 Asian Americans and Pacific Islanders 234 Hispanics 234 Summary, Tobacco Use Among Adults 235 Smoking Cessation 235 African Americans 235 American Indians and Alaska Natives 237 Asian Americans and Pacific Islanders 237 Hispanics 237 Summary, Smoking Cessation 237 Methodological Limitations of the Literature 238 Chapter Summary 239 Conclusions 240 Appendix. A Brief History of Tobacco Advertising Targeting African Americans 240 Early Assumptions 240 Early Targeted Advertising Efforts (1940s-1960s) 241 Recent Targeted Advertising Efforts (Late 1960s-1980s) 243 References 245 Introduction Tobacco Use Among U.S. Racial/Ethnic Minority Groups Tobacco use is determined and influenced by several kinds of factors: (1) individual factors (per- ceptions, self-image, peers); (2) social factors (societal norms); (3) environmental factors, such as advertising and economics; and (4) cultural factors, such as traditional uses of tobacco, acculturation, and the historical context of the tobacco industry in various communities. Behavior and patterns of tobacco use result from each of these factors and from their com- plex interplay, which is difficult to study and measure. Although available evidence has demonstrated that these factors contribute to behavior, research has been unable to quantify the distinct effect of each one and the effects of their interaction. The lack of definitive literature points to the need for further research to bet- ter quantify the ways in which a person’s exposure to various social, environmental, and cultural influences affects tobacco use behavior. Most likely, it is not a single factor but rather the convergence or interaction of some or all of these factors that significantly influ- ences both a person’s decision to use tobacco and pat- terns of tobacco use (U.S. Department of Health and Human Services [USDHHS] 1989; Lynch and Bonnie 1994; USDHHS 1994). This chapter examines the com- plex factors that influence tobacco use among the four major racial/ethnic minority groups. Tobacco has a role in all communities through social, economic, and cultural connections. These con- nections include (1) social customs, such as the shar- ing and giving of tobacco in Asian communities; (2) employment opportunities and economic growth provided to racial/ethnic groups through tobacco agriculture and manufacturing; (3) tobacco industry support of community leaders and organizations; (4) tobacco industry sponsorship of cultural events; and (5) ceremonial and medicinal uses of tobacco. Indeed, tobacco’s history has led to some positive social perceptions of tobacco, perceptions that may also influence use. Cigarette advertising and promotion may stimu- late cigarette consumption by (1) encouraging children and adolescents to experiment with and initiate regu- lar tobacco use, (2) deterring current tobacco users from quitting, (3) prompting former users to begin using again, and (4) increasing daily consumption by serv- ing as an external cue to smoke (Centers for Disease Control [CDC] 1990a). Whether or not they are intended to do so, advertising and promotional activi- ties appear to influence risk factors for adolescent tobacco use (USDHHS 1994). Cigarette advertising appears to affect young people’s perceptions of the per- vasiveness, image, and function of smoking. Because misperceptions in these areas constitute psychosocial risk factors for the initiation of smoking, cigarette ad- vertising appears to increase young people’s risk of smoking. The Food and Drug Administration (FDA) recently concluded that although advertising may not be the most important factor in a child’s decision to smoke, studies establish that it is a substantial con- tributing factor (Federal Register 1996). A different kind of influence is found in psycho- social variables, which help explain why people start using tobacco, why some continue using it, and why some stop using it. Published research findings are scant about individual and interpersonal factors that influence tobacco use among African Americans, American Indians, Alaska Natives, Asian Americans, Pacific Islanders, and Hispanics. This paucity of data, in fact, both inspired and hampered the development of this report. Although research findings based on samples of the majority white population may be applicable to racial/ethnic populations, such generalizability has not been sufficiently studied. Furthermore, cultural differences exist among commu- nities and members of various racial/ethnic groups in values, norms, expectancies, attitudes, and the histori- cal context of tobacco and the tobacco industry. Such differences, in turn, may influence both the prevalence of cigarette smoking in a particular racial/ethnic mi- nority group and the effect of certain associated risk factors (Marin et al. 1990a; Vander Martin et al. 1990; Robinson et al. 1992a). Another important factor that may influence to- bacco use behavior is the actual infrastructure within a community for conducting tobacco control activities that support a non-tobacco-use norm. This capacity of the community for tobacco control activities is also discussed in Chapter 5 of this report because it directly affects such programs, in addition to the influence it may have on the environmental context of tobacco use. The first part of this chapter summarizes the his- tory of tobacco use among members of the four major racial/ethnic groups in the United States—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispan- ics. The association between the tobacco industry and these communities, including economic influences and the role of targeted advertising and promotion, is also Factors That Influence Tobacco Use 207 Surgeon General's Report described. The second part of the chapter discusses psychosocial influences associated with initiation of tobacco use, maintenance, and cessation among the four groups. Unfortunately, the limited information available affects the length and comprehensiveness of the presentation. The appendix presents a short his- Historical Context of Tobacco tory of tobacco advertising targeting African Ameri- cans. Because so little information is available on the history of cigarette advertising aimed at American In- dians, Alaska Natives, Asian Americans, Pacific Island- ers, and Hispanics, these groups are not discussed in the appendix. African Americans The first recorded landing of Africans in the United States was in 1619, when a group of indentured servants was brought to Jamestown, Virginia (Foner 1981), and Jamestown quickly became the center for profitable tobacco trade with England and other Eu- ropean nations (USDHHS 1992). Indeed, a significant portion of the early colonies’ wealth derived from the exportation of tobacco (Northrup and Ash 1970). Cot- ton did not become preeminent until the invention of the cotton gin in 1793 (Foner 1981). Tobacco farming was widespread throughout the south, and although tobacco was later supplanted by other crops (includ- ing cotton) in many areas, it remains a major crop in six states—Georgia, Kentucky, North Carolina, South Carolina, Tennessee, and Virginia (Gale 1993). Whites initially were employed in tobacco culti- vation, but as tobacco prices fell in Europe, tobacco companies began using less expensive labor (Kulikoff 1986). Among other factors, the need for a larger and less expensive labor force to grow tobacco led the colo- nies to gradually transform the status of Africans from indentured servants, who earned their freedom after a period of involuntary servitude, to slaves, who were the property of their masters for life. In addition to slaves, many free African Americans worked in to- bacco farming during the 18th and 19th centuries. In- deed, more free African Americans were employed in tobacco production than in any other occupational category in the south during that time (Northrup and Ash 1970). Slaves also hired themselves out as tobacco laborers, and some earned enough funds to purchase their freedom. After emancipation, freed African Americans who had obtained some acreage began farming to- bacco because it was a cash crop that did not require much land to be profitable. In particular, freed African Americans farmed tobacco in Georgia, North Carolina, South Carolina, and Virginia. Nevertheless, 208 Chapter 4 the number of tobacco farms owned by African Ameri- cans has declined dramatically in the 20th century, pos- sibly because so many African Americans, including tobacco farm owners and laborers, were migrating to the north (U.S. Commission on Civil Rights 1982; Gale 1993). In the colonial period and early years of the United States, African Americans and whites worked side by side in cigarette-manufacturing factories, which tended to be primarily small cottage industries. However, the introduction of the cigarette-making machine in the mid-1880s changed this pattern. Be- cause white women were viewed as the only group that had the manual dexterity needed to operate the machines, and it was socially unacceptable for Afri- can American men and women to work alongside white women, African Americans were replaced as factory workers and relegated to less skilled, menial, field jobs (Northrup and Ash 1970; Meyer 1992). Dur- ing the early 1900s, the dirtiest, unhealthiest, and low- est paying jobs in tobacco factories were carried out by African American women (Jones 1984). Because the jobs held by African Americans in stemming and processing the tobacco leaf were low paying, the to- bacco industry made little effort to mechanize such jobs before the early 1930s. Thus, many African Americans remained employed in the tobacco industry, even as tobacco factories began replacing people with labor- saving machines (Northrup and Ash 1970). The high concentration of African Americans in certain occupations helped them gain a foothold in one of the few areas in which organized labor had achieved success in the south. Initial unionizing efforts by the Tobacco Workers International Union began in the early 20th century (Kaufman 1986). The efforts of the United Tobacco Workers Local 22 to encourage Afri- can American members to register for and vote in municipal elections are credited with the election of an African American to the city council of Winston- Salem, North Carolina, in 1947. At the same time, a rival—the Food, Tobacco, Agriculture, and Allied Workers Union—sought to involve African Americans in its unionizing efforts as equals. United Tobacco Workers Local 22, which represented workers at the R.J. Reynolds Tobacco Company in Winston-Salem, remained one of the strongest unions in the south. The union represented equal numbers of African Ameri- can and white workers. In addition, African Ameri- can women held significant leadership roles in the union (Lerner 1973; Foner 1981). This early unioniza- tion among African Americans in tobacco-producing states was of such historic importance that it is con- sidered one of the first civil rights movements (Korstad and Lichtenstein 1988). Probably as a result of the ra- cial divisions within the union movement and the re- sidual power held by African American workers, R.J. Reynolds was the first company to have African Ameri- cans operate cigarette-making machines after World War II and, in 1961, to open a factory with integrated production lines and desegregated facilities (Northrup and Ash 1970). Nevertheless, tobacco cultivation has not contrib- uted significantly to the economic well-being of Afri- can Americans in the southern states. In each of the decennial censuses conducted between 1960 and 1990, about one-third of all counties in the south where tobacco is a major agricultural product have been iden- tified as areas of persistent poverty. These poverty- stricken counties—concentrated in Georgia, North Carolina, and South Carolina—tend to have more farms owned and operated by African Americans than the south in general (Gale 1993). In addition, econo- mies of scale and the increasing mechanization of to- bacco growing have accelerated the decrease in tobacco farming, particularly by African Americans (U.S. Com- mission on Civil Rights 1982; Gale 1993). For example, by 1987, more than 50 percent of the farms operated by African Americans specialized in livestock produc- tion, and only 11 percent specialized in tobacco grow- ing (Gale 1993). In summary, tobacco has been a part of the expe- rience of African Americans since the early 1600s, when Africans were first brought to the Americas. The rela- tionship between African Americans and tobacco growers and manufacturers has changed in the postslavery era but remains strong and complex, par- ticularly since the mid-1940s. The strength derives from the important economic role of tobacco among African Americans, and the complexity comes from the contradictory social and economic forces that affected the African American worker. In addition, changing market forces helped make African Ameri- cans significant users of tobacco. As a result, the rela- Tobacco Use Among U.S. Racial/Ethnic Minority Groups tionship of African Americans to the tobacco industry was no longer primarily dependent on their role as workers in the tobacco labor force but was now influ- enced as well by their status as consumers. For ex- ample, until the mid-1940s, many African Americans held low-paying jobs in tobacco-related agriculture and industry; around the time of World War II, how- ever, some tobacco companies began to advertise to African Americans. Advertising efforts increased in the 1950s, a decade that saw African American men surpass white men in smoking prevalence. During this same time, the tobacco industry was hiring and pro- moting African American workers. Other influences affecting African Americans’ ties to tobacco were the tobacco industry’s increased attention to and positive steps toward civil rights in the 1950s and 1960s, the broadcast ban on tobacco advertising that led the to- bacco industry to seek more targeted market segments in the 1970s, and the expansion of African American political power in the 1980s and 1990s, which served to give the tobacco industry additional access to the African American community (Robinson et al. 1992b). The historical patterns underpinning the African American community’s relationship to tobacco may affect African Americans’ attitudes and behaviors to- wards tobacco. American Indians and Alaska Natives Tobacco has long played an important role in the cultural and spiritual life of North and South American Indians and Alaska Natives. When the Eu- ropeans colonized the Americas, tobacco already was being cultivated and used in many parts of the conti- nent. Early European explorers documented the cultivation and farming of tobacco and its extensive use among tribes throughout most of North and South America (Hodge 1910; Linton 1924) and in Alaska’s interior (Sherman 1972)—findings that have been sup- ported by archaeological discoveries at a variety of sites (Haberman 1984). When Europeans first arrived in the Americas, tobacco served various purposes among American Indians and Alaska Natives, including ceremonial, re- ligious, and medicinal functions (McCullen 1967; Seig 1971; Ethridge 1978). In ceremonial and religious rites, tobacco was a significant part of sacramental offerings. For example, tobacco was used to ensure good luck in hunting and to seal peace and friendship agreements. When used for medicinal purposes, tobacco often was mixed with other substances in topical ointments and ingested for internal healing. For example, in the Factors That Influence Tobacco Use 209 Surgeon General's Report northwest region of North America, tobacco was com- bined with shell lime powder and then formed into small marble-sized balls that were dissolved in the mouth (Linton 1924). Tobacco smoke often was used during prayers to aid in healing and was prescribed to cleanse people, places, and objects of unwanted spir- its. Tobacco smoke also was used at the beginning of meetings as a ritual to cleanse the room and secure the truth from the spoken word. Early inhabitants of the American continent also inhaled tobacco smoke (Linton 1924). They often placed burning or smoldering tobacco on the bare ground or on a mound and then waved the smoke to- ward their faces using the palms of their hands. Early inhabitants also smoked rolled sheets of dried tobacco leaves (cigars) and wrappings of cut tobacco, and they smoked tobacco through a flaxen reed. The most com- mon way to smoke tobacco was to place cut tobacco within the bowl of a calumet—either a stone or a hollowed-out bone pipe (Linton 1924). Tobacco smoking was part of many solemn oc- casions among American Indians, such as when lead- ers met (Paper 1988). In some tribes, the pipe became such a powerful object that it was considered sacred. Only certain individuals could use the pipe, and only sacredly gathered tobacco could be burned ina pipe’s bowl (Linton 1924). The Hopi Tribe used tobacco reli- giously, blowing smoke in the four sacred directions to invoke good planting and to encourage rainfall. Other tribes, such as the Delaware, Iroquois, and Sioux, smoked tobacco during prayers, at the opening of the sacred bundle—a collection of religious artifacts (Paper 1988). Tobacco also was used between enemies in battle to signify a truce. If one party offered the pipe and the other party accepted it, this signified the end of the battle, and both parties would then put down their weapons. As a result, the smoking of tobacco leaves, often with the peace pipe, became associated with the American Indian as a common symbol that had significant positive social and cultural connotations. During the 1700s, tobacco became one of the most important commodities traded among American In- dians and Alaska Natives. For example, Alaska Na- tives in the Arctic and sub-Arctic regions depended on trade with tribes from the east and south of the North American continent to obtain tobacco products (Fortuine 1989). Among the items traded were special smoking vessels, such as pipes made of stone quar- ried in what is now Wisconsin and Minnesota (Linton 1924; Paper 1988). With the European colonization of the American continent, tobacco became known in Europe, where it 210 Chapter 4 was at times expressly forbidden, primarily because of health concerns about the dangers of tobacco spit- ting. Following tobacco practices in the Americas, early European explorers smoked tobacco the way it was smoked by American Indians (Linton 1924). In- deed, many of the pipes these explorers used were fashioned after tribal pipes. Europeans also adopted many of the tribes’ medicinal uses of tobacco. How- ever, the use of tobacco for recreational purposes was widely accepted and soon became primary. Euro- peans also began to chew tobacco raw rather than ina mixture of powdered shells or roots, as was the cus- tom of North American tribes. Most early American Indian tobacco harvesting was done with farming technologies that originated in the Southern part of North America (Paper 1988). For example, nonfarming nomadic tribes and light farming tribes scattered tobacco seeds on holy grounds near waterways or marshes and let the plants grow without much cultivation. In fact, the Iroquois pro- hibited their people from cultivating tobacco plants or coming in contact with them while the plants were growing to maturity. Other tribes, such as the Blackfeet, Crow, and some Northern Plains Indian people, grew tobacco plants instead of food crops in small sacred patches for medicinal and ceremonial uses (Linton 1924). Over the centuries as American Indians and Alaska Natives experienced vast cultural and political upheaval, their attitudes about tobacco changed sig- nificantly. Today, among some contemporary Ameri- can Indian and Alaska Native groups, tobacco use has lost some of its traditional attributes and no longer is endowed with the same special meaning. However, some American Indians have maintained the traditional practices associated with tobacco. For example, tobacco is given as a gift to traditional healers and dancers at powwows and many other social gatherings, and it is presented to honor persons celebrating important events, such as marriages. Many American Indians consider tobacco to be a medicine that can improve their health and assist in spiritual growth when used in a sacred and respectful manner. It is important to rec- ognize the positive social context in which tobacco is viewed in American Indian communities and to recog- nize the difficulties these connotations may cause in preventing tobacco use among youth and helping adults to quit. It is possible that tobacco control efforts could be enhanced by emphasizing the distinction be- tween sacred uses of tobacco on ceremonial occasions and addictive tobacco use by individuals. An additional complicating factor for tobacco control efforts among this population is that American Indians have become increasingly reliant on tobacco sales and on the revenues these sales bring to the reservations (see Tobacco Industry Support for Racial/Ethnic Minority Communities later in this chapter). Asian Americans and Pacific Islanders Because about 63 percent of the Asian Americans and Pacific Islanders in the United States are immi- grants (U.S. Bureau of the Census 1993), their lives have been influenced by the history of tobacco use in Asia and the Asian Pacific. Asia’s many countries and cul- tures have different traditions regarding the use of to- bacco. These differences are also reflected in Asian Americans and Pacific Islanders themselves. Tobacco was introduced in Asia in the early 17th century by Europeans (Goodman 1992). Like the introduction of opium in China, the exportation of tobacco to Asia has led to an addiction that has dramatically changed the health behaviors of Asians (Chen and Winder 1990). The Dutch brought tobacco to China, where it was mixed with opium. The Chinese subsequently intro- duced tobacco in Mongolia, Tibet, and Eastern Siberia (Goodman 1992). Early Portuguese explorers then carried tobacco to India, Japan, and Java in 1605, and the Japanese in turn introduced tobacco in Korea (Laufer 1924). Asians later used tobacco in ways more similar to its medicinal uses in other parts of the world. In China, for example, tobacco was used as a remedy against colds, malaria, and cholera. The beliefs about the usefulness of tobacco as a medicine were so in- grained in China during the 17th century that two imperial edicts (1638 and 1641) prohibiting its use failed to curtail tobacco use. Currently, tobacco is a crop of great significance in Asia. In 1990, Asian countries produced approxi- mately 60 percent of the world’s tobacco crop (Goodman 1992). By 1995, United Nations statistics showed that Asian countries were producing 63.2 per- cent of tobacco leaves in the world (Food and Agricul- ture Organization of the United Nations [FAO] 1996). Both China (34.1 percent) and India (9.0 percent) ranked above the United States (6.3 percent) in the percentage of total tobacco leaf production (FAO 1996). In China, the manufacture and sale of tobacco prod- ucts are part of the economic role that tobacco plays. After foreign investment was legalized in China in 1979, the China National Tobacco Corporation entered into joint ventures with Philip Morris, RJ. Reynolds, and other foreign tobacco companies. The China Na- tional Tobacco Corporation has dramatically increased production after implementing western technology, and its 183 cigarette factories, 150 tobacco drying Tobacco Use Among U.S. Racial/Ethnic Minority Groups plants, 30 research institutes, and 520,000 workers make up a strong part of the local economy (Frankel and Mufson 1996). Whereas cigars, pipes, snuff, chewing tobacco, cheroots (cigars), bidis (cigarettes of India), and kreteks (clove cigarettes) initially were more commonly used than regular tobacco cigarettes in Asia, cigarettes now are an integral part of contemporary Asian and Asian Pacific life. As expected, Asians and Pacific Islanders who migrate to the United States bring with them the attitudes and expectancies that have characterized the use of tobacco in their countries of origin. Sharing ciga- rettes, particularly among adult male guests, is a ges- ture of hospitality in a number of Asian cultures (Tamir and Cachola 1994). For example, distributing ciga- rettes, particularly U.S. cigarettes, at Cambodian wed- dings is a customary way of honoring the bride and groom. In China, foreign visitors are expected to give cartons of cigarettes to their hosts. In this regard, the importance of using tobacco as a form of social ex- change is very similar to the reinforcement given to tobacco use among Hispanics. Cigarette smoking also has acquired utilitarian uses in some Asian countries. In Southeast Asia, for example, cigarette smoking is perceived as a way to keep warm at night and to keep mosquitoes away (Mackay and Bounxouie 1994). In some provinces in China, anecdotal information indicates that babies and toddlers are given puffs of lighted cigarettes to stop them from crying (Mackay et al. 1993). Cigarette smoking in Asian society has been popularly associated with affluence and sophistication (Frankel and Mufson 1996). Accordingly, the promo- tion of cigarette smoking in Asian countries follows patterns fairly similar to those found in the United States, where cigarette smoking is glamorized and of- ten associated with affluence. Ina recent article, Sesser (1993) recounted how in one week of traveling in Asia he “attended a Virginia Slims fashion show at a Tai- wanese disco, watched the finals of the Salem Open tennis tournament in Hong Kong, and followed the progress of the Marlboro Tour '93, a bicycle race in the Philippines” (p.78). Cigarettes made in the United States are not only promoted in those Asian countries where the importation of foreign cigarettes is allowed, but also in China, where U.S. cigarettes are not freely sold (Stebbins 1990). In these cases, brand recognition is an important outcome of promotional campaigns once the market is opened to imported cigarettes. Before market access trade actions by the United States in the 1980s, advertising was unnecessary in most Asian countries because tobacco production was operated through state-owned tobacco monopolies. Factors That Influence Tobacco Use 211 Surgeon General's Report As a result, few brands were available for purchase. The expansion of large transnational corporations (e.g., British American Tobacco Company, Ltd., and Philip Morris Companies Inc.) into Asian markets brought about more brand competition and, thus, more advertising. Advertising techniques have included sponsorship of rock concerts and teen dances and ex- tensive radio and outdoor advertising (Frankel and Mufson 1996). According to a study reported by the National Bureau of Economic Research using data from Japan, Taiwan, South Korea, and Thailand, “...in 1991, average per capita cigarette consumption was nearly ten percent higher than it would have been had the markets remained closed to U.S. cigarettes” (Chaloupka and Laixuthai 1996, p. 13). The paucity of information about tobacco use among Asian Americans and Pacific Islanders ham- pers the formation of substantive conclusions about the relationship between community attitudes and behaviors and the historical relationship with tobacco and the tobacco industry. Existing information, how- ever, is sufficient to show that factors associated both with the respective native cultures and with accultura- tion are important. Tobacco prevention and control programs must take these cultural factors into account to positively influence the norms, attitudes, and be- haviors of these racial/ethnic communities. Hispanics The cultivation and processing of tobacco have played a significant role in the economies of most Latin American countries, including Brazil (Nardi 1985), Colombia (De Montajia 1978), Cuba (Rivero Muniz 1964), and Mexico (Ros Torres 1984). In 1995, the level of production of tobacco leaf in South America alone reached 9.1 percent of the world total (FAO 1996). In the United States, Hispanics, primarily those of Cuban ancestry, have played a key role in the manu- facture of cigars in Florida factories. As is true of all immigrants, Hispanics who migrate from Latin America are influenced by historical conditions in their native countries regarding tobacco and the tobacco industry and bring with them the attitudes and ex- 212 Chapter 4 pectancies that characterize tobacco use in their coun- tries of origin. These attitudes and expectancies are often modified as the process of acculturation takes place (Marin et al. 1989a). The history of tobacco use in Central and South America as well as in the Caribbean predates the ar- rival of the European explorers and therefore has ac- quired a rich lore. Tobacco played a prominent role in religious and healing practices of native inhabitants of those regions. It was used by shamans or spiritual leaders to induce trancelike states, ensure fertility, and facilitate spiritual consultations. Many cultural and social norms surrounded tobacco, all of which have contributed to defining the role of tobacco in these societies. Tobacco became a staple crop of the Ameri- cas when the predominant means of obtaining food shifted from hunting to agriculture. Tobacco manu- facture and trade played a significant role in the econo- mies of the Caribbean, Latin America, and North America. A detailed account of the history of tobacco in the Americas can be found in the Surgeon General's report Smoking and Health in the Americas (USDHHS 1992). Recent surveys also indicate that Hispanic ciga- rette smokers have group-specific expectancies and attitudes that differentiate them from smokers of other racial/ethnic groups. These expectancies and attitudes are the product of social conditions and norms that have dictated the use of tobacco in Latin American countries for the last few centuries and are also the effects of certain relevant cultural values, such as simpatia (a social mandate for positive social relations), personalismo (the value placed on personal relation- ships), and familialism (the normative and behavioral influence of relatives) (Marin and Marin 1991). Among many Hispanics in the United States, cigarette smok- ing is a social activity (Marin et al. 1989a; 1990a,b). Although tobacco use remains a social activity among all communities, given the cultural values of simpatia and personalismo, sharing cigarettes often serves as a particularly strong form of social affiliation and friend- ship. This norm must often be considered when to- bacco prevention and control programs are initiated within Hispanic communities. Economic Influences Tobacco Use Among US. Racial/Ethnic Minority Groups Tobacco Industry Support for Racial/Ethnic Minority Communities . The tobacco industry’s longtime economic support for U.S. racial/ethnic communities may have contributed to the survival of many of these commu- nities’ institutions (Robinson et al: 1992b). For example, the tobacco industry supports African Ameri- can communities in five main ways: (1) direct employ- ment of African Americans, (2) support for social services and civil rights organizations, (3) contributions to politicians and political organizations, (4) support for educational and cultural programs, and (5) con- . tracts with small businesses (Blum 1989; Robinson et al. 1992a,b). More recently, the tobacco industry also has provided economic support to American Indian, Alaska Native, Asian American, Pacific Islander, and Hispanic communities. As detailed below, the tobacco industry has em- ployed members of racial/ethnic communities prima- rily in farming and manufacturing, although some have been employed in sales and marketing positions. The industry’s support for social services and civil rights organizations and its involvement in educational and cultural activities have been wide-ranging: This support has included contributions to endowments, scholarship funds, and literacy campaigns as well as support for artistic groups, exhibits, and performances. Contributions from tobacco companies and tobacco- related political action committees have underwritten - the growth of racial/ethnic political power at the local, state, and national levels. In addition, many to- bacco companies use the services of minority-owned businesses either through their own internal programs . or through formal alliances with such groups as Op- eration PUSH (People United to Save Humanity) and the National Association for the Advancement of Col- ored People (NAACP). In addition, tobacco product sales and promotions have contributed to the econo- mies of racial/ethnic communities. For example, the sale of cigarettes and smokeless tobacco contributes to the economies of small corner convenience stores catering to racial/ethnic minority communities in ur- ban areas. Tobacco is an important income-generating resource also on some Indian reservations. Because reservations are exempt from paying excise and sales taxes on tobacco products, tobacco shops are operated to produce additional income for the community. Al- though these shops are legally restricted to selling tax-free cigarettes to American Indians, this restriction is rarely monitored. A number of reservations are located a short distance from major cities whose resi- dents often drive to the reservations to purchase tax- free or low-tax cigarettes and other tobacco products. The interrelationships between. the tobacco in- dustry and racial/ethnic group leaders, industries, and community agencies may have served to strengthen bonds between the industry and the four racial/eth- nic groups that are the subject of this report. These relationships are based on several factors, one being that the tobacco industry has often been the only source of funds for community initiatives. In addition, the tobacco industry has built personal alliances with members of racial/ethnic groups through employment and personal relationships (Robinson et al. 1992b). Indeed, Philip Morris's record in making financial com- mitments to community programs as a result of racial/ethnic-related networking has been noted (Stanley 1996). Efforts in African American commu- nities to put tobacco control strategies in place have had to overcome some leaders and organizations who were reticent about such action because the commu- nity had a positive relationship with the tobacco in- dustry, partly based on the industry’s strong support for local economic, social, and cultural activities (Robinson et al. 1992b). Many leaders and members of these communities have a positive predisposition toward both the industry and cigarette smoking. Employment Opportunities . Although the tobacco industry initially discrimi- nated against African Americans, excluding them from many types of factory jobs, it eventually began hiring many African Americans in manufacturing positions (Northrup and Ash 1970). By the 1930s, African Ameri- cans made up about half of all persons employed in the process of taking tobacco from its leafy state to a finished product (Northrup and Ash 1970; Foner 1981). African Americans have been concentrated in the tobacco industry for three main reasons: (1) factories were located in the Southern states, where the African American population was largest; (2) more laborers were needed as the demand for cigarettes grew after World War I; and (3) other opportunities opened for whites in an expanding economy, leaving African Americans with few job alternatives because of racial Factors That Influence Tobacco Use 213 Surgeon General's Report discrimination and other factors (Northrup and Ash 1970). In the last few decades, the involvement of Afri- can Americans in the production and marketing of tobacco has changed significantly. By 1960, African Americans represented less than 25 percent of tobacco workers—a decline from more than 50 percent 30 years earlier. Possible reasons for this dramatic decrease include (1) the migration of African Americans from southern to northern states; (2) the imposition of the minimum wage, which eliminated many of the low- paying jobs in which African Americans were concen- trated; (3) the mechanization of tobacco factories, which required fewer people to produce the same number of cigarettes; and (4) the inability of unions to change the poor working conditions of African Ameri- can workers, leading to their exodus from those com- panies (Northrup and Ash 1970). Today, the tobacco industry employs African Americans as well as members of other racial/ethnic minority groups in a variety of factory, marketing, and promotional positions. In the latter two types of posi- tions, members of racial/ethnic groups conduct pro- motional and marketing activities with owners of local shops and convenience stores serving racial/ethnic neighborhoods in urban areas and racial/ethnic en- claves in metropolitan areas. The tobacco industry was one of the early lead- ers among corporations in providing opportunities in management to qualified African Americans. Two African American executives of tobacco companies were honored in 1997 by the Business Policy Review Council at its annual Corporate Pioneers Gala Tribute for their long-term contributions as corporate pioneers in breaking down color barriers in the business world (US Newswire, Inc. 1997). Members of various racial/ethnic communities also have been employed as models or spokespersons in the advertising and promotion of tobacco products. Advertising and public relations agencies select racial/ ethnic minority models and celebrities to promote and advertise tobacco products to targeted racial/ethnic groups in print and outdoor advertisements. These easily recognizable racial/ethnic models and celebri- ties are essential to targeted advertising, and advertis- ing agencies have relied heavily on members of racial / ethnic communities to fill these modeling jobs. For example, the tobacco industry used African American athletes extensively to advertise tobacco products dur- ing the 1950s and 1960s, when racial integration was taking place in sports (see the appendix). In a study of advertising in Ebony magazine during the 1950s and 1960s, investigators found that African American ath- letes were used in cigarette advertisements far more 214 Chapter 4 frequently than other African American celebrities and entertainers (Pollay et al. 1992). The use of well-known athletes, entertainers, and public figures in tobacco in- dustry marketing and public relations campaigns has continued into the 1990s. Advertising Revenues By placing advertisements in racial/ethnic pub- lications, primarily those with limited circulations, tobacco companies have become important contribu- tors of advertising revenues for these publications (Blum 1986). Asa result, many racial/ethnic minority publications—including community-oriented newspa- pers and national magazines—rely on revenues from tobacco advertising (Cooper and Simmons 1985; Milligan 1987; Blum 1989; Tuckson 1989; Robinson et al. 1992b). Some racial/ethnic publications indepen- dently sought closer economic ties with the tobacco industry. For example, after the ban on the broadcast advertising of tobacco products took effect in 1971, a group of African American newspaper publishers ap- proached the tobacco companies and asked them to in- crease their business with African American media (Williams 1986). Corporate media leaders are aware of the reli- ance of African American publications on tobacco advertising (Robinson 1992). The publisher of Target Market News, an African American consumer- marketing publication, has suggested that “reducing cigarette ads could deprive the inner city of much- needed revenues” (Johnson 1992b, p. 27). Similarly, the president of an African American advertising agency has predicted that “if they kill off cigarette and alcohol advertising, black papers may as well stop printing” (Johnson 1992b, p. 27). In 1988, the National Black Monitor, a monthly insert in about 80 African American newspapers, published a three-part tribute to the tobacco industry. The National Black Monitor has defended its relationship with the tobacco industry and has stated that “black newspapers . . . could not have survived without the past and continuing support from the tobacco industry” (1990, p. 4). National and local publications directed at other racial/ethnic groups also frequently carry tobacco product advertisements and promotions. These include full-page, four-color advertisements in magazines and full-page advertising spreads in community newspa- pers. In 1989, for example, Hispanic magazine ran a short story contest, sponsored by Philip Morris, which offered a $1,000 honorarium and publication of the winning story. The contest was promoted in a special issue cel- ebrating Hispanic Heritage Month, and announcements appeared in a message from the editor on the magazine’s first page and in a one-page display. The relatively high level of tobacco product ad- vertisements in racial/ethnic and general publications is problematic because the editors and publishers may limit stories dealing with the damaging effects of to- bacco or limit the level of antitobacco information in their publications for fear of retribution from tobacco companies (Evans 1990; Robinson et al. 1992a; Warner et al. 1992). Their concerns may be valid. For example, when New: week published an article on the nonsmok- ers’ rights movement, tobacco advertisers removed all tobacco advertisements from that issue and ran them later (Warner 1985). In addition, a study of cancer cov- erage and tobacco advertising over a six-year period in three African American popular magazines (Ebony, Essence, and Jet) found that these magazines published only nine articles that focused on cancers caused by cigarette smoking (six on lung or bronchus cancer, one on bladder cancer, and two on throat cancer). In the articles on lung cancer, smoking was rarely discussed as a major contributing cause; smoking was not men- tioned as a cause of throat cancer (Hoffman-Goetz et al. 1997). Although magazines and newspapers with large circulations can sustain the sporadic loss of advertis- ing revenues, the livelihood of racial/ethnic publica- tions can be effectively threatened by such losses. Tobacco companies typically place less than 10 per- cent of their advertising budgets with small African American weeklies (Russ 1993); however, these adver- tisements may often mean the difference between sur- vival and failure for small publications (Tuckson 1989; Robinson et al. 1992b). Magazine advertisements of tobacco products have decreased recently in all types of publications (Federal Trade Commission [FTC] 1997), indicating that magazines distributed nation- ally, including those serving racial/ethnic minority communities, may rely somewhat less on tobacco companies for advertising revenues. For example, 6.5 percent of Ebony’s full-page advertisements were for tobacco products in 1993, compared with 9.4 percent in 1988, 13.5 percent in 1983, and 11.6 percent in 1978 (Gerardo Marin and Raymond Gamba, unpublished data). Additionally, a comparison of revenues gener- ated from advertising for the first 11 months of 1989 showed that major African American publications such as Jet, Ebony, and Essence received proportionately higher revenues from tobacco companies than did major mainstream publications (Ramirez 1990). Industries associated with the tobacco industry may also provide public relations support to racial / ethnic publications. In 1992, for instance, an adver- Tobacco Use Among U.S. Racial/Ethnic Minority Groups tisement in Ebony paid for by the Nabisco Foods Group (RJR Nabisco, Inc., of which R.J. Reynolds Tobacco Company is a subsidiary) saluted the magazine's publisher and seven other African American entre- preneurs as “role models to our nation’s youth and as inspiration to all of us” (Nabisco Foods Group 1992, p- 2). Eight-sheet billboards are also frequently used to advertise tobacco products in racial/ethnic commu- nities. These billboards are small (5 x 11 feet) and are often placed close to eye level on the sides of build- ings and stores. In 1985 alone, tobacco companies spent $5.8 million on eight-sheet billboards in African American communities; this amount accounted for 37 percent of total expenditures for this medium. Tobacco companies spent $1.4 million on such billboards in Hispanic neighborhoods (Davis 1987). Funding of Community Agencies and Organizations The tobacco product and alcoholic beverage in- dustries have made significant financial and in-kind contributions to various racial/ethnic community or- ganizations at the local, regional, and national levels. These contributions have at times been described as marriages of convenience in which community orga- nizations and agencies receive much-needed income and tobacco companies gain, ata minimum, name rec- ognition and goodwill (Maxwell and Jacobson 1989). Trade publications suggest that such community rela- tions efforts are “effective ... devices to augment mi- nority advertising efforts and throw some water on any hot spots” (DiGiacomo 1990, p. 32). Recipients of tobacco industry support include most of the larger national organizations as well as a plethora of smaller local community agencies. In fiscal year 1989, for ex- ample, organizations receiving support from tobacco companies included the Congressional Hispanic Cau- cus, the National Black Caucus of State Legislators, the National Urban League, and the United Negro Col- lege Fund (UNCF) Johnson 1992a,b). Internal tobacco industry documents released by Doctors Ought to Care (DOC) show that Philip Morris gave more than $17 million to racial/ethnic, educational, and arts groups in 1991 (Solberg and Blum 1992). One large racial/ethnic minority organization that has refused the support of the tobacco industry is the National Coalition of Hispanic Health and Human Services Organizations (COSSMHO), which has adopted a formal policy not to accept money from to- bacco companies or their subsidiaries. The diversity Factors That Influence Tobacco Use 215 Surgeon General's Report of contributions to racial/ethnic community agencies can be illustrated through a review of contributions made to African American organizations. For example, Philip Morris has contributed to such organizations as the Leadership Conference on Civil Rights, the Na- tional Association of Black Social Workers, the National Association of Negro Business and Professional Women’s Clubs, the National Black Police Association, 100 Black Men of America, Inc., the National Coali- tion of 100 Black Women, the National Conference of Black Lawyers, the National Minority AIDS Council, and Operation PUSH (Jackson 1992; Rosenblatt 1994). RJ. Reynolds has contributed to the NAACP; UNCF; and Opportunities Industrialization Centers of America, a national network of job training centers (Russ 1993). Other tobacco companies and the Tobacco Institute itself have made similar contributions to African American and Hispanic organizations (Robinson et al. 1992a). In communities where tobacco companies have offices and factories, additional programs and activi- ties have been funded to the benefit of whites as well as members of racial/ethnic communities. This sup- port has ranged from funding for local sites of the Young Men’s Christian Association to sponsorship of Christmas tree-lighting ceremonies (Jackson 1992). The tobacco industry also has participated in special cel- ebrations and has sponsored awards and recognition events for various civic organizations. For example, at each year’s conference of the National Urban League, Philip Morris presents the Herbert H. Wright Awards to African American executives of major cor- porations who have excelled in working on behalf of humanitarian causes. The awards are named in memory of one of the first African American execu- tives at Philip Morris. Promotional materials further document the to- bacco industry’s involvement with racial/ethnic com- munities. Current information is difficult to obtain, but in 1986, RJR Nabisco published the booklet called A Growing Presence in the Mainstream, which summa- rized the company’s involvement with racial/ethnic communities amid quotations from Martin Luther King, Jr., John F. Kennedy, Booker T. Washington, Maya Angelou, and the New Testament, along with photo- graphs of an African American member of the company’s board of directors (RJR Nabisco, Inc. 1986). The booklet reported a number of the company’s ac- complishments, including RJR Nabisco’s record for employing members of racial/ethnic minority groups, the provision of more than 25 percent of RJR Nabisco’s total company-paid employee group life insurance by African American-owned insurance firms, the 216 Chapter 4 advertising of RJR Nabisco’s products in more than 200 racial/ethnic magazines and newspapers each year, and recognition by the UNCF as the largest con- tributor to the fund’s schools since 1983. The booklet also listed 122 different organizations to which the company provided funding, including the National Urban League; the NAACP; the League of United Latin American Citizens; Howard University; Alpha Kappa Alpha Sorority; the Portland Life Center; the Harlem Dowling-West Side Center for Children and Family Services; New Jersey’s Special Supplemental Food Pro- gram for Women, Infants and Children; the National Council of Negro Women; the National Puerto Rican Coalition; and ASPIRA, Inc., of New Jersey (RJR Nabisco, Inc. 1986). At the community level, tobacco companies rely on athletic, cultural, and social events to promote their products’ images, often in association with small com- munity agencies. In African American and Hispanic communities, tobacco companies frequently sponsor street fairs, jazz festivals, Little League baseball teams, soccer teams, symphony orchestras, auto races, and art exhibits, just as they do in white communities (Blum 1986; Robinson et al. 1992b; Sanchez 1993). These con- tributions place community agencies in a particular dilemma, because many of the agencies’ programs depend directly or indirectly on contributions received from the tobacco industry. At the same time, accep- tance of money and services from the tobacco indus- try may be perceived as an indirect endorsement of tobacco use. Community leaders generally are split in their opinions about the propriety of accepting sup- port from tobacco companies and alcoholic beverage companies (Robinson et al. 1992a). Opponents argue that the costs of compromised integrity, implicit en- dorsement of tobacco and alcoholic beverages, and current and future increases in disease and death in these communities are far greater than the benefits these funds provide. Proponents argue that these funds—when made available for such purposes as scholarships, conferences, business development, health fairs, and the organizations’ survival—benefit the various racial/ethnic communities, particularly when other sources of financial support have been in short supply or unavailable. Strategies and policies that promote funding sources other than tobacco com- panies are needed to alleviate communities’ reliance on tobacco-related support (Satcher and Robinson 1994), The tobacco industry also supports the opera- tions and activities of racial/ethnic organizations by providing special services, such as the publication of resource guides and other materials (Blum 1986). For example, Philip Morris has biennially published the Guide to Black Organizations since 1981 (Philip Morris Companies Inc. 1992). The guide lists national, regional, and local African American nonprofit orga- nizations throughout the United States, as well as Af- rican American state and regional caucuses of elected and appointed officials. Philip Morris also publishes and widely distributes two similar publications, the National Directory of Hispanic Organizations (Congres- sional Hispanic Caucus Institute, Inc. 1993) and the Na- tional Directory of Asian Pacific American Organizations 1997-1998 (Organization of Chinese Americans 1997). Support for Education For years, the tobacco industry has contributed to programs that aim to enhance the primary and sec- ondary education of children, has funded universities and colleges, and has supported scholarship programs targeting African Americans (the UNCF) and Hispan- ics (the National Hispanic Scholarship Fund). Philip Morris has contributed to Teach For America, a not-for-profit group that trains teachers, pri- marily those in racial /ethnic urban school systems, such as those in Baltimore City and the District of Columbia (Marriott 1992). In addition, both Philip Morris and R,J. Reynolds donate money to public school systems in racial/ethnic minority communities (Milloy 1990). For more thana century, the tobacco industry has provided financial support to historically and pre- dominantly African American colleges and universi- ties in the United States. This funding tradition can be traced to Richard Joshua Reynolds, who founded RJ. Reynolds about the time that African Americans were emerging from slavery. In 1891, Reynolds gave money to a school that eventually became Winston- Salem State University, a school that educated freed slaves (Russ 1993). The tobacco companies also have been strong supporters of the UNCF, which was founded in the mid-1940s to provide a central fund-raising arm for a number of small, struggling, predominantly African American private colleges and universities. When questioned in the mid-1980s about the appropriateness of accepting contributions from tobacco companies, a former head of the UNCF gave three reasons for ac- cepting the contributions: (1) the companies had been longtime supporters of higher education for African Americans, even when the cause was not popular; (2) the contributions from the tobacco companies were too large to reject because the colleges needed the money to survive; and (3) the tobacco companies had factories in communities where the African American Tobacco Use Among U.S. Racial/Ethnic Minority Groups colleges and universities were located (Blum 1985). In addition to supporting the UNCF, tobacco companies have supported African American higher education in a variety of other ways, such as through other scholarships and internship programs (Robinson et al. 1992b). In recent years, the tobacco industry has begun supporting adult literacy efforts. In 1990, Philip Mor- ris joined with the Pew Charitable Trusts and the Phila- delphia Mayor’s Commission on Literacy to launch the Gateway Program, an adult literacy campaign de- signed to serve as a national model. Philip Morris con- tributed $1.5 million to the program and an additional $1.5 million for media support (Robinson et al. 1992b). In yet another outreach effort, Philip Morris subsidized the Milwaukee County Youth Initiative, a program designed to help low-income and minority families become more involved in the education of their chil- dren (Haile 1991). Support for Political, Civic, and Community Campaigns The emergence of racial/ethnic minority politi- cal power, mostly at the local level, has provided yet another avenue for the tobacco industry to bolster its support of racial/ethnic communities. Although most of the contributions at the national level have gone to white legislators, two African American legislators were 14th and 16th ona list of tobacco industry-related campaign contributions received from January 1985 through September 1995 (Fisher 1995). At the state and local levels the tobacco industry has been generous to all, including racial/ethnic legislators, particularly those in a position to vote on increases in tobacco excise taxes and smoking restric- tions on the job and in public places. Since Califor- nians passed Proposition 99, which raised the cigarette sales tax by 25 cents per pack, political contributions from tobacco companies in California rose from less than $800,000 in the 1985-1986 elections to more than $7.6 million in the 1991-1992 elections (Begay et al. 1993). These politicians, some of whom are of racial/ ethnic origins, once elected, control how the excise tax revenues are spent and what proportion of the revenues is spent on tobacco control and tobacco- education projects. Other contributions have been made by the to- bacco industry to civic leaders through such mecha- nisms as Brown & Williamson Tobacco Corporation’s Kool Achiever Awards, which are designed to recog- nize a dozen or so urban achievers “working to create long-term benefits for urban communities” (Brown & Factors That Influence Tobacco Use 217 Surgeon General's Report Williamson Tobacco Corporation 1993, back cover). Each recipient chooses a nonprofit organization to which Brown & Williamson donates $5,000. In 1993, R.J. Reynolds began a similar campaign entitled Salem Freshside™ Salute, which recognizes African Americans working to improve the conditions usually found in center cities by giving these individuals do- nations of $5,000. In addition, promotional campaigns directed at the nation as a whole can affect racial/ ethnic minority communities. For example, in 1989, Philip Morris sponsored a touring exhibition of the Bill of Rights. Philip Morris placed advertisements cel- ebrating the freedoms guaranteed by the Bill of Rights in dozens of magazines and newspapers, including a large number of African American and Hispanic pub- lications. Photographs of admired celebrity members of racial/ethnic groups appeared in the tobacco company’s advertisements. Such efforts engender good will and name recognition among various racial / ethnic groups. Just as some organizations, such as COSSMHO and, more recently, the Tet Festival in San Jose, California, and the Dia De Fiesta Latina Day of the Del Mar Fair in California, have refused to accept tobacco industry dollars (Fernandez 1996; Levin and Perry 1996; San Diego Union-Tribune 1996), individu- als are also refusing to accept similar tributes. For ex- ample, a community activist was awarded but declined to accept the Kool Achiever Award because of the ethi- cal dilemma he perceived related to the high number of African Americans whose diseases or deaths are caused by tobacco use (Rosenberg 1993). Support for Cultural Activities Tobacco companies have been creative in their efforts to reach all members of society via cultural events (Johnson 1992b). Tobacco companies sponsor large museum exhibitions, concerts, and performances for the full spectrum of society. Advertisements for cigarettes and, in some cases, for smokeless tobacco are often placed conspicuously at these events, al- though sometimes the tobacco industry’s sponsorship is noted more subtly in catalogs and program notes. Some of the activities, however, are directed at racial / ethnic communities and are designed to support or enhance racial/ethnic pride and culture—such as Mexican rodeos; American Indian powwows; racial / ethnic minority dance companies; racial/ethnic pa- rades and festivals; Tet festivals; Chinese New Year festivities; Cinco de Mayo festivities; and activities re- lated to Black History Month, Asian/Pacific Ameri- can Heritage Month, and Hispanic Heritage Month (Warner 1986; Maxwell and Jacobson 1989). 218 Chapter 4 In some instances, tobacco products are associ- ated with popular community events through spon- sorships and store promotions. In 1989, for example, Skoal Bandit smokeless tobacco was tied to the promotion of Miami's Calle Ocho festival through live radio remotes from several 7-Eleven stores in the Mi- ami area (Gross 1989). During that same year, the pro- motion of Skoal Bandit was associated with a Hispanic festival in Corpus Christi, Texas, and with the 10th anniversary car and truck show of Lowrider magazine (Gross 1989). Recently, the 1994 Little Saigon Tet Fes- tival in Orange County, California, was sponsored by Marlboro and 555 State Express of London brands of cigarettes. Booths at the festival were used to promote the two brands of cigarettes through displays and the distribution of promotional items. The sponsorship of artistic events has been one of the fastest growing segments of special events marketing, and tobacco companies have taken full ad- vantage of this trend to expand and strengthen their linkages with various racial/ethnic communities (Bergin 1990). The tobacco industry’s link with racial/ ethnic music and art is not new; for example, in the 1950s, tobacco companies featured African American jazz artists in cigarette advertisements in Ebony maga- zine. However, these links are more complex today (Pollay et al. 1992; Robinson et al. 1992b). For example, in 1994, New York City art institutions that received funds from Philip Morris were placed ina difficult situ- ation when the tobacco company asked them to in- form city council members about the role that Philip Morris had played in sponsoring artistic events in New York City. At that time, the city council was consider- ing a ban on cigarette smoking in most restaurants and public places, and Philip Morris was threatening to move the company headquarters away from New York City if such a ban was approved (Goldberger 1994). The headquarters did not move despite the city’s pas- sage of a 1995 law that banned smoking in workplaces (except for physically separated, separately ventilated smoking rooms and private offices), restaurants seat- ing more than 35 patrons, day care centers, and play- grounds (Smith 1995). Musical events have long been a primary outlet for targeting support among racial/ethnic groups. For example, jazz, rap, blues, rhythm and blues, salsa, gospel, and world music concerts are often heavily sponsored by tobacco companies and are identified with specific cigarette brands targeted toward African Americans, Hispanics, and Asian Americans and Pa- cific Islanders. Tobacco companies heavily promote these concerts on racial/ethnic minority radio stations, in the press, and through magazines that have large circulations (Robinson et al. 1992a,b). At these concerts, companies often promote their cigarette brands by naming events after the brands, by placing promotional signs on and around stages, and by dis- tributing free cigarettes and other promotional items featuring cigarette brand logos. These musical events have included the Parliament World Beat Concert Se- ries, Brown & Williamson’s Kool Jazz Festival, Benson & Hedges’s blues and jazz concerts, and Philip Morris's Superband Series. The Superband Series was launched in 1985 by Philip Morris to support and publicize jazz as “America’s unique contribution to the field of mu- sic” (Jet 1990, p. 36). The Superband, which featured African American musicians, performed throughout the world and the United States. Racial /ethnic dance troupes and the visual arts have been strongly supported by tobacco companies. Philip Morris has contributed significantly to African American troupes, including the Alvin Ailey Ameri- can Dance Theater and the Dance Theatre of Harlem (Blum 1989; Rothstein 1990; Jackson 1992; Johnson 1992b). Philip Morris also has provided substantial funding to the Studio Museum in Harlem, one of the main repositories of African American paintings, sculptures, and crafts. In addition, tobacco companies have underwritten traveling art shows featuring Afri- can American and African artists and have displayed the artists’ work in corporate settings (Jackson 1992; Robinson et al. 1992b). Traveling exhibits of Hispanic and Asian American artists have received significant support from tobacco companies as well. One of the longest running cultural events in African American communities is the annual eight- month tour of the Ebony Fashion Fair. Founded in 1958 by the publisher of the leading African American magazine, this event is attended by more than 300,000 women in 190 cities. From the late 1970s to the early 1990s, R.J. Reynolds’s More cigarettes supported the fair (Assael 1990). Proceeds from the tour have ben- efited African American churches, sororities, and other charitable and civic organizations whose antidrug campaigns, health fairs, and other projects are cited in the program. When the show was supported by More cigarettes, fashion models lit cigarettes during walks down the runway. In addition to reciting the names of clothing designers, the announcer noted that the Tobacco Use Among ULS. Racial/Ethnic Minority Groups models smoked More cigarettes. Free samples of More cigarettes were distributed to members of the audi- ence as they left the performance. At the Chicago per- formance of the 1984 Ebony Fashion Fair, RJ. Reynolds marked the UNCF’s 40th anniversary by donating a $250,000 ruby necklace to the fund as part of the tradi- tion of giving rubies on 40th anniversaries (Joyner 1984; Blum 1985, 1986). Estimating how much money is actually spent by the tobacco industry on the sponsorship of racial / ethnic cultural and social activities is difficult. Detailed financial records of tobacco manufacturers are not public record, and the financial information that is published in annual reports and similar company pub- lications does not separate the amount of money spent on the promotion of cultural and artistic events among racial/ethnic groups from the amount spent on adver- tising and other forms of product promotion. Support for Sports Events Although the negative effect of tobacco on health has made direct links between tobacco companies and sports less tenable today than they were in the 1950s and 1960s, tobacco companies have increased their involvement in sports by sponsoring community- based softball, golf, soccer, and baseball (Blum 1989; Robinson et al. 1992b). One such example is U.S. Tobacco’s Skoal Brand sponsorship of the Hispanic championship soccer tournament, Copa Nacional (Brandweek 1995). Tobacco companies have maintained a link to sports and racial/ethnic communities through such means as sponsoring the Jackie Robinson Foun- dation Awards Dinner. In 1995 alone, the six major cigarette-manufacturing companies in the United States spent $83 million to sponsor, advertise, or promote sporting events; to support individual athletes or group teams; to advertise in sports venues; and to promote items connected with sporting events (FTC 1997). To- bacco industry support for sports is consequential, in part, because of the perception among some youth, par- ticularly African Americans, that athletic ability pro- vides an avenue of personal advancement. Factors That Influence Tobacco Use 219 Surgeon General's Report Advertising and Promotion Advertising is an important influence on tobacco use initiation and maintenance, as documented in Preventing Tobacco Use Among Young People (USDHHS 1994). Cigarette advertising and promotion may stimulate cigarette consumption by (1) encouraging children and adolescents to experiment with and ini- tiate regular use of cigarettes, (2) deterring current smokers from quitting, (3) prompting former smokers to begin smoking again, and (4) increasing smokers’ daily cigarette consumption by serving as an external cue to smoke (CDC 1990a). In addition, cigarette ad- vertising appears to influence the perceptions of youths and adults about the pervasiveness of cigarette smoking and the images they hold of smokers (USDHHS 1989, 1994), Cigarette advertising also may contribute to the perception that smoking is a socially acceptable, safe behavior and may produce new perceptions about the functions of cigarette smoking in social situations. All of these perceptions have been shown to be risk factors for the initiation of cigarette smoking (Lynch and Bonnie 1994; USDHHS 1994; Federal Register 1996). Unfortunately, the specific effect of advertising on youth in racial/ethnic minority communities is not well understood, to some extent because research is scarce on youth in racial/ethnic communities. Available data indicate that young people smoke the brands that are most heavily advertised. In 1993, the three most heavily advertised brands of cigarettes, Marlboro, Camel, and Newport, were the three most commonly purchased brands among adolescent smokers. More than 45 percent of Hispanic and 63 percent of white teenagers reported purchasing Marlboro. African American teenagers most often chose Newport, one of the men- tholated cigarettes heavily marketed to the African American community (Cummings et al. 1987; CDC 1994a), Although combined sales of these three brands represented only 35 percent of the adult market share, they represented 86 percent of the adolescent market share. These data suggest that tobacco advertising in- fluences brand preference among youths and that there are differences in preference among racial/ethnic groups (CDC 1994a). Another reason that research to date has been unable to quantify the specific effect of tobacco adver- tising on racial/ethnic groups is that advertising for tobacco products is ubiquitous and uses images, such as glamour, independence, and attractiveness, that appeal to all segments of society. Overall, tobacco 220 Chapter 4 products are among the most heavily advertised products in the United States. However, studies have documented that some tobacco products are advertised disproportionately to members of racial/ethnic groups, such as mentholated products to African Americans and brands named “Rio” and the earlier “Dorado” to Hispanics (Gloede 1985; Leviten 1985; Walters 1985). In a study of adolescents who had never tried smoking, Evans and colleagues (1995) reported an association between a measure they constructed on receptivity to tobacco marketing and a measure of sus- ceptibility to begin smoking. Higher scores on the receptivity index were associated with increasing like- lihood of being susceptible to start smoking. The association persisted, even after statistical control for exposure to other smokers, race/ethnicity, and other socioeconomic status variables. Racial/ethnic minor- ity-group specific analyses were not conducted. The findings in this study, though suggestive, require further validation. Market segmentation is a well-developed strategy for crafting advertising campaigns that present particu- larly persuasive appeals to targeted audiences (Murphy 1984). It has been suggested that the tobacco industry strategically targets new consumer groups (e.g., women, racial/ethnic groups, and youths) by developing ad- vertisements that exploit the psychological interests and needs of those targeted populations (e.g., Basil et al. 1991). Alarge and increasing portion of advertising and marketing is targeted to racial/ethnic groups, especially youth (Moore et al. 1996; Zbar 1996). The challenge for the audience is to distinguish the advertising that rep- resents consumer goods with benefit or satisfaction from advertising that represents products that may harm the target community (Moore et al. 1996). Targeted tobacco advertising presents images of success, wealth, happi- ness, and sophistication, all of which are attractive to racial/ethnic groups, perhaps particularly in contrast with other, less flattering images of those communities presented by the news media. A recent article on the health of African American women discussed the at- tractive images used to target the African American community. “We have grown almost numb to negative images of ourselves in the media—Black teen girls sur- rounded by screaming babies or men in handcuffs. Except in cigarette or liquor advertisements. In these we are beautiful, confident, well-dressed, happy, wealthy, in love...” (Villarosa 1994, p. 13). Concern about targeted tobacco advertising has been the subject of various congressional hearings (e.g., U.S. Congress 1987, 1990). Efforts have been made by communities to counteract such advertising. Indeed, tobacco companies’ targeting of racial/ethnic commu- nities appears in some cases to have created a reverse marketing effect, such as that seen with the African American community’s negative and forceful response to Uptown and X brand cigarettes (see Targeted Products later in this chapter). Recent data show that African Americans’ spending on tobacco decreased 5 percent between 1994 and 1995 (Schmeltzer 1996), perhaps due in part to an adverse reaction to the tar- geted marketing of a harmful product (McIntosh 1995). Counteradvertising has also been used; one poster dis- tributed by Harlem Hospital in 1991 depicted the Marlboro man lighting a cigarette for an African American child. The caption read, “They used to make us pick it. Now they want us to smoke it.” A televi- sion spot, “Rappers/Pick It,” produced by the California Department of Health Services, conveys a similar theme (Kizer et al. 1990, p. 76). Although many companies are sensitive about disclosing targeted marketing strategies, particularly efforts focused on racial/ethnic minority markets, re- cent analyses of marketing trends document tobacco companies’ efforts to sell their products to racial /eth- nic groups and to youths (Davis 1987; Altman et al. 1991; Johnson 1992a; Moore et al. 1996; Stoddard et al. 1997). At least one major tobacco company, Philip Morris, has argued that it does not exclusively target any particular group (Nelson and Lukas 1990). Ques- tions also have been raised about the appropriateness of using targeted advertising and promotional tech- niques when the quantity and intensity of these efforts are well beyond the proportional purchasing power of the targeted group or when particular promotional techniques such as billboard placements are used in quantities that are out of proportion to the population size of the targeted groups. Examples of targeted ad- vertising and promotion that may be inappropriate in- clude the overly frequent placement of billboards that advertise tobacco products in racial/ethnic enclaves, the use of cultural values and symbols valued by mem- bers of racial/ethnic groups to promote tobacco prod- ucts, and the use of certain promotional practices (e.g., coupons, discounts, tie-ins, and free gifts). Magazine Advertisements Certain tobacco products are advertised dispro- portionately to members of racial/ethnic groups. For example, menthol cigarettes are more frequently Tobacco Use Among ULS. Racial/Ethnic Minority Groups advertised in magazines targeting African Americans than in magazines directed at the general public (Cummings et al. 1987). An analysis of one year of issues (June 1984 through May 1985) of three maga- zines primarily directed at African Americans—Jet, Ebony, and Essence—and of four magazines directed at the general population—Newsweek, Time, People, and Mademoiselle—found that 12 percent more adver- tisements for cigarettes appeared in the African Ameri- can magazines. In addition, 65.9 percent of the cigarette advertisements in the African American magazines were for menthol cigarettes, compared with 15.4 percent of those in the general population maga- zines (Cummings et al. 1987). Indeed, Newport, a menthol brand, is the number one preferred cigarette among African American adults and youth (CDC 1990b, 1994a). Outdoor Advertisements Early research showed that marketing ap- proaches such as billboards and point-of-sale displays have been particularly effective in reaching African Americans. Inone early study, Bullock (1961) sampled 1,106 African Americans and 537 whites from Atlanta, Birmingham, Houston, Memphis, and New Orleans to assess a variety of consumer behaviors. Bullock found that billboards and point-of-sale materials were particularly effective in reaching a high proportion of African American consumers and that African American consumers were more likely than whites to trust advertising. In addition, a disproportionately high number of billboards and other outdoor adver- tisements promoting cigarettes and other tobacco prod- ucts have been placed in racial/ethnic minority communities. A recent study in Los Angeles found that the density of cigarette advertisements on bill- boards was 4.6 times greater in the city proper than in the suburbs (Ewert and Alleyne 1992). Ina study con- ducted in San Diego, Elder and colleagues (1993) found that the highest proportion of billboards featuring to- bacco products was in Asian American (13.0 percent) neighborhoods, followed by African American (9.6 per- cent), Hispanic (4.7 percent), and white (1.1 percent) neighborhoods. The volume of outdoor advertising in Asian American neighborhoods was relatively low, although the proportion of that space devoted to to- bacco products was high (Elder et al. 1993). In an ear- lier study, Mitchell and Greenberg (1991) found that most billboards in racial/ethnic communities in four New Jersey cities were predominantly dedicated to advertised alcoholic beverages and tobacco products. In several urban centers, the proportion of billboard Factors That Influence Tobacco Use 221 Surgeon General's Report tobacco advertising has been found to be higher in Af- rican American neighborhoods than in white areas (Tuckson 1989; Mitchell and Greenberg 1991; Mayberry and Price 1993). Stoddard and colleagues (1997) docu- mented tobacco billboard advertising in four neigh- borhoods (African American, Asian American and Pacific Islander, Hispanic, and white) in Los Angeles during 1993 and 1994. Tobacco billboard density (the number of billboards per mile) was highest in African American communities, intermediate in Hispanic and Asian communities, and lowest in white communities. The models in billboards in African American neigh- borhoods were more likely to appear younger than in the other neighborhoods. In addition, 91 percent of the billboards in African American neighborhoods fea- tured an African American as the central character; in the other three neighborhoods, whites portrayed the central characters. In-Store Promotions In-store and over-the-counter promotions for to- bacco products also seem to disproportionately target racial/ethnic communities. For example, in racial/ ethnic neighborhoods in San Diego, Asian American retail outlets had the highest average number of to- bacco promotion displays (6.4), compared with His- panic (4.6) and African American (3.7) stores (Elder et al. 1993). In addition, low-cost or generic cigarettes that have begun to capture increasing market shares may be particularly effective as part of a targeted cam- paign directed at members of racial/ethnic groups with low-socioeconomic status and for whom price may be an important consideration in the purchase of cigarettes (Assael 1990). Convenience store owners often are eager to promote tobacco products, which account for about 26.5 percent of their total sales (National Association of Convenience Stores 1993). In such stores, tobacco companies frequently promote their products through special displays and point-of-sale promotions that pro- vide monetary or product allowances for the store owners (Cummings et al. 1991; Wildey et al. 1992; Davis 1993; USDHHS 1994). Ina study of 23 super- markets and convenience stores in San Diego, Wildey and colleagues (1992) found that 52 percent of store owners reported receiving payments from tobacco companies for displaying advertisements in their stores and that 69 percent of the stores displayed to- bacco advertisements on the outside walls, windows, or parking lot signs. The researchers also found that stores in Asian American neighborhoods were more likely than stores in white communities to have 222 Chapter 4 outside advertisements for tobacco products. A San Francisco study found that a large number of small stores in racial/ethnic minority neighborhoods display outside placards and small billboards for tobacco prod- ucts (Gerardo Marin and colleagues, unpublished data). About 57.6 percent of small stores in predomi- nantly African American neighborhoods displayed at least one advertisement for tobacco products, com- pared with 37.7 percent in predominantly Hispanic neighborhoods and 28.6 percent in predominantly Asian American and Pacific Islander neighborhoods. Racial/Ethnic Symbols, Names, and Events Another area of concern about targeted adver- tising and promotion is the use of clearly identifiable racial/ethnic models; group-specific messages, such as salutes to Latino community organizations during Hispanic Heritage Month, and group-relevant place- ments. Examples of group-relevant placements are cigarette advertisements appearing during Black His- tory Month and featuring pictures or quotations of African American leaders and Philip Morris’s salute to its Bill of Rights campaign during news coverage of Nelson Mandela’s release from prison. These adver- tisements target racial/ethnic communities by mak- ing use of symbols and events that are held in high esteem by community members. Individuals’ psychosocial characteristics are com- monly used in the design of targeted advertising and marketing campaigns (Basil et al. 1991). Consumers, particularly those who identify with an racial/ethnic group’s culture, tend to prefer buying goods that are specifically advertised to their cultural group. Deshpande and colleagues (1986) found that Hispan- ics who strongly identified with their racial/ethnic culture preferred Spanish language advertising, were more likely than those with less cultural identification to maintain brand loyalty, and were more likely than those with less cultural identification to buy prestige brand goods and those advertised specifically to their racial/ethnic minority group. In addition, Lee and Barnes (1989-1990) found that advertisements target- ing African Americans differ from those directed at the general population in that they feature certain bright colors. Tobacco product promotions also feature sym- bols and names that have special meaning for racial / ethnic groups. Certain names have special significance for particular groups (Uptown among African Ameri- cans), the use of non-English names may appeal to certain linguistic groups (Rio and Dorado among Hispanics), and the use of certain words can conjure symbols that are meaningful to a particular group (American Spirit among American Indians). The use of racial/ethnic events and symbols to market tobacco can present a complex issue that is difficult for communities to resolve. For instance, the American Spirit cigarette package portrays an American Indian smoking a pipe, and the product’s literature features American Indian cultural themes, stating that the American Indian custom was to smoke tobacco leaves the “natural way” and that American Spirit cigarettes are “natural” cigarettes. In early 1997, the American Indian Tobacco Education Network criticized the Sante Fe Tobacco Company for exploiting sacred Indian tra- ditions and imagery to sell its tobacco products. The Sante Fe Tobacco Company countered that it honors Indian traditions in its use of community symbols and even donates tobacco to tribes for ceremonial purposes (Guthrie 1997). The fact remains that American Spirit cigarettes contain tobacco with amounts of tar and nicotine similar to those of commercial brands and are thus dangerous to health, despite their lack of addi- tives. Although targeted marketing of products may bring economic benefits to racial / ethnic communities, when such marketing is for a harmful product such as cigarettes, the target community is challenged to choose between potential economic gain and social recognition versus the inevitable long-term adverse health outcomes from use of the product (Moore et al. 1996). Cigarette advertisements also have been accused of trivializing social causes and cultural values. For ex- ample, a Virginia Slims advertisement that appeared in the July 1994 issue of Life uses the concept of racial /eth- nic equality to promote use of the product. In addition, certain tobacco product advertisements have used visual images, such as American Indians as warriors, that de- mean the culture and insult some individuals (Green 1993). Another significant concern is the effect that targeted tobacco advertising may have on recent im- migrants. For many immigrants, the advertising of cigarettes in their country of origin has helped mold their attitudes and perceptions of tobacco use. These perceptions in turn create expectations about the social effects of cigarette smoking as portrayed in ad- vertisements, as well as brand recognition and brand loyalties toward the most frequently advertised brands. Targeted promotional and marketing practices also can affect the decisions of consumers who have recently migrated to the United States and who, in general, have not been exposed to marketing tech- niques and promotional approaches common in the United States. Immigrants not exposed to lifelong Tobacco Use Among U.S. Racial/Ethnic Minority Groups learning from the commercial practices of a market economy may be less critical and overly trusting of the messages and implied promises presented in ad- vertisements. Webster (1990-1991) found that highly acculturated Hispanics rated certain consumer prod- ucts as defective and overpriced and claimed that ad- vertising was problematic, whereas less acculturated Hispanics were more accepting of such defective prod- ucts and saw advertising not only as informative but also as enjoyable. Immigrants also respond differently to promotional techniques with which they are unfa- miliar. For example, Hispanics who have a low level of acculturation may not respond to certain novel pro- motional techniques such as the use of coupons (Donthu and Cherian 1992) but are more influenced by radio and billboard advertisements and point-of- sale displays (Webster 1992). Other studies have also found that promotional techniques have differential effects on various sectors of the Hispanic population. The more acculturated Hispanics report being prima- rily influenced by magazine advertisements, bro- chures, product labels, and consumer guides, such as Consumer Reports and the Yellow Pages (Webster 1992). Targeted Products Although a few cigarette brands have names that imply specific racial/ethnic minority targeting (e.g., Rio and Dorado for Hispanics), their promotion has been limited to a few states. The recent introduction of American Spirit seems to be directed at American Indians as well as youths and individuals preferring natural products. In addition, Japan Tobacco Inc. has begun to market its top-selling brand, Mild Seven, in the United States (Stebbins 1990; Sesser 1993). The brand is being promoted as a cigarette manufactured by Asians for Asians, and full-page advertisements ap- pear in magazines primarily targeting Asian Americans (Koeppel 1990b). Mild Seven billboards also have ap- peared in Koreatown and Little Tokyo in Los Angeles as well as in other US. cities with large Asian Ameri- can populations. One of the best examples of product targeting was the cigarette Uptown, designed by R.J. Reynolds in the 1980s to reach African American smokers (Dagnoli 1989; Simmons 1989; Koeppel 1990a; Robinson and Sutton, in press). The attempted introduction of this cigarette is a case study in racial/ ethnic product targeting. The characteristics, packag- ing, and planned promotion of Uptown cigarettes allegedly were designed specifically for African Ameri- cans. The menthol formulation of this new brand was designed to compete directly with Lorillard’s Newport Factors That Influence Tobacco Use 223 Surgeon General's Report cigarette, which was one of only three full-price ciga- rettes to gain market shares in 1989 along with Philip Morris’s Marlboro and Virginia Slims cigarettes (Dagnoli 1989). In 1986, Newport was the leading brand of cigarettes among African American smokers, ahead of Brown & Williamson’s Kool cigarettes and RJ. Reynolds’s Salem cigarettes (Simmons 1989; CDC 1990b). The mentholated Uptown cigarettes were to be packed with their filters down in the belief that African American blue-collar workers often open their cigarettes from the bottom to avoid crushing the fil- ters or having to put unwashed hands on the part of the cigarette that goes into their mouth (Ramirez 1990). Furthermore, in its statement announcing Uptown cigarettes, the company defined African Americans as the primary market for the new brand. Unlike New- port cigarettes, which were purported to be aimed at all smokers rather than just African Americans, R_J. Reynolds was specific (Dagnoli 1989). “We expect Uptown to appeal most strongly to black smokers,” said Lynn Beasley, vice president of strategic market- ing for the company. “Our research led us to believe that Uptown’s blend .. . will be an appealing alterna- tive to smokers currently choosing a competitive brand. We have developed a product based on re- search that shows that a significant percentage of black smokers are currently choosing a brand that offers a lighter menthol flavor than our major menthol brand, Salem” (Philadelphia News Observer 1990, p. 7). Uptown cigarettes were to yield 19 milligrams of tar per cigarette, which was the highest level of tar in all of R.J. Reynolds’s cigarette brands, with the ex- ception of unfiltered Camel cigarettes. The planned advertisements were to depict African American couples enjoying cigarettes in a sophisticated urban environment with the slogan “Uptown. The Place. The Taste” (Koeppel 1990a). The marketing plan for Uptown cigarettes was designed to take advantage of media that were particularly effective in reaching African Americans, including billboards, transit adver- tising, bus shelters, point-of-purchase signs, and advertisements in racial/ethnic newspapers and magazines. The introduction of Uptown cigarettes was planned for the first week in February 1990 to coin- cide with Black History Month activities, including receptions, exhibits, festivals, award ceremonies, and other events highlighting the African American expe- rience. Promoting Uptown cigarettes during this high level of activity—through the distribution of free 224 Chapter 4 samples and the underwriting of events—would afford R.J. Reynolds a prime opportunity to promote the new brand (Simmons 1989). RJ. Reynolds selected Philadelphia as the test market site because of its demographics. In 1990, the city’s population was approximately 40 percent Afri- can American and was served by several African American newspapers. In addition, African Ameri- cans tended to live in distinct neighborhoods that could be reached effectively through billboards and transit advertising. Furthermore, unlike some communities that had mobilized against excessive billboard adver- tising of alcoholic beverages and tobacco products, Philadelphia’s African American community had been quiet in this respect. In the wake of a firestorm of negative national publicity (see Chapter 5), R.J. Reynolds withdrew its plans to test-market Uptown cigarettes in Philadelphia. The protest against this targeted product involved community members, civic and religious leaders, health professionals, and then-Secretary of Health and Human Services Dr. Louis W. Sullivan. Ultimately, RJ. Reynolds decided to withdraw Uptown cigarettes from the market permanently. The same leadership and strategy were used again in Boston in early 1995 and similarly resulted in the withdrawal of a new brand of cigarettes called “X,” thought to be targeted to African Americans because of its red, green, and black packaging and the suggestion of the name of noted leader Malcolm X. In this instance, however, both the manufacturer and the distributor denied that the brand was targeted to African Ameri- cans or any other racial/ethnic market Jackson 1995) (see Efforts to Control Tobacco Advertising and Pro- motion in Chapter 5). In January 1997, R.J. Reynolds released a men- tholated version of Camel cigarettes. R.J. Reynolds had last marketed a mentholated brand of Camels in 1966 (Tobacco Merchants Association of the United States 1978). Approximately three-fourths of African Ameri- can smokers smoke mentholated cigarettes (USDHHS 1990) and Camel cigarettes are popular, so the African American community has been concerned that a new menthol brand may escalate smoking among African Americans. In an event similar to that precipitating the withdrawal of Uptown cigarettes, key religious leaders, led by the National Association of African Americans for Positive Imagery, launched a national crusade against the new brand extension of Camel Menthols (Rotzoll 1997). Psychosocial Determinants Tobacco Use Among U.S. Racial/Ethnic Minority Groups Psychosocial variables help explain why people start using tobacco (initiation), why some continue using it (maintenance), and why some stop using tobacco products (cessation). This section of the chap- ter provides a summary of research to date on the factors associated with initiation, maintenance, and cessation of tobacco use among ethnic groups. Unfor- tunately, the literature is sparse on individual and in- terpersonal factors that influence tobacco use among African Americans, American Indians, Alaska Natives, Asian Americans, Pacific Islanders, and Hispanics. Research and etiologic theory on smoking and smokeless tobacco use have largely excluded members of racial/ethnic groups. In fact, few researchers have included persons other than whites as part of their stud- ies. Although research findings based on samples of the majority white population may be applicable to racial/ethnic minority populations, such general- izability has not been sufficiently studied. Racial / ethnic groups may have different exposure levels and different reactions to risk factors or protective condi- tions than do whites. Furthermore, cultural differences in values, norms, expectancies, and attitudes may dif- fer among members of various racial/ethnic groups. These differences, in turn, may influence the prevalence of cigarette smoking in a particular racial/ethnic group and the relationship between smoking behavior and as- sociated risk factors (Marin et al. 1990a; Vander Martin et al. 1990). Certain experiences and values associated with tobacco use thus may be unique to some racial/ ethnic groups and may not be relevant to others. Understanding group-specific and community-based factors is necessary to help shape the development of culturally appropriate interventions. (Interventions are detailed in Chapter 5. For a detailed discussion of the range of variables that prompt youths to start smoking and to use smokeless tobacco, see Preventing Tobacco Use Among Young People, USDHHS 1994.) Initiation and Early Use of Tobacco Much of the research on tobacco use among racial/ethnic minority groups has focused primarily on a constellation of risk factors that affect people’s behaviors (Bry et al. 1982; Newcomb et al. 1986, 1987; Moncher et al. 1990; Scheier and Newcomb 1991; Felix- Ortiz and Newcomb 1992; Newcomb and Felix-Ortiz 1992; Vega et al. 1993). These studies have assessed environmental, behavioral, psychological, and societal attributes proposed by the various theories of tobacco use initiation (Ajzen and Fishbein 1970; Jessor and Jessor 1977; Kandel 1980; Yamaguchi and Kandel 1985; Elder and Stern 1986; Newcomb and Bentler 1988; Chassin et al. 1990, 1992), considering these attributes as individual risk factors or as a set of variables that affect an individual’s behavior (Hawkins et al. 1992). Some studies have proposed that the particular fac- tors that increase an individual’s vulnerability are not as important as the accumulation of such factors in a person’s life and that tobacco use is but one of many responses people use to cope. Investigators have fo- cused on some environmental and behavioral factors (such as parental and peer smoking or the availability of cigarettes) that may be useful in developing preven- tion strategies, but they have paid less attention to other equally important environmental conditions (such as price, access, exposure to advertising, economic history, customs and practices associated with tobacco in the native country, and tobacco industry influence on community organizations and leaders) that are differ- entially related to tobacco use and initiation. Some investigators have studied the onset of adolescent smoking as a phenomenon of gradual pas- sage through various cognitive and behavioral stages of change—for example, from abstaining to using to- bacco regularly (Conrad et al. 1992). Following Prochaska and DiClemente’s (1983) paradigm for studying smoking cessation, Stern and colleagues (1987) found that a predominantly white sixth-grade population progressed through stages, such as precontemplation (when the youth would not even consider smoking), to decision making (thinking about taking up the behavior and experimenting with cigarettes), to maintenance (regular smoking). Similar results were found ina study of California high school students, about one-third of whom were Hispanic (Elder et al. 1990), but potential differences between white and Hispanic students were not fully explained. More recently, Pierce and colleagues (1996) found that baseline susceptibility to smoking (defined as the absence of a firm decision not to smoke) was a stron- ger independent predictor of experimentation than the presence of smokers among either family or best friends. In this study, African American, Asian Ameri- can, and Pacific Islander adolescents were significantly less likely to experiment than whites or Hispanics. However, exposure to smokers was more important than susceptibility to smoking in distinguishing Factors That Influence Tobacco Use 225 Surgeon General's Report adolescents who progressed to established smoking from those who remained experimenters. African American, Asian American, and Hispanic adolescents appeared less likely than whites to become established smokers (Pierce et al. 1996). African Americans A few studies have tried to identify variables that predict cigarette smoking among African Americans. Brunswick and Messeri (1983) examined five domains of variables to assess their effects on the onset and con- tinuation of cigarette smoking among 379 African Americans aged 18-23 years who resided in the Harlem area of New York City. In this eight-year prospective study, multiple regression analyses showed that variables in each of five domains— personal background, school achievement, family and peer orientations, emotional conflict, and health atti- tudes and behaviors—were significant predictors of smoking initiation, although the patterns of influence differed by gender. In further analyses, Brunswick and Messeri (1984) found that poor school achievement predicted the onset of cigarette smoking among the young men and women. In addition, young women who reported higher cigarette use had low self- efficacy and were worried more about school. Among white youths, the presence of a best friend who smokes is a significant predictor of smok- ing, but the data on African American youths are contradictory. Some studies have shown that having peers who smoke is a poor predictor of cigarette smok- ing among African American youths (Headen et al. 1991), whereas others have found the opposite (Botvin et al. 1992, 1993). Botvin and colleagues (1993) found that the most powerful predictor of cigarette smoking among those students initially sampled was having friends who smoke, together with personal factors such as lack of assertiveness in refusing cigarettes. Astudy of 757 African American and Hispanic seventh grad- ers in six New York City public schools yielded simi- lar results (Botvin et al. 1994). A few studies have analyzed retrospectively the predictive power of various sets of variables. Benson and Donahue (1989), for example, studied cigarette use among African Americans and whites by analyz- ing data from the 1976, 1979, 1982, and 1985 Nation- al High School Senior Surveys that were part of the University of Michigan’s Monitoring the Future (MTF) Project. The researchers analyzed 10 predictors of ciga- rette use: personal importance of religion, region of the country where respondents resided, gender, school type, community size, college plans, hours worked, a 226 Chapter 4 father present, level of parental education, and mater- nal employment. For each year examined, the researchers found that the association between these 10 variables and cigarette use was substantially lower for African American high school seniors than for white high school seniors. Among both African Ameri- cans and whites, cigarette smoking was associated with the frequency with which the respondents went out at night, low levels of religiousness, and lack of concrete plans for college. In another study, Wallace and Bachman (1991) analyzed data from the MTF surveys for the years 1985-1989. They found that among Afri- can American high school seniors, four variables were significantly associated with cigarette smoking in the 30 days preceding the survey: living in a nonurban area, being truant, frequently attending rock concerts, and having peers who used cigarettes. Among white high school seniors, 10 variables were significantly associated with cigarette use: being female, living in a single-parent family, having low attachment to school, being truant, going to parties, going to rock concerts, doing poorly in school, not being committed to future education, spending evenings out for fun and recreation, and having peers who used cigarettes (these last 4 variables were also associated with cigarette use among African Americans, but the association was stronger among whites). Weinrich and colleagues (1996) examined the relationship among three factors—adolescent smoking under stress, psychological distress, and social support—among 1,168 sophomore and junior high school students. They found that race was strongly associated with smoking to cope with stress, as measured by indices of anger/anger control, depres- sion, somatization (expression of anxiety in physical symptoms), anxiety, obsessive/compulsive behavior, and social support. In each case, white students were more likely than African American students to engage in stress-related smoking. Also using a risk factor approach, Farrell and colleagues (1992) found that among 1,352 African American adolescents from the Southeastern United States, the following risk factors were associated with cigarette use: being home alone after school, having friends who approved of and used drugs, knowing adults who used drugs, feeling pressured to use drugs, expecting to use drugs in the future, being highly in- volved in delinquent behavior, having a history of trouble with the police, and having used cigarettes and alcohol previously. As noted, comparison of these studies is hampered by the noncomparability of the variables assessed. American Indians and Alaska Natives Among American Indians and Alaska Natives, tobacco use has a long and unique history that includes its use in rituals and spiritual ceremonies (Weibel- Orlando 1985; Siegel 1989). Despite this important his- tory, little is known about current predictors of the initiation of cigarette smoking and smokeless tobacco use among young American Indians and Alaska Natives. Schinke and colleagues (1989) have reviewed the scant literature and theories regarding tobacco use and believe that because of the historical association of tobacco with spiritual rites (Weibel-Orlando 1985), its contemporary daily use is also imbued with posi- tive cultural attributes. But more behavioral explana- tions for tobacco use among American Indian and Alaska Native youths include peer pressure and expected pharmacologic effects (Schinke et al. 1990). In a study of cigarette smoking initiation among North American Indians, Pickering and colleagues (1989) surveyed a sample of 689 Cree schoolchildren aged 9-18 years in Canada’s James Bay Region. Fac- tors associated with being a smoker included being older, being female, having a mother who smoked, and having a best friend who smoked. In a larger study, conducted in the northwestern United States, Moncher and colleagues (1990) examined tobacco use in a cross- sectional sample of 1,147 fourth and fifth graders of American Indian and Alaska Native descent. The re- searchers assessed 16 possible risk factors related to peer and family use of various drugs, school adjust- ment, intentions to use various drugs, quality of fam- ily relationships, nondrug-related deviant behavior, cultural identity, and religiousness. All of the 16 risk factors correlated with the prevalence of any current or ever use of cigarettes or smokeless tobacco by these children. In an earlier study, also in the northwestern United States, Hall and Dexter (1988) studied smoke- less tobacco use in a sample of 1,180 adolescents that included 257 American Indians. Multiple regression analyses revealed that among male adolescents, smokeless tobacco use was significantly associated with having friends who used smokeless tobacco; with cigarette smoking; and with tobacco use by the youths’ siblings, father, and other relatives. Among female adolescents, a similar pattern was observed, except that age also was positively associated with more smokeless tobacco use. Other explanations of tobacco use may include the relatively weak tobacco control infrastructure within American Indian communities and the presence of other environmental factors, such as advertising, that promote the use of tobacco prod- ucts (Hodge 1995; Robinson et al. 1995). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Asian Americans and Pacific Islanders Research on the factors that influence initiation of tobacco use among Asian Americans is sparse, and there is no such information about Pacific Islanders. Zane and Sasao (1992) reviewed the literature to iden- tify possible explanations for the use of substances (in- cluding tobacco) among Asian Americans and Pacific Islanders. They mention several influences observed in other populations that may be relevant for Asian Americans and Pacific Islanders: (1) multiple stressful life events related to cultural adjustment; (2) culture-specific social skills needed in the United States, particularly direct self-expression, asser- tiveness, and individualism, which are often the op- posite of traditional Asian and Pacific Island values and role expectations; and (3) family cohesion, which may reduce the role of peer influences that are central among members of other racial/ethnic groups. Wiecha (1996) studied 226 Vietnamese adoles- cents in two public middle schools and two public high schools in Worcester, Massachusetts, to examine the correlates and patterns of tobacco use. Four factors were independently and significantly associated with smoking among Vietnamese adolescents: male gender, older age, smoking by friends, and reporting carrying a weapon in the last month. Other factors that suggested associations but did not reach statisti- cal significance included performing poorly in school, ever using marijuana, and fighting. Acculturation was inversely associated with current cigarette smoking, i.e., study participants who were more acculturated, as indicated by longer time in the United States, better spoken English, or no use of Vietnamese translation on the survey, were less likely to be current smokers. Findings also suggest that the adolescents in this study knew less about the health consequences of cigarette smoking and might share a lower-than-average perceived susceptibility to cancer (Wiecha 1996). Data from adults may be of use in identifying factors related to initiation among youths. Chen (1993), for example, found that the influence of friends or peers was the most frequent reason for smoking ini- tiation reported by 13 adult Cambodian immigrant men. Data collected in 1991 indicate that among 296 adult Chinese Americans in Oakland, California, 40 percent of those who smoked reported that they began smoking “to be sociable” (Rod Lew and Art Chen, unpublished data). Other factors mentioned frequently were peer pressure (25 percent) and boredom (16 percent). Factors That Influence Tobacco Use 227 Surgeon General's Report Hispanics Research on why Hispanics begin to smoke of- ten is narrowly focused on subgroups, such as those from a specific city or with a particular national back- ground. Smith and colleagues (1991), using a cross- sectional design, examined numerous potential factors affecting cigarette smoking and intentions to smoke among Puerto Rican teenagers in Boston, Massachu- setts, and Hartford, Connecticut. Few statistically sig- nificant associations were found. Among Puerto Rican male adolescents, current cigarette smoking was asso- ciated with greater acculturation, more close friends who smoked, older age, and greater exposure to smok- ing at recreational activities. Among female Puerto Rican teenagers, the only factor associated with smok- ing was having close friends who smoked. In this study, the smoking status of parents had no effect on teenagers’ smoking behavior. Three studies have analyzed possible factors associated with tobacco use among Hispanic youths in the New York City area. Among Puerto Rican and Dominican seventh graders (Bettes et al. 1990), the researchers found that tobacco use was unrelated to language use (a possible proxy variable for accul- turation) but was significantly associated with nega- tive self-esteem, lower psychological well-being, higher psychological distress, and risk-taking. In a subsequent study, Dusenbury and colleagues (1992) examined possible factors associated with smoking experimentation and current cigarette use among New York City Hispanic youths aged 10-18 years. The researchers found an almost identical set of significant factors for both experimental and current use of ciga- rettes. These predictors included being older; having poor academic performance; having friends, parents, and siblings who smoked; believing that smoking was highly normative; and having parents with neutral or favorable attitudes toward cigarette smoking. More recently, Dusenbury and colleagues (1994) found that among Hispanic sixth- and seventh-grade students in New York City, those who smoked cigarettes tended to be older and to have a greater proportion of friends and relatives who smoked. They also found that speaking both English and Spanish at home and with friends (a behavior related to biculturalism) increased these students’ probability of smoking cigarettes. Separate analyses for boys and for girls showed that boys from bilingual homes were more likely to smoke; however, this was not true among girls. Data from two Southwestern cities indicate that a low level of maternal education and low grades obtained in school were associated with cigarette smoking among His- panic youths (Schinke et al. 1992). 228 Chapter 4 Cowdery and colleagues (1997) analyzed cohort data collected in the 1989 and 1993 Teenage Attitudes and Practices Survey (TAPS) from a nationally repre- sentative sample of Hispanic adolescents aged 15-22 years in 1993. They found that among Hispanic ado- lescents, the most strongly associated risk factor for smoking initiation was peer smoking. Additionally, not reporting a dislike for being around smokers and believing that smoking helps people relax and re- duces stress were associated with an increased risk of smoking among males and females. The belief that smoking helps keep weight down was significantly associated with smoking among females. Among males, believing that there was no harm in an occa- sional cigarette, that smoking reduces boredom, and that smoking helps ease nervousness at social events were all associated with an increased risk of smoking. School participation may be an important pre- dictor of tobacco use among Hispanics because they have the highest high school dropout rates of the ma- jor racial /ethnic groups in the United States (Kaufman and Frase 1990; Tomas Rivera Center 1993). Among white youths, dropping out of high school is a distinct correlate of cigarette use (Weng et al. 1988), but the results are not as clear for Hispanics. Chavez and col- leagues (1989) studied three groups of Mexican Ameri- can respondents—a group of youths who had dropped out of school, a group of youths at serious academic risk of dropping out of school, and a control group— from three Southwestern U.S. locations that varied in population size. Among Mexican American male youths, those at risk of dropping out of school and those who had dropped out of school had a higher prevalence of cigarette use but a lower prevalence of smokeless tobacco use than the control group. No sig- nificant differences in tobacco use were found among the three groups of Mexican American female youths. Watts and Wright (1990) compared Mexican Ameri- can adolescents in Texas who were incarcerated with those who were attending high school and found that both minor delinquency and violent delinquency were significantly associated with tobacco use. The results from a recent study by Felix-Ortiz and Newcomb (1992) provide additional insights into the variables related to smoking among Hispanic adoles- cents. The researchers assessed risk factors and protective factors as predictors of both the frequency of cigarette smoking and the quantity of cigarettes smoked. Multiple regression analyses showed that among Hispanic boys (but not among girls), risk factors such as low academic achievement, low law abidance, low religiousness, and high level of depres- sion significantly predicted both the quantity of cigarettes smoked and the frequency of smoking. Ina more recent study, Felix-Ortiz and Newcomb (1995) found that neither familiarity with Hispanic culture nor familiarity with the larger U.S. culture was directly associated with tobacco use among boys and girls. Among Hispanic boys, cigarette use was associated with less respeto—a cultural value that grants preroga- tives to adults and others with social power and that refers to a sense of personal self-worth. Among Hispanic girls, cigarette use was related to more in- volvement in Hispanic groups and political activities. A significant interaction was found between English- and Spanish-language proficiency (usually considered a proxy measure of acculturation) and frequency of cigarette smoking among both boys and girls. For example, Hispanic youths with poor English- and Spanish-language skills had the highest frequency of cigarette use, whereas those with poor English- language skills but strong Spanish-language skills re- ported the lowest frequency of cigarette use. Hispanic youths with strong English-language skills had mod- erate levels of cigarette smoking frequency, regardless of their degree of Spanish-language proficiency. Another study of 1,411 females of Latino origin (Latinas) found differences in knowledge and percep- tions about cigarette smoking between Spanish- language and English-language/bilingual young women (Campbell and Kaplan 1997). In this study, Latinas who either spoke English or were bilingual were less likely than their counterparts who spoke only Spanish to acknowledge the danger associated with smoking an occasional cigarette or to recognize the difficulty in quitting smoking, were more likely to identify beneficial aspects of smoking, and were more likely to consider smoking socially. For many Hispanic youths, adaptation to life in the United States may produce psychological stress and anxiety. Whether these factors are directly associated with smoking among Hispanic youth is not known. In a recent study of migrant adolescents in the San Diego, California, area, Lovato and colleagues (1994) reported that respondents’ level of acculturation was not related to cigarette smoking or alcohol use, even though the more acculturated adolescents were more likely to en- gage in binge drinking. Acculturation remains a strong theoretical consideration in smoking initiation, but current findings are limited by the methodological issues previously cited. In addition, a variety of accul- turation measures have been used, and these have intrinsic limitations for assessing the cultural learning process (Marin 1992). Interpretation is particularly problematic when researchers use proxy measures such as language proficiency to measure complex psycho- Tobacco Use Among US. Racial/Ethnic Minority Groups social processes like acculturation. The existence of multiple cultures within Hispanic communities adds to the complexity of this issue, as is also the case in Asian American communities. Multiple Group Studies Several studies have examined initiation and early use of tobacco among more than one racial /eth- nic group and have compared data within and among these groups. Some of these studies have concentrated on analyzing the prevalence of perceived risk factors commonly associated with tobacco use, and other stud- ies have addressed the question of what differentiates smokers from nonsmokers. CDC and 13 universities conducted research ina collaborative partnership that involved a series of focus groups and in-depth interviews among African American, American Indian, Asian American and Pacific Islander, Hispanic, and white teenagers. The purpose of the research was to assess differences in the functional value of smoking, the images associated with and social norms that surround smoking, and the messages that youths report receiving about smoking. The universities used common methodologies, proto- cols, definitions, and coding schemes for transcripts of focus groups and interviews. Preliminary findings of this research are that (1) young smokers know about the addictive nature of nicotine; (2) smoking is viewed as “cool” and “grown up”; (3) smoking derives func- tional value from group belonging and stress management; (4) among girls, notions of “respect” and “reputation” are influential for nonsmoking in some groups; and (5) parental messages about smoking vary by race/ethnicity, but African American and Hispanic parents give clearer messages about not smoking than parents in other groups. Other emerging issues noted in this analysis are that (1) smoking is not seen as im- age enhancing among African American girls; (2) African Americans were more likely to pair ciga- rette smoking with marijuana to maintain a “high”; (3) parental smoking is a negative influence, particu- larly among American Indian families; and (4) varia- tion exists among the racial/ethnic groups with regard to the media channels through which messages are received (Mermelstein et al. 1996). Prevalence of Risk Factors for Cigarette Use Several studies have analyzed how possible risk factors for tobacco use differ among youths in various racial/ethnic groups. For instance, in a study of Los Angeles County students in grades seven through Factors That Influence Tobacco Use 229 Surgeon General's Report nine, Maddahian and colleagues (1986) found that African American adolescents reported having the highest number of friends who provided cigarettes, followed by white, Hispanic, and Asian American ado- lescents. Perceived ease in acquiring cigarettes was highest among white adolescents and lowest among Asian American adolescents; Hispanic and African American adolescents reported moderate ease in ac- quiring cigarettes. In assessing how earned income vs. allowance income related to cigarette use, the re- searchers found that Asian American and white ado- lescents reported having a higher earned income than adolescents in the other two racial/ethnic groups; in comparison, Hispanic and African American adoles- cents reported receiving more allowance income than Asian American or white adolescents. Maddahian and colleagues (1988) subsequently found that African American and Hispanic youths reported greater inten- tion to use cigarettes than white and Asian American youths. In a more recent study, involving northeast- ern U.S. youths in grades six through eight, Vanderschmidt and colleagues (1993) found that physi- cal violence and sexual activity were the risk behav- iors most highly associated with smoking among African American, Hispanic, and white students. Smoking-related perceptions and risk factors also differ among older youths of different racial/ ethnic backgrounds. Ina study of high school seniors Table 1. High school seniors’ perceptions about the risks associated with cigarette smoking, Monitoring the Future surveys, United States, 1980-1989 African American Americans Indians Perceived risks Gender % N* % N* Percentage who believe that people Male 68.4 1,586 52.5 221 take a great risk of harming them- Female 71.0 1,901 63.5 181 selves if they smoke one or more packs of cigarettes per day Percentage who believe that people Male 77.6 1,717 64.1 220 disapprove or strongly disapprove Female 80.4 2,076 63.1 210 of people aged 18 years and older smoking one or more packs of cigarettes per day Percentage who think their close Male 75.4 1,193 65.2 179 friends disapprove or strongly Female 80.5 1,610 69.1 155 disapprove of their smoking one or more packs of cigarettes per day Percentage who report that none vs. most or all of their friends smoke cigarettes None Male 17.1. 1,340 12.8 200 Female 19.9 1,807 11.0 184 Most or all Male 19.0 1,340 30.0 200 Female 18.7. 1,807 36.8 184 *The number of respondents (N) varied for each question. Each of the numbers (N) reported represents the total number of students who were asked a particular question, not the number of students who responded affirmatively. 230 Chapter 4 participating in the MTF between 1980 and 1989, Wallace and Bachman (1993) found that American In- dians, both males and females, were less likely than students in other racial/ethnic groups to perceive that smoking one or more packs of cigarettes per day posed a great risk to their health (Table 1). The perception that friends and people in general disapproved of smoking one or more packs of cigarettes per day was least prevalent among male and female American Indian high school seniors and most prevalent among female Asian American seniors. Finally, the percent- age of students who reported that most or all of their friends smoked cigarettes was highest among Ameri- can Indian seniors and lowest among Asian American seniors. Tobacco Use Among ULS. Racial/Ethnic Minority Groups Factors Associated with Initiation of Cigarette Use Numerous researchers have assessed patterns of cigarette use initiation among young people of vari- ous races/ethnicities. For example, Botvin and col- leagues (1994) studied potential predictors of cigarette smoking onset among seventh graders in six New York schools within low-socioeconomic communities. Ap- proximately 50 percent of the children were African American, and 36 percent were Hispanic. Statistically significant predictors for ever smoking included the absence of one or both parents, low grades in school, high prevalence of smoking among friends, and a sense of hopelessness. The data were not analyzed sepa- rately by race/ethnicity. Asian Mexican Puerto Ricans and Americans Americans Latin Americans Whites % N* % N* % N* % N* 67.6 309 69.7 456 66.2 228 64.0 11,266 71.8 307 67.1 477 64.2 241 66.6 11,764 80.4 350 77.3 486 82.7 280 77.1 11,970 85.6 311 81.2 477 82.2 258 70.0 12,459 77.0 277 76.3 335 77.1 163 73.1 10,346 81.7 270 80.2 414 79.0 165 73.6 11,163 19.1 298 14.3 429 10.9 185 11.6 11,226 29.6 274 17.2 439 12.4 213 9.9 11,760 12.8 298 16.9 429 19.5 185 19.3 11,226 11.4 274 17.4 439 21.9 213 25.4 11,760 Source: Adapted from Wallace and Bachman 1993. Factors That Influence Tobacco Use 231 Surgeon General's Report In assessing differences among racial/ethnic groups, Koepke and colleagues (1990) compared 14 po- tential predictors of cigarette smoking onset among seventh- through ninth-grade African Americans, Asian Americans and Pacific Islanders, Hispanics, and whites from Los Angeles and San Diego, California. The re- searchers found that most variables were not related to smoking onset among any of the racial/ethnic groups, and no single factor was a statistically significant pre- dictor among all four groups. Greater anger increased the likelihood of smoking onset for African American and Hispanic youths but was unrelated to smoking on- set for Asian American, Pacific Islander, and white youths. The number of close friends who had tried ciga- rettes was a significant predictor of smoking onset for Hispanic, Asian American, and Pacific Islander youths but not for African American or white youths. These studies underscore the variability of predictors among groups. Peer influences also were identified in a study of sixth and seventh graders in San Diego. Elder and colleagues (1988) found that white girls, African Ameri- can boys, and Asian American boys who believed that a large number of their peers smoked cigarettes were more likely to experiment with smoking. When ac- tual continued use of cigarettes was considered, the normative belief (that a large proportion of their peers smoked) predicted cigarette smoking for Hispanic boys and for white boys and girls. These normative perceptions were most strongly associated with experi- menting with chewing tobacco among white boys and girls and Asian American boys. Other studies also have found that peer smoking had a significant effect on cigarette smoking initiation. Sussman and col- leagues (1987), for example, examined predictors of cigarette smoking among Southern California adoles- cents in Los Angeles and Orange Counties and found that peer pressure to smoke was not a predictor of smoking, although peer cigarette use was a critical predictor for Asian Americans, Hispanics, and whites (but not for African Americans). In this same study, parental pressure to smoke and knowledge of the health consequences of smoking were not associated with smoking for any group. On the other hand, three variables were statistically significant predictors for all four groups—general availability of cigarettes, difficulty in refusing offers to smoke, and intent to start smoking. The strongest predictors of cigarette smok- ing were different for each racial/ethnic group: for white youths, adult and peer models of smoking were the strongest predictors; for Hispanic youths, self- image as a smoker and adult or peer approval of smoking were the strongest predictors; for African 232 Chapter 4 American youths, preference for risk-taking was the strongest predictor; and for Asian American youths, low self-esteem and poor achievement in school were the strongest predictors. Castro and colleagues (1987) also found that peer smoking behaviors were significantly correlated with cigarette smoking among African American, Asian American, Pacific Islander, Hispanic, and white teen- agers in Los Angeles County. Disruptive family events (e.g., number of relocations) were significantly corre- lated with cigarette smoking among Asian American, Pacific Islander, and white youths but not among African American and Hispanic youths. In addition, law abidance, liberalism, and religiousness were sig- nificantly associated with less frequent cigarette smok- ing among African American, Asian American, Pacific Islander, and white youths but were associated with more frequent cigarette smoking among Hispanics. A more recent study (Landrine et al. 1994) has found that although cigarette smoking among peers is a good pre- dictor of cigarette smoking among white adolescents, it is a less powerful predictor of cigarette smoking among African Americans, Asian Americans, and Hispanics. The role of personal psychological characteris- tics in predicting cigarette smoking has also been stud- ied in a multiracial/multiethnic setting. Among seventh graders in New York City, Bettes and colleagues (1990) found that certain psychosocial variables—negative self-esteem, positive self-esteem, psychological distress, psychological well-being, and risk-taking—had no differential effect on tobacco use, except that psychological well-being and high risk- taking were found to be particularly protective for African American seventh graders. Factors Associated with Initiation of Smokeless Tobacco Use Riley and colleagues (1991) found that among African Americans, American Indians, and whites, self- reported use of smokeless tobacco was associated with the perceived consequences of use, the use of alcoholic beverages and cigarettes, peers’ use of smokeless to- bacco, beliefs about the health consequences of smoke- less tobacco use, and level of perceived control over one’s own health. The strongest predictors for all groups were previous use of alcoholic beverages and tobacco and peers’ use of smokeless tobacco. Perceived negative consequences were considered most impor- tant among American Indians and whites. For Afri- can Americans and American Indians, the strongest predictor of the amount of smokeless tobacco used was previous use of alcoholic beverages and cigarettes. For whites, the strongest predictor of the amount of smoke- less tobacco used was peers’ use of smokeless tobacco. Summary, Initiation and Early Use of Tobacco The limited number of studies renders the results fragmentary, but some general findings emerge. Certain categories of variables—sociodemographic, environmental, behavioral, personal, and psychologi- cal—may be related to tobacco use initiation and con- tinued use among youths of various racial/ethnic minority groups. Some of these categories of variables may predict initiation of tobacco use for all people, regardless of their race/ethnicity (USDHHS 1994), but the predictive strength of these variables likely differs across racial/ethnic groups. Because of the method- ological problems previously mentioned, the summa- rized findings are not comparable across racial/ ethnic groups; these findings are meant to suggest a pattern rather than to convey a body of evidence. Future research must establish the strength of various predictors by using comparable and culturally appro- priate measurements. In addition, several important predictors of tobacco use among racial/ethnic youth and the environmental factors surrounding it have not been thoroughly researched. One such example is the role of tobacco advertising, which has been shown to affect a number of risk factors related to smoking ini- tiation, such as perceptions about the pervasiveness of cigarette smoking, its social acceptability, its dan- ger, and its function in social situations (USDHHS 1994). Finally, the relative strength of a community’s tobacco control infrastructure may influence behav- iors and policies about tobacco and the tobacco indus- try. Robinson and colleagues (1995) suggested that this fact should be considered in assessments of initiation and early use of tobacco products. Tobacco Use Among Adults The factors associated with tobacco use among adult members of racial/ethnic groups have been stud- ied even less than those among young people. Few studies have analyzed tobacco use among adult Ameri- can Indians, Alaska Natives, Asian Americans, or Pacific Islanders, and only limited information is avail- able on predictors of continued tobacco use among African Americans and Hispanics. African Americans Romano and colleagues (1991) examined the association between cigarette smoking, social support, Tobacco Use Among U.S. Racial/Ethnic Minority Groups and stress in a sample of adult African Americans in the San Francisco and Oakland areas of California. African American men and women who reported high levels of stress were more likely to smoke than those reporting fewer stressful conditions. The role of stress in cigarette smoking among adult African Americans also has been supported by the findings of Feigelman and Gorman (1989) and Ahijevych and Wewers (1993). Ina national sample of adults interviewed for the 1987 General Social Survey, Feigelman and Gorman (1989) found that the highest proportion of smokers were African Americans who were exposed to high levels of stress and who had a low level of occupational pres- tige. In comparison, whites with low stress and high occupational prestige had the lowest proportion of smokers. African American women with underdevel- oped social networks were also more likely to smoke than those with strong social support. The role of so- cial support was not statistically significant for Afri- can American men. In fact, African American men who appeared to have little emotional support from friends or family were less likely to smoke than African Ameri- can men who had such support. American Indians and Alaska Natives Hodge and colleagues (1996) studied adult American Indian patients in Northern California. The sample included members of the Hupa, Maidu, Pit River, Pomo, and Yurok Tribes of California as well as a number of Sioux Indians. The researchers found few differences in the type and amount of social support experienced by American Indian smokers and non- smokers. In the urban areas of San Francisco and San Jose, American Indians who reported high levels of stress were more likely to be current smokers than those who reported lower levels of stress. American Indians living in urban areas also reported being more motivated to quit than those in rural areas. Ina study of 614 American Indian women (East- ern Band Cherokee) in western North Carolina, Spangler and colleagues (1997) found several corre- lates with higher prevalence of current smoking, in- cluding younger age, alcohol use, no yearly physical examination, marital status of separated or divorced, lack of friends, and lack of church participation. Having a lower level of education and having con- sulted an Indian healer were correlated with higher smokeless tobacco use. Factors That Influence Tobacco Use 233 Surgeon General’s Report Asian Americans and Pacific Islanders Ina study of adult male Vietnamese refugees liv- ing in the San Francisco area, Jenkins and colleagues (1990) found that cigarette smoking was significantly related to having immigrated to the United States within the previous nine years, not knowing that smok- ing causes cancer, having an income below the federal poverty level, and having limited proficiency in English. No significant associations were found between men’s cigarette smoking and education, alcohol use, marital or employment status, health con- dition, or age. In another study, conducted between 1989 and 1991 (CDC 1992), cigarette smoking among Chinese, Vietnamese, and Hispanics in California was associated with an annual income of less than $25,000, a high school education or less, recent immigration to the United States, and limited proficiency in English. In a survey of Southeast Asian men—primarily Cambodian, Laotian, and Vietnamese—Chen and col- leagues (1993) found that compared with former smok- ers and persons who had never smoked, smokers were more likely to have limited proficiency in English, to be more traditional (less acculturated), and to report that almost all of their five best friends were smokers. Only about one-third of the men surveyed had heard that cigarette smoking may cause heart disease. In addition, Chen and colleagues observed no statistically significant differences in the knowledge of smoking danger reported by smokers, former smokers, or per- sons who had never smoked. In a survey of 832 Cambodian, Vietnamese, and Laotian men in Ohio, Moeschberger and colleagues (1997) found that the odds of never smoking and of being a former smoker were significantly higher among men who were employed than among those unemployed. In addition, current smokers were more likely than nonsmokers to be traditional or bicultural, whereas men who had assimilated into U.S. culture were four times as likely to have quit. Hispanics The literature on correlates of cigarette smoking among Hispanic adults is more substantive than that for the other racial/ethnic minority groups. These studies permit exploration of the interaction of cultural pride and acculturation with other correlates of ciga- rette smoking (Marin et al. 1989a, Castro et al. 1991) and drug use among Hispanics (see Chapter 2). The possible relationship between symptoms of depression and cigarette smoking was investigated by Pérez-Stable and colleagues (1990), who examined the association between smoking status (i.e., current smok- 234 Chapter 4 ers, former smokers, and those who had never smoked) and depressive symptoms in a random sample of 551 Hispanics in San Francisco. After controlling for gen- der, acculturation, age, education, and employment status, significant differences in depression (as mea- sured by the Center for Epidemiological Studies De- pression [CES-D] Scale) remained between current smokers and nonsmokers (both former smokers and lifetime abstainers). Current smokers had a 70 per- cent greater risk for having depressive symptoms than persons who had never smoked. A recent study that used data from the HHANES identified an association between patterns of smoking initiation and depressed mood, a history of major depression, or both (Escobedo et al. 1996). The belief that cigarette smoking reduces tension has been identified as a potent reason for smok- ing, according to researchers studying Hispanics from South America and the Caribbean who live in the New York City area (Larino et al. 1993), as well as Mexican Americans in San Francisco (Marin et al. 1989a). To identify additional correlates of tobacco use among adult Hispanics, Lee and Markides (1991) com- pared three age groups of adults in a sample of Mexi- can Americans in the Southwestern United States who were interviewed between 1982 and 1984 as part of the HHANES. Among Mexican Americans aged 20-39 years, being a smoker was associated with the increased consumption of alcohol for both men and women, with poorer health for men, and with more depressive symptoms for women. Among Mexican American men aged 40-59 years, those who smoked cigarettes also consumed more alcohol than those who did not smoke. Among Mexican American women aged 40-59 years, those who smoked cigarettes also consumed more alcohol and had lower diastolic blood pressure, lower body mass, and more depressive symptoms than those who did not smoke. Among Mexican Americans aged 60-74 years, men who smoked were more likely to consume alcohol and cof- fee and to have lower body mass than men who did not smoke; women who smoked were also more likely to consume coffee and alcohol than those who did not smoke. A Mexican American subsample of the HHANES showed that cigarette smoking was associ- ated with the presence of other smokers at home or at the workplace and with the respondent's level of acculturation (Coreil et al. 1991). These data also showed that cigarette smoking status was not related to educational level or to employment status but that age was positively associated with the number of cigarettes smoked per day among younger men and women aged 20-39 years. A study of Hispanic adults in New Mexico (Samet et al. 1992) found a rela- tionship between low levels of formal education and prevalence of cigarette smoking. Low socioeconomic status, often indicated by education, was also related to cigarette smoking in that study. A number of studies conducted in San Francisco have compared the psychosocial characteristics of His- panic smokers with those of white smokers. These studies provided an understanding of culture-specific differences in attitudes, norms, and expectancies of smokers and served as the basis for developing a culturally appropriate smoking cessation interven- tion—Programa Latino Para Dejar de Fumar (Hispanic Program to Quit Smoking) (see Chapter 5). In one such study (Marin et al. 1990a), Hispanic smokers were sig- nificantly more concerned than white smokers about harming their children’s health. White smokers, on the other hand, were significantly more con- cerned than Hispanic smokers about burning holes in their clothes and feeling controlled by the need to smoke. White smokers were more likely than Hispanic smokers to view other smokers as friendlier and more sociable, aggressive, attractive, and feminine than non- smokers (Marin et al. 1989b). More acculturated Hispanics provided responses that more closely resembled the responses of whites than the responses of less acculturated Hispanics (Marin et al. 1989b). Acculturation also was found to affect an individual's willingness to quit smoking on the basis of advice from his or her parents and physicians. Similarly, ina New York City area survey of 88 Hispanics who expressed interest in quitting cigarette smoking, Mahony and colleagues (1993) found that their reasons for smok- ing differed by their level of acculturation. Summary, Tobacco Use Among Adults A few variables have been associated with the continued use of cigarettes among adults from racial/ ethnic groups. Cigarette smoking among members of the four racial/ethnic groups seems to be associated with depression, psychological stress, and environ- mental factors such as tobacco advertising and pro- motion and the influence of peers who smoke. The high levels of stress among members of the four racial/ethnic groups may be the product of such fac- tors as low-prestige jobs; poverty; difficulties associ- ated with living in a new environment or culture; limited proficiency in English; prejudice and discrimi- nation; pressures to acculturate; limited free time; and multiple demands on time related to jobs, substandard housing, and the care of small children. Smoking ces- sation programs directed at members of these racial / ethnic groups should address stress reduction in the same way that tobacco prevention and control strat- Tobacco Use Among U.S. Racial/Ethnic Minority Groups egies should consider the historical context of tobacco and the tobacco industry in the community and cultural differences among racial/ethnic minority communities. These data also indicate that Hispanic smokers have expectations and attitudes related to cigarette smoking that differ from those of white smokers—a finding that supports the need for culturally appro- priate cessation interventions. Future studies should determine if similar differences in expectancies and attitudes exist among smokers of the other three racial/ethnic groups considered in this report. The limited data available support the need for more and better designed studies of tobacco use among mem- bers of the various racial/ethnic groups. Smoking Cessation Little is known about the psychosocial factors that influence cigarette smoking cessation among members of racial/ethnic groups. Although people’s level of addiction is an important determinant of whether they will successfully stop smoking, limited information is available on patterns of addiction among members of various racial/ethnic groups. (For more information on patterns of addiction, see Chap- ter 3. For details about other variables that affect smok- ing cessation, such as smoking patterns and access to culturally appropriate cessation services, see Chapters 2 and 5.) African Americans Knowledge about the damaging effects of smok- ing can be an important motivator of smoking cessa- tion (Orleans et al. 1989; Jepson et al. 1991; also see Chapter 5). Studies of African Americans’ knowledge about the health consequences of tobacco smoking have produced contradictory findings. Klesges and colleagues (1988), for example, interviewed African American and white adults in Fargo, North Dakota, and Memphis, Tennessee, and found that proportion- ately more whites than African Americans knew that cigarette smoking was related to heart attacks, emphy- sema, premature births, and skin wrinkles. Similarly, Vander Martin and colleagues (1990) found that Afri- can Americans from the San Francisco Bay area who smoked cigarettes were less concerned about the health effects of cigarette smoking than were whites who smoked. African Americans also were less likely to believe that cigarettes were addictive, produced harm- ful health effects, or caused heart attacks. Factors That Influence Tobacco Use 235 Surgeon General's Report Conversely, in a 1990 study in St. Louis and Kan- sas City, Missouri, Brownson and colleagues (1992) found that about the same percentage of African Ameri- cans and whites believed that smoking was harmful to people’s health. Although African Americans recognized the harmful effects of environmental to- bacco smoke (ETS), they tended to minimize some of the health effects of smoking, particularly its link with heart disease. Similarly, an ABC News/The Washing- ton Post survey conducted in February 1993 found that a large proportion of African American and white adults perceived ETS to be a health risk (Roper Center for Public Opinion Research 1993). In that poll, how- ever, a greater proportion of African Americans than whites reported that they worried a great deal about ETS. In studies limited to African Americans, research- ers have reported differences based on smoking sta- tus. Warnecke and colleagues (1978) interviewed A fri- can American women in Buffalo, New York, and found that current smokers were less likely to say they be- lieved that cigarette smoking was related to a variety of conditions, including cancer and heart disease, than were former smokers or persons who had never smoked. Most African American smokers want to quit, and many have tried. Ina 1986 study of African Ameri- can smokers who were policyholders of the North Carolina Mutual Life Insurance Company, Orleans and colleagues (1989) found that 79.3 percent of respon- dents had tried to quit smoking at least once in their lifetime. Hoffman and colleagues (1989) found that most of the patients in a general community hospital in Chicago who smoked reported previous attempts to quit on their own, and 65 percent wanted to stop smoking immediately. More than two-thirds of these African American smokers indicated that they would like a formal program to help them quit smoking. Ina more recent survey, Ahluwalia and McNagny (1993) found that among all African American patients visit- ing a county-operated health facility in Atlanta, Geor- gia during a three-week period, 86 percent of the smokers wished to quit. Ninety-nine percent of those who wanted to quit smoking indicated they would par- ticipate in a smoking cessation program even if it in- volved visits to the hospital. According to data from the 1993 NHIS (CDC 1994b), 71.4 percent of African Americans aged 18 years or older who currently smoked were interested in quitting. Royce and colleagues (1993) used a sample drawn from metropolitan communities in California, New Jersey, New York, and North Carolina as part of the Community Intervention Trial for Smoking Ces- sation (COMMIT) project and found that more Afri- can Americans than whites reported a strong desire to 236 Chapter 4 quit smoking and more attempts to quit in the past year. These researchers also observed that a larger percentage of African Americans than whites reported a need to smoke within 10 minutes of awakening (a behavioral symptom of nicotine dependence), even after the analysis controlled for age, education, and gender. In the San Francisco Bay area study by Vander Martin and colleagues (1990), African American adult smokers were more interested in quitting smoking than were white adult smokers and were also more confi- dent that they could successfully quit. When smoking cessation trends are compared, a different pattern emerges by gender. Hahn and col- leagues (1990) found a slightly higher proportion of white women in Minneapolis and St. Paul (33 percent) than of African American women (29 percent) who reported trying cigarettes with lower levels of tar and nicotine in the previous year, and a higher proportion of white men (63 percent) than African American men (52 percent) reporting that they had tried to quit smoking. In their study of African American women in Buffalo, New York, Warnecke and colleagues (1978) found that many women who had quit smoking attributed their quitting to the fact that cigarette smok- ing causes cancer (44 percent) or other diseases (45 percent); to physical side effects such as coughing or headaches (36 percent); or to negative cosmetic ef- fects such as bad breath, stained teeth, or bad smell (34 percent). More recently, in a series of eight focus group discussions with African American women smokers residing in Chicago public housing develop- ments, respondents said that quitting was difficult for them because they lived in a highly stressful environ- ment that made it difficult to manage their personal lives (Lacey et al. 1993). Cigarette smoking was one of the few pleasures available to them in such an envi- ronment, and the women had few if any sources of information on how to quit smoking. In addition, these women tended to believe that cigarette smoking posed minimal health risks, that the behavior was quite com- mon among other adults, and that all that was needed to quit was the willingness to do it. In a study of ur- ban pregnant women, O’Campo and colleagues (1992) found that the only predictor of quitting smoking during pregnancy for African American women was intention to breast-feed, whereas among white women, the best predictors were educational level, age, and parity. About 46 percent of African American women who quit smoking during pregnancy relapsed within 6-12 weeks after delivery. Formula feeding of the in- fant was the best predictor of postpartum smoking relapse for both African American and white mothers. American Indians and Alaska Natives Few studies have focused on smoking cessation among American Indians, and no studies have ad- dressed smoking cessation trends among Alaska Na- tives. In a survey of American Indians in Northern California, respondents were found to have fairly high levels of information regarding the health effects of cigarette smoking (Hodge et al. 1994). For example, a similar proportion of urban (94 percent) and rural (91 percent) American Indian smokers knew that smok- ing during pregnancy would harm the fetus. Although American Indian smokers were as knowledgeable as nonsmokers regarding the health effects of cigarette smoking, attitudes about smoking differed between the two groups. American Indian smokers were more likely than nonsmokers to think that it is acceptable to smoke and chew tobacco, to permit the advertising of tobacco products, to let visitors smoke in one’s home, and to allow smoking in restaurants. In addition, American Indian women who smoked reported a greater number of depressive symptoms (as measured by the CES-D) than nonsmoking women. However, researchers observed no differences in the number of depressive symptoms among men who smoked com- pared with men who did not smoke. A fairly large number of American Indians reported that they were not interested in quitting (45 percent of residents in urban areas and 55 percent of residents in rural areas). In the 1993 NHIS, however, 65.0 percent of American Indian or Alaska Native smokers aged 18 years or over reported that they wanted to quit smoking cigarettes completely (CDC 1994b). In another study of current smokers who were patients at Indian health clinics, Lando and colleagues (1992) found that the most com- monly mentioned reasons for relapse were cravings, stress, nervousness, and the pressure to smoke in so- cial situations. Asian Americans and Pacific Islanders Little has been published about smoking cessa- tion among Asian Americans and Pacific Islanders. In one study that addressed this issue, Jenkins and colleagues (1990) found that among adult Vietnamese refugees living in the San Francisco area, 82 percent of smokers wanted to quit, but 71 percent of them felt that quitting would be difficult. About 69 percent of the Vietnamese smokers had been advised by their physicians to reduce or quit smoking. Lack of infor- mation about the health consequences of cigarette smoking is a problem among some Asian American groups. In a study of Chinese Americans in Oakland, Tobacco Use Among U.S. Racial/Ethnic Minority Groups California, Lew (1992) found that 53 percent of the re- spondents did not know that heart disease was asso- ciated with cigarette smoking, and 26 percent of them said they did not know that lung cancer was related to cigarette smoking. Of current Asian American or Pacific Islander smokers aged 18 years or more in the 1993 NHIS, 60.2 percent reported being interested in quitting smoking completely (CDC 1994b). Hispanics Several studies have examined what motivates adult Hispanic smokers to quit. Marin and colleagues (1990b) found that family-related consequences and concerns (e.g., to set a good example for one’s chil- dren) contributed more to Hispanics’ desire to quit smoking than to whites’ desire to quit. Hispanic smok- ers who intended to quit believed that by doing so they would improve family relations, breathe more easily, and have a better taste in their mouths. They also be- lieved that they would gain weight. In an earlier study, Hispanic smokers who subjectively considered them- selves to be highly addicted to tobacco had the lowest levels of perceived self-efficacy to avoid cigarette smoking (Sabogal et al. 1989). The level of perceived self-efficacy to avoid smoking also declined as the re- ported number of cigarettes smoked per day increased. In the 1993 NHIS, 68.7 percent of Hispanic smokers aged 18 years or over said they wanted to quit smok- ing cigarettes entirely (CDC 1994b). Research with Hispanic adults has shown that their expectancies for quitting and for continued cigarette smoking differ in terms of their level of acculturation so that those Hispanics who have acculturated more tend to re- semble whites in their expectations (Marin et al. 1989a, 1990b). Summary, Smoking Cessation Although the literature on predictors or corre- lates of smoking cessation among members of these four racial/ethnic minority groups is limited, an important theme emerges from the studies reviewed in this section. Some studies, primarily those of Afri- can Americans (see also Chapter 5), have shown that smokers tend to report having little knowledge of the health effects of smoking or techniques to quit smok- ing. Smokers’ lack of information about cessation techniques available in the community is consistent with underdeveloped tobacco control infrastructures and the low levels of resources for research and program delivery (Robinson et al. 1995; Shelton et al. 1995). Information alone is not enough to produce a Factors That Influence Tobacco Use 237 Surgeon General's Report behavior change as complex as quitting, but informa- tion on the health consequences of smoking is still perceived by some researchers as necessary to develop the motivation to quit. Information on resources and techniques for quitting may also be essential for the success of a smoking cessation program. The lack of information may appear surprising in view of the decades-long smoking education campaigns conducted by federal and state agencies and voluntary associations, but it is consistent with the thesis that resources allo- cated for tobacco control research and programs have been proportionately lower in racial/ethnic communi- ties than in white communities (Robinson et al. 1995). Equally important, information may not have been presented through appropriate channels, and the motivational messages may not have been culturally appropriate (see Chapter 5). This literature review has identified several ar- eas for which more appropriate approaches are needed. First, the effects of stress and depression on attempts to quit smoking are particularly important among members of racial/ethnic groups. Culturally appropriate cessation interventions need to identify the sources of stress and then present stress-reduction techniques that are perceived as appropriate and ef- fective by members of racial/ethnic groups. Second, group-specific motivations and attitudes predict a person’s interest in and success at quitting smoking. Future research should focus on group-specific attitudes and expectancies as well as those that are shared by racial/ethnic groups. The effects of accul- turation and group identification also need to be addressed, particularly because research involving Hispanics has shown that acculturation plays an im- portant role in shaping the attitudes and expectancies held by Hispanic smokers (Marin et al. 1989a; 1990a,b). In summary, the distinctive psychosocial envi- ronment of disparate racial/ethnic minority, groups requires that additional tailored intervention materi- als be designed. Existing smoking cessation programs and strategies currently designed for the general popu- lation cannot simply be adapted or translated for use with a particular racial/ethnic group (see Chapter 5 for more discussion of cessation). Methodological Limitations of the Literature The content of the literature must be interpreted in light of its methodological limitations. The weak- nesses of the studies demand caution, but on a more positive note, they suggest appropriate directions for, 238 Chapter 4 future research. These limitations fall into four main categories: (1) nongeneralizability, (2) noncompar- ability, (3) sample size and aggregation problems, and (4) nonreporting. Nongeneralizability. Most studies of psychosocial factors in racial/ethnic groups have been conducted in big cities such as Chicago, Los Angeles, New York, and San Francisco. Some of the findings may not ap- ply to persons residing in smaller cities or rural areas where the psychosocial environment that influences tobacco use may differ from that in large urban areas or racial/ethnic enclaves in large cities. Similarly, primary prevention research in this field has relied heavily on urban school populations. Most studies have excluded school dropouts; students attending alternative, parochial, or private schools; those housed in detention facilities; those living and working in rural environments; and other at-risk youths, and therefore may have limited generalizability. Noncomparability. Many studies have used dif- ferent variables to measure the same phenomenon, or they have measured the same variables differently. Differential instrumentation (Cook and Campbell 1979) is a problem because a construct may not only differ in meaning from one culture to another, but its appropriate measurement (operationalization) may also differ (Berry 1969; Triandis and Marin 1983; Marin and Marin 1991). For example, if a risk factor survey initially developed for a white population is adminis- tered unchanged to African Americans or Hispanics, it may prove to be culturally inappropriate and invalid. Instead, researchers should consider what meanings the survey terms or constructs have for the group members (Brislin et al. 1973). Few researchers have conducted the basic ethnographic and psychosocial research needed to identify these culture-specific con- structs. With the exception of some investigators who have studied smoking cessation among Hispanics (discussed earlier in this chapter), most researchers have ignored a central assumption of cross-cultural research—that equivalent and culturally appropriate instrumentation must first be developed and used. Another difficulty in analyzing and comparing studies of tobacco use among young respondents is that the studies rarely measure comparable behaviors. For example, some researchers attempt to predict the first instance when a person uses a tobacco product. Other researchers, primarily in cross-sectional studies, use their data to predict current reported to- bacco use and assume that those variables may help explain initiation of tobacco use. Aggregation problems. A common problem with some of the studies reviewed in this chapter is that racial/ethnic populations have not been assessed separately from larger populations. For example, some studies of African Americans and whites have failed to separate these groups when reporting the results. Other studies, particularly those with small sample sizes, have not separated subgroups within racial/ethnic minor- ity groups—for example, distinguishing Chinese from Vietnamese—even when such separation is essential to properly understanding the results. Such results would be difficult to reproduce without knowledge of the population mix. Nonreporting. The data summarized in this chapter are further limited by a bias in the reporting of results. Some researchers report only significant re- sults and fail to indicate the equally important obser- Chapter Summary Tobacco Use Among U.S. Racial/Ethnic Minority Groups vation that some associations are not significant. This limitation can negatively affect the design of cultur- ally appropriate prevention strategies. In addition, few of the studies reviewed in this chapter adequately de- scribe the procedures followed or the data collected. Properly understanding the meaning and measure- ment of many of the variables included in these research reports is difficult because of the paucity of detail. Finally, few of these studies have reported on issues of statistical power in their designs, which fre- quently are characterized by a small sample and a large number of variables. Despite such limitations in the quality and com- parability of data, these studies identify the variables that should be the focus of future research and variables that need to be considered in culturally appropriate prevention programs (see Chapter 5). Tobacco use patterns are influenced by many factors. In addition, the factors themselves and their importance in influencing tobacco use vary among ra- cial and racial/ethnic groups. Some common experi- ences and themes, however, emerge: the targeted advertising and promotions through racial /ethnic- specific media channels, the influence of peers who smoke on initiation of tobacco use, the association of depression and stress with cigarette smoking and ces- sation among adults from different racial/ethnic groups, and the influence of acculturation. Psycho- social variables help explain individual tobacco use behavior. Tobacco advertising and promotion are influential because they appear to affect the perceived sense of pervasiveness, function, and image of tobacco use, which in turn affect these psychosocial variables. Another possible influence is the historical relation- ship between racial/ethnic minority communities and the tobacco industry. Most likely, it is not any one single factor but the interplay or convergence of these factors that significantly influences both a person's de- cision to use tobacco and the resulting tobacco use pat- terns. The effects of each factor have so far eluded quantification by researchers based on available evi- dence; more research is needed to better understand the etiology, exposure, and effects of these factors. Factors That Influence Tobacco Use 239 Surgeon General's Report Conclusions 1. The close association of tobacco with significant events and rituals in the history of many racial/ ethnic communities and the tobacco industry’s long history of providing economic support to some racial/ethnic groups—including employ- ment opportunities and contributions to commu- nity groups and leaders—may undermine prevention and control efforts. 2. The tobacco industry’s targeted advertising and promotion of tobacco products among members of these four U.S. racial/ethnic groups may un- dermine prevention and control efforts and thus lead to serious health consequences. 3. The high level of tobacco product advertising in racial/ethnic publications is problematic be- cause the editors and publishers of these publica- tions may omit stories dealing with the damaging effects of tobacco or limit the level of tobacco-use prevention and health promotion information in- cluded in their publications. 4. Although much of the original research on psy- chosocial factors that influence tobacco use reflects general processes that may apply to racial/ethnic populations, documenting such generalizability requires further research. 5. The initiation of tobacco use and early tobacco use among members of the various racial/ethnic mi- nority groups seem to be related to numerous cat- egories of variables—such as sociodemographic, environmental, historical, behavioral, personal, and psychological—although the predictive power of these categories or of specific risk factors is not known with certainty because of the paucity of research. 6. Cigarette smoking among members of the four racial/ethnic groups is associated with depression, psychological stress, and environmental factors such as advertising and promotion and peers who smoke, as is also the case in the general popula- tion. The role of these factors in tobacco use among members of these racial/ethnic groups deserves attention by researchers and persons who develop smoking prevention and cessation programs. Appendix. A Brief History of Tobacco Advertising Targeting African Americans A previous report of the Surgeon General (USDHHS 1994) presented a brief historical perspec- tive of cigarette advertising in the United States focusing on advertising strategies targeting youths. Because targeted marketing to other racial/ethnic groups is a more recent phenomenon and because in- formation about this practice with African Americans is more available, this appendix focuses on advertis- ing to African Americans. This appendix updates the review in the 1994 Surgeon General's report, particu- larly as it relates to African Americans. Early Assumptions A significant proportion of cigarette advertising targeting African Americans was based on the belief 240 Chapter 4 that consumer behavior among African Americans differs from that of whites. In the 1950s, a primary belief of advertising agencies working on cigarette advertising was that status-seeking was a central mo- tivator of African Americans. A survey of Ebony read- ers, published in Advertising Age (1950), showed that “prestige and quality—not cost—are the most impor- tant factors to stress when appealing to colored buyers. Because of the psychological considerations involved, Negroes are extremely desirous of being identified as customers who recognize and demand quality merchandise” (p. 17). Another early assumption of advertising agen- cies targeting African Americans was that advertise- ments featuring African American models were more effective—or at least more appealing to African Americans—than advertisements portraying whites. In a 1950 survey of the buying habits and motivations of African Americans, Starch and colleagues found that the majority of Ebony readers preferred advertisements featuring African American models, although about one-third of the African American respondents said that it did not matter whether African American mod- els were used (Advertising Age 1950). In a later study of consumer reactions to the use of white or African American models, 93 white and 88 African American college freshmen in Houston were asked to react to four cigarette advertisements, indicating whether the models were ugly or beautiful, low class or high class, and friendly or unfriendly (22 bipolar scales were pre- sented) (Barban and Cundiff 1964). In general, the ciga- rette advertisement with white models and the same advertisement with African American models drew similar reactions from whites and African Americans. In a more recent study, however, African Americans who strongly identified with their culture were more likely to prefer African American models (Whittler 1989). Another recent study has shown that African American college students preferred television com- mercials for consumer products that included African American models (Pitts et al. 1989). These findings were replicated recently among African American Chicago youths aged 12-14 years who perceived Afri- can American models in cigarette advertisements as more appealing (Huang et al. 1992). A central belief related to targeted advertising and marketing is the assumption that members of ra- cial/ ethnic groups, particularly African Americans and Hispanics, are brand-conscious and brand-loyal con- sumers. This approach to purchasing is believed to motivate consumers to spend extra money to purchase a product with a recognized brand name or a product that has been used by family members and neighbors for a relatively long period of time. Large multina- tional brand names often are associated with quality in the immigrants’ countries of origin, and purchas- ing of those brands in the United States may serve as an example of having “arrived” or achieved a sought- after economic status. Other researchers hypothesize that previous consumer experiences and an increase in disposable income produce brand consciousness. For example, Dallaire (1955) argued that “the Negro’s desire to improve his lot, his increasing income and the fact that he’s been burned so badly and so often in the past with shoddy merchandise makes him a highly brand-conscious consumer” (p. 58). Whether brand loyalty is indeed a characteristic of certain racial/eth- nic minority groups continues to be debated (Deshpande et al. 1986; Donthu and Cherian 1992); Tobacco Use Among ULS. Racial/Ethnic Minority Groups however, this assumption often has been invoked in the design of advertising directed at members of racial/ethnic groups. Promotional campaigns directed at African Americans and members of other racial/ethnic groups also operate under the assumption that these individu- als are more likely than whites to trust advertising, although most of the studies on which this perception is based have been limited by methodological flaws such as nonrandom sampling and a small sample size. In a 1961 study of 1,106 African Americans and 537 whites, about twice as many whites as African Ameri- cans had unfavorable attitudes toward all types of advertising (Bullock 1961). In a 1968 study of 1,846 persons, the 77 African Americans interviewed had the highest proportion (53 percent) of favorable responses to the open-ended question “How do you yourself feel about advertising?” compared with 1,707 whites (40 percent) (Bauer and Greyser 1968). Eleven years later, Durand and colleagues (1979) interviewed 80 persons and found that African Americans were consistently more trusting of television and newspapers than whites were, and they relied less on magazine adver- tisements. Soley and Reid (1983) interviewed a ran- dom sample of 185 Atlantans and found that African Americans were more satisfied with the informational value of magazine and television advertising than whites were and that high-income respondents were the least satisfied with advertising. Early Targeted Advertising Efforts (1940s-1960s) Turn-of-the-century advertisements for tobacco products tended to include women, to emphasize fe- male sexuality, and to portray women as dangerous and delightful. Conversely, American Indians and African Americans often were pictured as childlike and unattractive (Mitchell 1992). Tobacco companies have depicted African Americans in their advertisements since the first Bull Durham advertisements appeared at the turn of the century, but only since the 1940s have they aggressively targeted African Americans as a dis- tinct consumer market. In the decades that have followed, tobacco com- panies have been described as “bold pioneers in both their use of new media and their targeting of other segments even when controversial” (Pollay et al. 1992, p- 49). In 1942, the advertising agency of the Lorillard Tobacco Company, J. Walter Thompson Company, be- gan to monitor cigarette sales in African American neighborhoods as part of an Old Gold cigarette promotion (Pollay 1988). By 1948, Philip Morris was Factors That Influence Tobacco Use 241 Surgeon General's Report running its “no cigaret hangover” campaign in the African American press and in daily newspapers pub- lished in languages other than English (Tide 1948, p. 18). By 1955, several cigarette companies, in- cluding Philip Morris, were producing advertising ma- terials targeting African Americans and Hispanics (Printers’ Ink 1955). Soon thereafter, Philip Morris began placing point-of-sale materials in English as well as Spanish for the newly repositioned Marlboro ciga- rettes (Ullman Gravure, Inc. 1957). A decade after tobacco firms first displayed an interest in African American consumers, the firms were described as “leaders among advertisers gunning for a bigger share of the Negro market” (Dallaire 1955, p. 58). One of the earliest targeting efforts, conducted on behalf of Liggett & Myers’s Chesterfield cigarettes, targeted African Americans via advertisements featur- ing athletes’ testimonials and placed in racial/ethnic newspapers and magazines, such as Ebony, Our World, and Tan. The company also launched an extensive point-of-sale advertising campaign featuring African American sports figures (Dallaire 1955). The campaign included a series of six documentary films that pre- sented African American achievements. Each film was viewed by about 3 million people in 500 primarily African American theaters. These films also were shown at more than 100 African American colleges, where free cigarette samples were distributed, reach- _ ing an estimated 900,000 additional people. The suc- cess of this effort led to the filming of 13 five-minute films featuring interviews with African American celebrities (Dallaire 1955). The 1950s also marked the introduction of men- tholated cigarettes. Although a greater proportion of African Americans now smoke mentholated cigarettes compared with members of other racial/ethnic groups (Chapter 2), no evidence exists that the menthol mar- ket was initially conceived as having any special ap- peal to African Americans or other racial/ethnic groups. Mentholated cigarettes are relative newcom- ers to the tobacco market, and they have been well re- ceived by smokers. In 1956, Brown & Williamson’s mentholated and then unfiltered Kool cigarette enjoyed an increasing market share that attracted its competitors to introduce mentholated cigarettes with filters. These competitors and their entries included RJ. Reynolds’s Salem, Philip Morris’s Spud, Liggett & Myers’s Oasis, and Lorillard’s Newport cigarettes. By the end of 1957, 5 percent of all cigarettes consumed were mentholated, representing “a relatively sharp gain for a fledgling cigarette movement exploring a new taste” (Wootten 1957, p. 22). 242 Chapter 4 By 1959, The American Tobacco Company, the only firm without a mentholated cigarette, was preparing to market a cigarette tentatively called Rich- mond. The campaign concept allegedly argued that the Richmond cigarette “gives you all of smoking’s pleasure, with none of its penalties” (Printers’ Ink 1959a, p. 12). Around the same time, Brown & Williamson was ready to test market a second menthol brand, Belair, and was introducing three other menthol brands into the market—Riviera, Spring, and Alpine (Print- ers’ Ink 1959c). Tobacco companies also were begin- ning to use technical jargon to market their menthol products. For example, in 1959, advertising profession- als described R.J. Reynolds’s advertisements for Salem as “breathlessly reporting ‘an amazing new develop- ment’ in copy that was both opaque and studded with scientific jargon” to inform consumers about the highly porous paper that “air softens every puff. There are, obviously, just no limits to the company’s tender regard for the smoker” (Printers’ Ink 1959b, p. 8). In a study of early cigarette advertisements targeting African Americans, investigators compared a complete set of cigarette advertisements from Ebony for the years 1950-1965 with a matched set of adver- tisements from Life (Pollay et al. 1992). The results, which follow, are important in promoting a better un- derstanding of the principles followed in advertising targeted to African Americans. By 1965, all six major U.S. cigarette firms had advertised in the pages of Ebony as well as Life. While the cigarette advertising in Life increased over the years, particularly between 1963 and 1965, the amount of such advertising in Ebony more than tripled during the same period. Ebony initially had fewer cigarette advertisements (16 in 1950) than Life (31 in 1950), but a dramatic increase in efforts targeting African Ameri- cans soon led Ebony to have more than twice the num- ber of cigarette advertisements (57 in 1962) as Life (28 in 1962) (Pollay 1990; Pollay et al. 1992). An analysis of the page costs indicated that this pattern was not related to the relative costs of the two magazines nor was it likely related to cigarette firms’ joining other firms to offer their products to African Americans through African American-owned media. Although this was a period of general growth for Ebony, “ciga- rette firms increased their spending and page acquisi- tion even more than the average, keeping themselves out in front of the pack” and making cigarette firms the source of an estimated 6.5 percent of Ebony’s total advertising income in 1962 (Pollay et al. 1992, p. 54). The investigators also found that the manifest race/ethnicity of the models portrayed in cigarette advertisements increased between 1950 and 1965, Out of the 540 cigarette advertisements in Ebony, more than 84 percent featured identifiable human models, and more than 90 percent of those used African American models. In the early 1950s, the white endorsers who occasionally appeared in Ebony included physicians who claimed “more doctors smoke Camels” and tele- vision and movie stars (Pollay et al. 1992). Since 1958, virtually all models in Ebony’s cigarette advertisements have been African American. Yet none of the African American cigarette endorsers appearing in Ebony ad- vertisements have appeared in Life advertisements, not even the widely popular sports stars and musicians. During the early years of targeted advertising, professional athletes were most often featured in cigarette advertisements. Sports stars were used in advertisements even when the advertising copy was inconsistent with athletics. A Lucky Strike cigarette advertisement in Ebony, for example, referenced sci- entific tests in 1950 but showed a picture of an African American Olympic athlete. These advertisements sometimes differed from advertisements appearing in media targeting the general population. In 1960, Kent cigarettes illustrated its “scientist’s choice” campaign in Ebony with another Olympic champion, not with a scientist as was done in the advertisement placed in Life. Although athletes also appeared in cigarette ap- peals to the larger public, “cigarette ads aimed at black readers of Ebony were significantly more likely to use athletes than those aimed at white readers of Life. For 1950-1965, endorsements from athletes were about five times more common in Ebony than in Life” (Pollay et al. 1992, p. 51). Although most tobacco-producing companies were targeting the African American market through Ebony, these companies advertised significantly fewer cigarette brands in Ebony than in Life (Pollay et al. 1992). Advertising of new products seems to have lagged in African American publications. Whereas advertise- ments for filtered tobacco products first appeared in Life in 1953 and made up one-half of all cigarette ad- vertising in Life by 1955, advertisements for filtered tobacco products did not appear in Ebony until 1955 and did not represent one-half of its cigarette adver- tising until 1958, three years later than for Life. Recent Targeted Advertising Efforts (Late 1960s—1980s) By the late 1960s, with racial/ethnic pride en- hanced by the success of the civil rights movement, the nature and appeal of advertising began to change Tobacco Use Among ULS. Racial/Ethnic Minority Groups to better tailor the contents of the advertisements to targeted racial/ethnic groups. In an analysis of ad- vertisements for all consumer products in selected is- sues of Ebony and Life in 1960, Berkman (1963) found that in about two-thirds of the advertisements featur- ing models, African American models were substituted for white models in advertisements placed in Ebony, although the content of the advertisements was basi- cally identical. The African American models initially featured were predominantly light skinned, accord- ing to Berkman (1963), but subsequent studies of all Ebony advertisements between 1952 and 1968 showed that the use of male models with more African Ameri- can features and hair texture became more common over time, whereas the advertisements continued to use female African American models with Caucasian features (Gitter et al. 1972; Weiss 1972). Cigarette advertising has changed in similar ways. In the late 1960s, Lorillard’s advertisements for Kent cigarettes featured an African American model wearing an Afro hairstyle and saying “that’s where it’s at” (Advertising Age 1968, 1969). By 1971, Liggett & Myers employed an advertising agency that special- ized in targeting the African American market. The agency’s campaign for L&M cigarettes featured a slo- gan that called the brand “super bad” (meaning excel- lent), and research indicated the advertisement had “great appeal among members of the black commu- nity” (Advertising Age 1971a, p. 20). Not all cigarette advertisements aimed at Afri- can Americans have been successful at employing meaningful role models or at credibly using street or popular language. One African American marketing professional asserted that neither the Marlboro cow- boy nor the Viceroy race car driver was meaningful to most African Americans and that Winston’s use of the phrase “How good it is!” in a racial/ethnic advertise- ment was a “white man’s cliché that retired with Jackie Gleason.” In contrast, Kool’s slogan, “Come all the way up to Kool, America’s #1 selling menthol,” was lauded for astutely positioning the leader as a sign of upward mobility (Wall 1973, p. 71). In the 1970s, Liggett & Myers began targeting African American women with advertising for its “arty female oriented” Eve cigarettes by running advertise- ments with African American models in Black America Magazine, Black Enterprise, Ebony, Essence, Jet, New Lady, and Tuesday Magazine (Advertising Age 1971b, p. 24). The next year, Liggett & Myers began promoting L&M cigarettes to African American men and women via advertisements in African American magazines, in- cluding Contact, National Scene, and Soul Illustrated Factors That Influence Tobacco Use 243 Surgeon General’s Report (Advertising Age 1971a). In 1974, Kool cigarette adver- tisements in African American magazines featuring African American models used the copy “Nobody makes cool like Kool” (Advertising Age 1974, p. 76). During the mid-1970s, products targeted to Afri- can Americans began to emerge. For example, R.J. Reynolds created an extra-strong menthol product, Salem Extra, which was advertised as offering “differ- ent smokes for different folks.” The cigarette was market-tested in Birmingham and New Orleans through outdoor advertisements as well as newspa- per and regional magazine advertisements that were supported by sampling. These efforts indicated to the advertising trade that Salem Extra should be targeted to African Americans, along with another extra-strong menthol brand, Super M, which was being tested by The American Tobacco Company in Pittsburgh (O’Connor 1974). In the late 1970s, tobacco companies began us- ing billboards to advertise cigarettes in racial/ethnic minority communities. Over the past two decades, billboards have appeared more frequently in commer- cially zoned areas and in older, poorer, and otherwise less desirable residential neighborhoods that border major highways and mass transit systems. In surveys of six cities in the late 1980s, Scenic America, a national organization opposed to billboards, found far more billboards advertising tobacco products in minority neighborhoods than in other neighborhoods 244 Chapter 4 (McMahon and Taylor 1990). For example, 76.7 percent of advertising messages on billboards in one impoverished African American community in Philadelphia were for alcoholic beverages and tobacco products. In San Francisco, 62 percent of the billboards in predominantly African American neighborhoods advertised cigarettes, compared with 36 percent of ail billboards citywide (McMahon and Taylor 1990). Ac- cording to the Outdoor Advertising Association of America Marketing Division, tobacco companies are the leading outdoor advertisers, accounting for ap- proximately one-third of all billboards (McMahon and Taylor 1990). Furthermore, data for 1988 show that cigarettes are the most heavily advertised product in outdoor media (CDC 1990a). A study conducted in Columbia, South Carolina, confirmed that African American communities have 2.6 times as many bill- boards advertising cigarettes as white communities have (Mayberry and Price 1993). In the late 1970s, cigarette producers and their advertising agencies were becoming very aware of the significance of the African American market, as exem- plified by this quotation from a well-known advertis- ing agency: “While Blacks represent only 10.3% of the total U.S. population, they account for 18% of all smok- ers and 31% of all menthol smokers” (Rosser Reeves Inc. 1979, p. 12). As a result, tobacco companies have heavily advertised and promoted cigarettes to racial/ ethnic minorities, particularly African Americans. References Tobacco Use Among U.S. Racial/Ethnic Minority Groups Advertising Age. "Ebony" survey reveals Negro buy- ing habits. Advertising Age 1950;21(35):16-7. Advertising Age. Use of Negro models in ads won’t reduce sales to whites, Johnson advises workshop. 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Chapter 5 Tobacco Control and Education Efforts Among Members of Four Racial/Ethnic Minority Groups Introduction 259 Principles for Developing Culturally Appropriate Tobacco Control Strategies 259 Information Needs 262 Research and Development Limitations 263 Primary Prevention Efforts 266 Efforts to Restrict Youth Access to Tobacco 266 School-Based Health Education Approaches 269 Project SMART (Self-Management and Resistance Training) 271 Life Skills Training Program 271 Project SHOUT (Students Helping Others Understand Tobacco) 271 Southwestern Cardiovascular Curriculum Project and Pathways to Health 272 Other Primary Prevention and Intervention Efforts 272 Mass Media Efforts to Prevent Tobacco Use 273 Smoking Cessation Programs 274 Self-Help Approaches 275 Rompa Con el Vicio: Una Guia Para Dejar de Fumar (Break the Habit: A Guide to Stop Smoking) 275 Pathways to Freedom 276 Lam Thé’ NaoDé Bé Hit Thud'’c? (How to Quit Smoking) 276 It’s Your Life—It’s Our Future 276 Victory Over Smoking—A Guide to Smoking Cessation for You and Your Family = 277 Smoking: Facts and Quitting Tips Series 277 Hot Lines 277 Group Approaches 277 Community Approaches 278 Stanford Five-City Multifactor Risk Reduction Project 279 Programa Latino Para Dejar de Fumar (Hispanic Program to Quit Smoking) 279 Si Puedo (Yes,{ Can) 280 Pathways to Freedom Community Demonstration Project 280 Quit Today! 280 Chicago Lung Association’s Multifaceted Smoking Cessation Intervention 281 Chicago Community-Based Interventions for Low-Income African Americans 281 Freedom from Smoking® for You and Your Family on TV/Por Su Salud y Su Familia 281 A Su Salud (To Your Health) 282 University of North Carolina/North Carolina Mutual Quit for Life Guide 282 Legends 282 Great American Smokeout 283 Suc Khoe La Vang! (Health is Gold!) 283 Involvement of Health Care Providers 283 For You and Your Family 284 American Indian Cancer Control Project 286 Involvement of Employers 286 Involvement of Nontraditional Providers 286 Environmental Tobacco Smoke and Clean Indoor Air Policies 287 Economic Efforts to Reduce Tobacco Use 292 Efforts to Control Tobacco Advertising and Promotion 293 Tobacco Product Regulations 298 Conclusions 299 References 301 Introduction Tobacco Use Among US. Racial/Ethnic Minority Groups Various approaches have been used to prevent and control tobacco use among racial/ethnic minority groups in the United States. This chapter addresses six major approaches to tobacco control: (1) primary prevention efforts, (2) smoking cessation programs, (3) environmental tobacco smoke (ETS) and clean in- door air policies, (4) economic efforts to reduce tobacco use, (5) efforts to control tobacco advertising, and (6) tobacco product regulations (Satcher and Eriksen 1994). Each section presents a selection of interventions and focuses on activities that reflect the specific character- istics of given racial/ethnic groups. Because most of these efforts are relatively new among racial/ethnic group members and many have been developed or applied in predominantly white communities, little information is available about the ease and feasibility of their implementation or repli- cation in racial/ethnic contexts. Although data exist on the overall effectiveness of programs that do not differentiate racial/ethnic minority groups from whites, data are limited on the effectiveness of racial/ ethnic-specific tobacco control efforts, because results of their evaluations are just beginning to appear in the literature. Although an increasing number of tobacco control programs are being implemented among vari- ous racial/ethnic groups, many of these programs lack evaluation components. To remedy the lack of infor- mation, culturally appropriate research and evalua- tions need to be conducted in the future, and more professionals need to be trained in culturally appro- priate research and evaluation methodologies. More- over, the types of tobacco control efforts that are most effective, easiest to implement, and most cost-effective among racial/ethnic groups must be identified (Fiore et al. 1996). Insome instances, smoking cessation treat- ments that have been shown to be effective with non- Hispanic whites also have produced positive effects with racial/ethnic populations (Fiore et al. 1996). It is already well known that preventing tobacco use is of paramount importance because cessation is difficult. Tobacco control infrastructures in white and racial/ethnic minority communities have developed differently, although the reasons are not well under- stood. This development has been influenced by many factors: immigration; the historical and current role of the tobacco industry in the economic, political, social, and cultural life of the community; and the resources invested in communities for research and the estab- lishment of tobacco control programs (Robinson et al. 1995; Shelton et al. 1995). Robinson and colleagues developed an index to measure the capacity of racial/ ethnic communities to engage in, develop, and imple- ment tobacco control initiatives. The researchers then applied the index to racial/ethnic communities on a national level. They defined capacity in the index as being made up of four broad components, each of which is composed of numerous elements: (1) research, (2) infrastructure, (3) diffusion of programs, and (4) internalization of policy initiatives. The index as- sumes that a logical order exists among these compo- nents, that is, that a community’s ability to gather data and assess its needs precedes program development and dissemination. During this process, it is likely that a community’s capacity grows through the evolution of new leaders, establishment of more communication networks, and emergence of a deeper understanding and acceptance of community needs and interventions to meet those needs. Robinson and colleagues (1995) concluded that racial/ethnic communities have fewer resources and less infrastructure to develop and imple- ment tobacco control initiatives than the white com- munity. In addition, racial/ethnic communities were compared with one another, and findings demon- strated variability among communities. The index can be considered a preliminary but important step in providing a useful framework for evaluating the rela- tive tobacco control capacity of racial/ethnic minority communities. Mature tobacco control infrastructures provide leadership, advocacy for a smoke-free environment, communication systems, established re- search initiatives, effective tobacco control programs, and environmental norms; these elements enable communities and their residents to counter tobacco industry marketing strategies and the appeal of an addictive substance. Principles for Developing Culturally Appropriate Tobacco Control Strategies To be culturally appropriate, interventions must properly reflect the characteristics of the group mem- bers; that is, programs must recognize that cultural groups—whether they are based on race/ethnicity, na- tional origin, or other characteristics—are not mono- lithic entities. Behavior can be affected by not only demographic characteristics, such as gender, employ- ment status, educational level, literacy, income, and Tobacco Control and Education Efforts 259 Surgeon General's Report age but also such variables as national background (i.e., the place of birth of individuals, their parents, or grandparents); acculturation (with its correlates of generational history, time of migration, and language preference); and large social circumstances such as rac- ism, discrimination, and poverty. In particular, and as discussed in Chapter 4, tobacco prevention and con- trol strategies must respond to the historical context of racial/ethnic communities as well as to their current needs (Ellis et al. 1995). Those attitudes and behaviors that have been shaped by the historical re- lationship between the community on one hand and tobacco and the tobacco industry on the other need to be considered when tobacco control strategies are developed. Although few tobacco control programs target- ing racial/ethnic groups have been culturally appro- priate, they are increasing, and their evaluation will further guide the development of culturally appropri- ate tobacco control strategies. Such programs would address these racial/ethnic groups’ differing psycho- social and large social factors related to tobacco use. Development of culturally appropriate interven- tions also must go beyond language translations and adaptations of materials (e.g., Rogler et al. 1987; Marin 1993; Bayer 1994) and should do more than simply include contemporary, group-specific traditions or ancestral symbols and traditions. In addition, plan- ners should not assume that the involvement of com- munity leaders and organizations will automatically guarantee a program's success. Marin (1993, p. 149) has argued that to be culturally appropriate, an inter- vention must meet these requirements: “(1) it is based on the cultural values of the group, (2) the strategies that make up the intervention reflect the subjective culture (attitudes, expectancies, norms) of the group, and (3) the components that make up these strategies reflect the behavioral preferences and expectations of the group’s members.” Recent studies have identified numerous inter- group differences in beliefs, attitudes, expectancies, and norms that are useful in designing effective to- bacco control programs by identifying optimal mes- sages or techniques that are culturally appropriate. Racial /ethnic cultural values are often an asset in to- bacco control efforts. For example, Marin and col- leagues (1990a) found that Hispanic smokers were more likely than white smokers to think that an effec- tive motivator to quit smoking was the knowledge that adults who smoke set a bad example for children and endanger children’s health. According to Robinson and colleagues (1992), African Americans responded to the use of prayer during smoking cessation 260 Chapter 5 programs, and Hodge and colleagues showed that American Indians were unresponsive to confronta- tional approaches for curtailing tobacco use (Ameri- can Indian Cancer Control Project 1991). Materials developed for Chinese Americans have offered the use of martial arts as a behavioral alternative to cigarette smoking (Chinese Community Smoke-Free Project 1992). Another example of a culturally appropriate message is a billboard used by the California Depart- ment of Health Services to target Hispanics (Figure 1). The billboard makes use of a basic Hispanic value (familialism) within the context of a message that is an important motivator to Hispanics to quit smoking— quitting to protect the health of the family (Marin et al. 1989, 1990a). More recently, in an analysis of a popu- lation-based survey of Californians 18 years of age and older, researchers found that African Americans and Hispanics were more likely than whites to plan to quit smoking in the near future and to have tried to quit at least one time (Kaplan et al. 1993). In a comparison of smoking cessation intentions and behaviors among white and African American smokers, white smokers were more likely to set quitting smoking as a goal, whereas African Americans were more likely to focus on a goal of reducing the number of cigarettes they smoked per day or making other changes in smoking behavior (Hahn et al. 1990). Another study found that intentions to breast-feed predicted smoking cessation among African American pregnant women (O’Campo et al. 1992). Other recent studies of smoking cessation pro- grams indicate that members of most racial/ethnic groups tend to be very interested in quitting smoking. In the 1993 National Health Interview Survey (NHIS), current smokers in all racial/ethnic groups said they were willing to quit smoking (Table 1) (National Cen- ter for Health Statistics [NCHS], public use data tape, 1993). African Americans (71.4 percent) reported the desire to quit in greater proportions than members of the other racial/ethnic groups, whereas Asian Ameri- cans and Pacific Islanders (60.2 percent) showed the least interest in quitting. In all four racial/ethnic groups, women were more likely than men to want to stop smoking. Moreover, data from the Community Intervention Trial for Smoking Cessation’s (COMMIT) initial survey in 10 U.S. communities showed that more African Americans than whites, both men and women, said they wanted “a lot” to quit (Royce et al. 1993). In a San Francisco study, Hispanics considered a high interest in quitting smoking to be more desir- able than did whites (Marin et al. 1989). Despite their interest in smoking cessation, mem- bers of these racial/ethnic minority groups have been Tobacco Use Among U.S. Racial/Ethnic Minority Groups Figure 1. Billboard used by the California Department of Health Services in targeting Hispanics to quit smoking* $i tu fumas, Emit lay: Departamento de Servicios de la Salud. Estado de California. “Translation: If you smoke, she smokes. Source: California Department of Health Services, Tobacco Control Media Education Campaign, Sacramento, 1993. Table 1. Percentage of adult smokers who would like to stop smoking,* by race/ethnicity and gender, National Health Interview Survey, United States, 1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +clt % +C1 % +CI % +Cl % +Cl Total 714 48 65.0 14.6 60.2 12.2 68.7 5.8 704 1.8 Men 68.6 7.3 57.3 23.4 58.3 14.6 63.8 7.8 67.8 2.6 Women 74.9 SA 70.3 16.1 65.3 22.6 79.3 8.1 72.4 2.1 “In response to the question, “Would you like to completely stop smoking cigarettes?” t95% confidence interval. Source: National Center for Health Statistics, public use data tape, 1993. less likely than whites to actually quit. In a study of 786 adult smokers in the Minneapolis-St. Paul area, Hahn and colleagues (1990) found that 52 percent of African American men had tried to quit smoking in the previous year, compared with 63 percent of white men. They also found that 56 percent of African Ameri- can women had tried to quit, compared with 58 per- cent of white women. Ina recent survey conducted in California, African Americans, Asian Americans, and Hispanics were more likely than whites to report that they tried to quit smoking in the previous year; how- ever, relapses were more common among African Americans (49.5 percent), Asian Americans (39.8 per- cent), and Hispanics (37.8 percent) than among whites (35.0 percent) (Burns and Pierce 1992). NHIS data from 1991 that were statistically adjusted for gender, age, education, and poverty status indicate that African Americans and Hispanics were more likely than whites to quit for a day during the previous year but that Af- rican Americans who tried to quit were more likely than whites to relapse (Centers for Disease Control and Prevention [CDC] 1993b). In another study— conducted in Milwaukee, Wisconsin; Minneapolis, Minnesota; and Seattle and Spokane, Washington— Tobacco Control and Education Efforts 261 Surgeon General's Report American Indians who were patients at Indian Health Service (IHS) clinics reported a moderate desire to quit smoking (mean of 5.97 ona scale of 0 to 10) but a high rate of relapse (70 percent) (Lando et al. 1992). These data suggest the need for culturally appropriate pro- grams that not only help smokers stop smoking but also support them in their efforts to maintain a smoke- free lifestyle and to avoid relapses. In addition to considering intergroup differences, tobacco control programs targeting members of racial / ethnic groups must involve culturally competent staff—persons with the academic and interpersonal skills needed to understand and appreciate racial/ ethnic groups’ cultural differences and similarities and to respect these groups’ beliefs, attitudes, norms, and behaviors (Cross et al. 1989; Roberts 1990; Orlandi 1992). Such staff must have the skills to understand their own cultural beliefs and values, to understand the dynamics of cultural differences, and to translate that understanding into culturally appropriate behav- iors. Cross and colleagues (1989) and Davis and Voegtle (1994) propose that culturally competent health care systems—and by implication culturally compe- tent staff—should (1) be aware and accepting of cultural differences, (2) have the capacity for cultural self-assessment, (3) be conscious of the dynamics in- herent when cultures interact, (4) have relevant cul- tural knowledge of the targeted group, and (5) have skills that promote adaptation to diversity. Other au- thors, such as Corcoran and Robinson (1994), assert that public health professionals need to actively include the community by establishing planning teams composed of key community leaders and that staff be willing to redefine the project as community needs change. Furthermare, persons designing and implement- ing tobacco control programs ideally should determine whether theoretical models and approaches originally developed for certain populations would be relevant to the racial/ethnic groups being targeted. Most cur- rent theoretical approaches to health promotion have been developed by white researchers who work pri- marily with white populations. Some researchers have questioned the overall validity and usefulness of these theoretical approaches because the approaches that are developed do not necessarily reflect the cultural values shared by other racial/ethnic groups and do not consider how variables such as acculturation, rac- ism, and poverty may affect peoples’ health behaviors (Prochaska 1992; Robinson and Sutton, in press). This concern can be addressed only through an empirical approach that analyzes the usefulness of theories ini- tially developed for groups other than the ones being targeted by an intervention (Orlandi 1992). 262 Chapter 5 Information Needs To ensure that prevention and cessation programs will provide members of a racial/ethnic minority group with the information that they need most, program designers must find out three things. (1) Do members of the community need basic information about the harmful health effects of tobacco use? (2) What culture- specific experiences directly influence the role of tobacco and the tobacco industry and how can they be addressed in health promotion messages? (3) Which media and information sources would be most effective in convey- ing information to the targeted group? Because information about the dangers of cigarette smoking has been provided to the public for more than 30 years, most U.S. citizens and residents are well aware of these health consequences. American Indians, for ex- ample, tend to have a high level of knowledge about the hazards of smoking. In a study of 1,369 northern Cali- fornia American Indians who were patients at IHS clin- ics, Hodge and colleagues (1995) found that most Ameri- can Indians knew about the health effects of tobacco use, particularly its relationship with cancer and the dangers of smoking while pregnant. Conversely, this basic information may not have reached persons who have limited English proficiency, who have recently arrived in the United States, or who may not have been exposed to media and information sources that traditionally have carried messages about the dangers of cigarette smoking. It is possible for ex- ample, that Asian Americans, Pacific Islanders, and Hispanics who have recently immigrated to the United States are not familiar with the dangers of cigarette smoking. Less acculturated Asian Americans, Pacific Islanders, and Hispanics who have resided in the United States for several years may not have benefited from large-scale public education campaigns directed at persons who are proficient in English and those who interact frequently with mainstream society. To help _address this need, the Agency for Health Care Policy and Research translated the consumer cessation guide “You Can Quit Smoking” into Cambodian, Laotian, Vietnamese, Tagalog, Korean, and Chinese (U.S. Depart- ment of Health and Human Services [USDHHS] 1996 and 1997). Chen and colleagues (1993) reported that less than 40 percent of Cambodian, Laotian, and Vietnam- ese smokers in Columbus, Ohio, had heard that smok- ing caused heart disease. Earlier, Jenkins and colleagues (1990) reported that only 74 percent of Vietnamese adults surveyed in San Francisco knew that smoking caused cancer. Nevertheless, Campbell and Kaplan (1997) found that both less acculturated and more ac- culturated Hispanic women (as measured by language orientation) agreed that cigarette smoking is harmful to children’s health. However, less acculturated His- panic women were more likely to agree that it is safe to smoke for a year or two. Even long-term U.S. residents who have been receiving information on the dangers of tobacco smoke for many years may have limited or incorrect infor- mation. For example, in a study of Chicago women living in subsidized housing, 46 percent of African American women agreed that the chances of getting lung cancer were the same for smokers and nonsmok- ers, compared with 27 percent of white women (Manfredi et al. 1992). In that study, African Ameri- can women also reported that the causes of lung can- cer were unknown or that lung cancer was the result of environmental pollution (Lacey et al. 1993). Con- versely, in a multivariate analysis, African Americans compared with whites were found to have higher lev- els of knowledge about the benefits of not using to- bacco and the health consequences of tobacco use, but blue collar status emerged as the most significant pre- dictor of lower levels of knowledge (Robinson et al. 1991). In another study, African American residents of urban Missouri areas recognized the harmful effects of ETS but were less likely than whites to know the health risks associated with active smoking, particu- larly its link with heart disease (Brownson et al. 1992). In a 1989 survey of Hispanic and white clients of a San Francisco health maintenance organization (HMO), Hispanics had numerous misconceptions about the causes of cancer, but a similar proportion of Hispanics (97.5 percent) and whites (98.4 percent) knew that cigarette smoking caused cancer (Pérez- Stable et al. 1992). Similarly, Vander Martin and colleagues (1990) surveyed patients of primary care physicians and found that African Americans (87.8 percent) and Asian Americans (86.5 percent) were significantly less likely than whites (92.1 percent) and Hispanics (91.6 percent) to recognize that cigarettes had harmful health effects. They also found that A fri- can American (58.9 percent), Asian American (56.3 per- cent), and Hispanic (60.1 percent) smokers were less likely than white smokers (80.3 percent) to recognize that they were addicted to cigarettes. In the 1992 NHIS, members of racial/ethnic groups were generally less likely than whites to indicate concern over the carci- nogenic characteristics of cigarette smoking, although they expressed the same level of agreement as whites regarding the need for pregnant women not to smoke and about the harmfulness of ETS (Table 2) (NCHS, 1992 Cancer Control Supplement, public use data tape). In addition, racial/ethnic group members were less likely than whites to believe that there were health benefits to quitting smoking. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Once program planners decide what information needs to be conveyed, they must consider which me- dia would be most effective in reaching the targeted audience. Many researchers have suggested employ- ing the media most frequently used by the targeted ethnic group. To reach African American smokers, for example, Stotts and colleagues (1991) suggest that smoking cessation programs should use African American broadcast and print media to address this group’s information and motivational needs. Moreover, prevention and cessation programs should use the information channels (e.g., radio, tele- vision, and newspapers) and information sources (e.g., physicians, peers, and actors) that members of the targeted racial/ethnic group perceive to be trustwor- thy and reliable. Unfortunately, little is known about how credible the various media and information sources are perceived to be by members of racial/ ethnic groups. In one of the few studies focusing on this issue—research involving African Americans in Columbia, South Carolina; Durham, North Carolina; Hartford, Connecticut; and Springfield, Massachu- setts—television was perceived as the most trustwor- thy information channel (by 70 percent of participants), followed by newspapers (59 percent), radio (53 per- cent), and magazines (53 percent) (Cernada et al. 1989- 1990). A recent study among Hispanics (Marin 1996) showed that the most credible channels for dissemi- nating information about cigarette smoking among Hispanics are (in descending order) books, newspa- per articles, pamphlets, magazine articles, and televi- sion news shows; the least credible were fotonovelas (illustrated comic-book type of booklet targeting adults) and telenovelas (Spanish-language soap operas). The same study found that the most credible sources of cigarette smoking information among Hispanics were (in descending order) a physician, a cancer pa- tient, and a peer of the respondent; the least credible sources of information were a politician, a singer, an actor, and a child. Research and Development Limitations In a recent analysis of racial/ethnic minority groups’ expertise for engaging in tobacco control ef- forts, Robinson and colleagues (1995) suggested that African American, American Indian, Alaska Native, Asian American, Pacific Islander, and Hispanic groups all have been significantly limited in conducting re- search and developing program and policy initiatives for tobacco control. According to Robinson and col- leagues, these limitations may exist, in part, because racial/ethnic groups tend to have fewer resources for tobacco control activities than whites. Tobacco Control and Education Efforts 263 Surgeon General's Report Table 2. Adults’ beliefs about the health effects of smoking, by race/ethnicity, gender, and smoking status, National Health Interview Survey, United States, 1992 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +cr % tcl % +Cl % +Cl % +cl So many things cause cancer that it does not really matter if you smoke. Overall Total 28.6 3.0 25.6 9.6 27.3 7.0 30.7 3.0 16.5 1.0 Men 278 4.7 30.7 14.1 25.2 10.5 28.1 43 18.0 1.5 Women 293 3.6 21.3 113 29.3 8.4 33.2 3.9 15.2 1,2 Nonsmokers Total 25.2 3.6 18.7 7.8 22.9 6.6 254 3.1 10.9 1.0 Men 23.7 6.2 19.9 14.6 15.3 9.2 23.3 4.6 1.8 15 Women 263 41 17.7 11.0 28.1 8.6 27.3 4.1 10.0 8961.2 Smokers Total 38.2 5.6 39.4 21.9 47.6 18.9 50.5 7.0 325 23 Men 36.4 7.9 54.1 28.5 45.9 21.0 43.3 9.2 33.7 3.2 Women 40.2 73 27.4 24.2 64.9 34.7 588 99 31.2 3.1 Smoking by a pregnant woman may harm the baby. Overall Total 90.7. 17 90.8 6.1 92.3 3.9 92.0 19 92.5 0.7 Men 90.5 2.6 86.0 10.4 91.9 6.3 929 2.7 914 10 Women 90.9 2.0 94.9 6.4 92.6 4.7 91.2 24 935 0.8 Nonsmokers Total 926 17 94.5 5.2 92.2 4.5 93.2 2.0 94.9 0.6 Men 92.2 2.7 87.8 10.5 91.1 8.8 925 3.2 93.7 1.0 Women 92.9 2.2 100.0 0.0 93.0 4.8 93.8 24 96.0 0.7 Smokers Total 90.1 29 89.1 11.6 94.3 6.1 92.1 4.2 895 15 Men 90.1 4.0 92.7 14.3 95.6 6.1 95.0 4,7 88.5 2.2 Women 90.2 3.8 86.2 17.4 81.2 24.7 88.8 6.9 905 18 The smoke from other people’s cigarettes is harmful to you. Overall Total 82.1 2.2 79.8 9.1 80.3 6.2 86.7 2.2 85.2 0.9 Men 815 3.4 77.1 16.2 83.8 74 854 3.4 82.8 14 Women 82.7. 2.7 82.2 10.9 76.9 9.4 879 2.7 874 1.1 Nonsmokers Total 89.7 2.0 94.9 4.2 81.1 7.1 89.8 23 916 08 Men 90.0 3.2 92.8 6.0 86.1 9.4 88.9 3.5 89.7 13 Women 894 2.4 96.6 6.5 77.6 9.8 906 28 93.4 0.9 Smokers Total 66.8 5.2 57.6 20.8 78.4 11.7 80.0 5.1 71.0 2.2 Men 678 7.0 57.8 29.7 80.6 12.5 763 7.9 68.4 3.1 Women 65.7 7.5 57.4 29.5 56.4 36.4 84.3 6.1 73.7 2.9 *95% confidence interval. Source: National Center for Health Statistics, 1992 Cancer Control Supplement, public use data tape. 264 Chapter 5 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 2. Continued African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +Cl %o +CI % +CI %o +CI % +CI Most deaths from lung cancer are caused by cigarette smoking. Overall Total 73.7 2.9 79.3 10.4 77.1 6.1 774 28 75.0 1.1 Men 74.9 46 75.5 15.6 79.9 8.4 76.7 4.3 73.9 1.7 Women 72.8 3.4 82.6 10.5 74,3 8.7 78.2 3.5 76.1 1.3 Nonsmokers Total 80.0 2.9 84.6 9.0 79.1 6.8 794 3.2 81.7 1.1 Men 816 5.2 71.2 18.0 83.4 10.2 78.5 49 80.3 1.7 Women 78.8 3.5 95.6 5.8 76.1 8.8 80.3 3.7 829 14 Smokers Total 615 5.46 74.1 18.4 69.4 14.2 73.8 6.2 59.8 2.3 Men 646 7.6 91.2 16.8 74.5 14.6 718 888 604 3.5 Women 57.7 7.7 60.3 28.6 19.1 25.3 76.2 78 59.3 3.1 Even if a person has smoked for more than 20 years, there is a health benefit to quitting. Overall Total 82.6 2.5 81.3 9.1 78.2 6.3 80.9 2.9 914 04 Men 82.0 3.9 80.7 11.2 78.6 8.7 82.00 4.2 91.1 1.0 Women 83.0 3.0 81.7 14.1 77.8 91 79.8 3.5 91.7 09 Nonsmokers Total 85.5 28 79.6 12.3 78.9 7.1 82.1 3.1 93.9 0.7 Men 855 46 81.8 11.9 80.6 10.8 82.2 4.6 94.0 1.0 Women 8.4 3.3 77.8 19.8 77.7 9.3 82.1 3.9 93.8 1.0 Smokers Total 790 45 88.2 11.0 76.6 13.1 80.3 58 88.0 1.7 Men 77.7 68 87.8 17.0 76.0 14.6 82.9 8.2 86.9 24 Women 80.7 5.9 88.5 14.0 81.9 24.3 77.2 8.0 89.2 2.0 Overcoming these limitations will be imperative in future years because the need for culturally appro- priate tobacco control programs will likely grow. Numerous researchers have argued that culturally ap- propriate health promotion efforts need to be devel- oped for racial/ethnic groups (Rogler et al. 1987; Edwards and MacMillan 1990; Nestle and Cowell 1990; Gonzalez et al. 1991; Robinson et al. 1991; Uba 1992; Vega 1992; Alcalay et al. 1993; Marin 1993). Early out- come data on interventions targeting racial/ethnic groups further indicate the need for such strategies (Chen et al. 1994; Pérez-Stable et al. 1994; Marin and Pérez-Stable 1995). Moreover, in a National Cancer Institute (NCI) analysis of self-guided strategies for smoking cessation, Glynn and colleagues (1990) sup- ported the need for targeted programs and suggested that the availability of self-guided smoking cessation materials tailored to the needs of a racial/ethnic group “enhances their adoption and may positively affect quit rates” (p. 11). Therefore, culturally appropriate interventions may prove to be more acceptable and easier to implement and also may have increased effec- tiveness (Fiore et al. 1996). Cultural values, in fact, often support the messages given in effective tobacco control programs. In addition, if the development process in- cludes community leaders and researchers who repre- sent the community, the process itself will enhance the existing tobacco control infrastructure (Robinson et al. 1995). Tobacco Control and Education Efforts 265 Surgeon General's Report Primary Prevention Efforts Most of the programs that seek to prevent tobacco use among racial/ethnic minority groups focus on children and adolescents. These interventions include efforts to restrict minors’ access to tobacco products, school-based health education programs, and mass media efforts. Efforts to Restrict Youth Access to Tobacco A comprehensive national effort to address the problem of minors’ access to tobacco was made in 1992 with the passage of the Synar Amendment to the Al- cohol, Drug Abuse, and Mental Health Administra- tion Reorganization Act (Public Law 102-321), which amended the Public Health Service Act. The draft regulations were made final in 1996. These regula- tions require the 50 states, the District of Columbia, and U.S. jurisdictions to enact and enforce legislation restricting the sale and distribution of tobacco prod- ucts to minors, as a condition of receiving federal block grant funds for substance abuse and treatment. Asa result, all states now designate an agency to enforce their minimum-age laws on purchase of tobacco prod- ucts. Many local governments have attempted over the years to limit access to tobacco among youths un- der the age of 18 years by enacting or strictly enforc- ing legislation that limits minors’ ability to purchase tobacco over the counter and through vending machines, whereas others have opted to educate re- tailers and encourage them to voluntarily comply with legislation that limits the sale of tobacco products to minors (Lynch and Bonnie 1994; USDHHS 1994). Stud- ies show that over-the-counter sales of tobacco to adolescents under the age of 18 years are indeed wide- spread, although all states prohibit such sales (Altman et al. 1989; Jason et al. 1991; NCI 1991; DiFranza and Brown 1992; Forster et al. 1992). Despite laws in every state that prohibit the sale of tobacco products to per- sons under 18 years of age, underage buyers in 1996 were able to purchase tobacco products from retail outlets a median of 40 percent of the time, according to reports from states, compared with rates ranging from 60 to 90 percent in previous studies (USDHHS 1998). In addition to requirements of the Synar Amend- ment, the recent regulations on tobacco products pro- posed by the Food and Drug Administration (FDA) and made final on August 23, 1996, sought to reduce 266 Chapter 5 both minors’ access to tobacco products and the appeal those products have to minors (see Efforts to Control Tobacco Advertising and Promotion later in this chapter). Three key provisions address minors’ access to tobacco: (1) requiring vendors to check a pho- tograph identification as proof of age and prohibiting sales to those under age 18, (2) prohibiting most vend- ing machines and self-service displays of cigarettes except in facilities totally inaccessible to persons un- der age 18, and (3) prohibiting free samples of ciga- rettes and sales of individual cigarettes or packs of fewer than 20 cigarettes (so-called kiddie packs). Both the Synar Amendment and the FDA regulations hold promise for reducing tobacco use by all young people, including those who are members of racial/ethnic groups. In general, adults in the four racial/ethnic groups perceive that minors have fairly easy access to tobacco products. In the 1992-1993 Current Population Sur- vey,' a greater proportion of white respondents (55.6 percent) said that it was very easy for minors to pur- chase tobacco products, compared with American In- dians and Alaska Natives (52.6 percent), Hispanics (49.8 percent), African Americans (49.0 percent), and Asian Americans and Pacific Islanders (44.3 percent) (Table 3) (U.S. Bureau of the Census, NCI Tobacco Use Supple- ment, public use data tapes, 1992-1993). Men and non- smokers were more likely than women and smokers to think that minors had easy access to tobacco products. Data from the 1989 Teenage Attitudes and Practices Survey (TAPS) showed that most youths 12-18 years old who reported cigarette smoking bought their ciga- rettes primarily at small stores or through cigarette vending machines (Allen et al. 1993). For example, 86.9 percent of white adolescents reported often or some- times buying their cigarettes from small stores, com- pared with 80.0 percent of African Americans and 90.0 ! The Current Population Survey (CPS) is a continuous monthly survey conducted by the U.S. Bureau of the Census and focuses primarily on labor force indicators for the civilian noninstitu- tionalized U.S. population aged 15 years and older. Questions on smoking and tobacco use (NCI Tobacco Use Supplement) were added to the CPS for the September 1992, January 1993, and May 1993 surveys. About 57,000 eligible households are surveyed each month and yield approximately 110,000 interviews; interviews are conducted with a knowledgeable household respondent who responds for all household members aged 15 years and older. The knowledge, attitude, and belief questions described in this report were asked only of self-respondents. percent of Hispanics. In contrast, 51.4 percent of white smokers reported often or sometimes buying cigarettes from large stores, compared with 56.6 percent of His- panics and 39.8 percent of African Americans. Data from a 1993 follow-up survey (TAPS-II) that were statistically adjusted for participant correlation Tobacco Use Among U.S. Racial/Ethnic Minority Groups and age showed that African Americans were less likely than whites to have ever been asked to show proof of age when buying or trying to buy cigarettes; Hispanics were less likely than non-Hispanics to ever have been asked to show proof of age (CDC 1996). In 1989, 12- to 17-year-old whites who smoked were Table 3. Adults’ beliefs about minors’ ease in purchasing cigarettes and other tobacco products,* by race/ ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +cit % +CI % +cl % +CI % +Cl Total Very easy 49.0 0.7 52.6 3.3 44.3 1.6 49.8 0.9 55.6 0.3 Somewhat easy 15.4 0.5 15.9 2.4 16.6 1.2 15.4 0.6 17.6 0.2 Men Very easy 52.5 1.2 55.6 49 46.0 2.3 51.9 1.3 57.4 0.4 Somewhat easy 16.1 0.9 14.5 3.5 17.6 1.8 15.7 1.0 = 18.7 0.3 Women Very easy 46.8 0.9 50.1 4.5 42.6 2.2 48.1 1.2 54.0 0.4 Somewhat easy 14.9 0.7 17.0 3.4 15.7 1.6 15.2 0.9 16.7 0.3 All nonsmokers Very easy 50.9 0.9 51.4 4.2 44.1 1.7 50.4 1.0 57.2 0.3 Somewhat easy 16.1 0.6 16.2 3.1 17.2 1.3 15.5 0.7 17.9 0.2 All smokers Very easy 44.2 1.4 54,2 5.3 45.5 4.1 47.1 2.1 50.9 0.6 Somewhat easy 13.4 1.0 15.4 3.8 13.8 2.8 15.1 1.5 17.0 0.4 Nonsmokers Men Very easy 54.8 1.4 52.2 6.6 46.4 2.6 53.3 1.5 58.9 0.5 Somewhat easy 16.7 1.0 14.3 4.6 18.5 2.0 15.6 11 19.0 0.4 Women Very easy 48.6 1.1 50.7 5.6 42.3 2.3 48.3 1.3 55.7 0.4 Somewhat easy _—15.7 0.8 17.5 4.2 16.1 1.7 15.5 0.9 16.9 0.3 Smokers Men Very easy 47.8 2.1 59.3 7.4 45.4 49 47.7 2.7 53.6 0.8 Somewhat easy 14.8 15 14.9 5.3 14.9 3.5 16.3 2.0 18.0 0.6 Women Very easy 41.0 1.9 49.1 7.5 45.8 7.5 46.4 3.3 48.4 0.8 Somewhat easy 12.2 1.3 15.9 5.5 11.3 4.7 13.2 2.3 16.0 0.6 “In response to the question, “In your opinion, how easy is it for minors to buv ci arettes and other tobacco ° r y' P. . . y wu products in your community?” Response categories included “very easy,” “somewhat easy,” “somewhat difficult,” “very difficult,” and “don’t know.” 95% confidence interval. Source: U.S. Bureau of the Census, public use data tapes, 1992-1993. Tobacco Control and Education Efforts 267 Surgeon General’s Report more likely (58.7 percent) than same-aged African Americans who smoked (43.3 percent) to report that they usually bought their own cigarettes. By 1993, however, 62.1 percent of whites who smoked and 64.1 percent of African Americans who smoked reported that they usually bought their own cigarettes. In 1989, 12- to 17-year-old non-Hispanics who smoked were more likely (59.0 percent) than Hispanics of the same age who smoked (41.3 percent) to report that they usu- ally bought their own cigarettes. By 1993, however, 62.4 percent of non-Hispanics who smoked and 59.1 percent of Hispanics who smoked reported that they usually bought their own cigarettes (CDC 1996). Ina study in San Bernardino and Riverside Counties, Cali- fornia, Klonoff and colleagues (1994) found that the purchase of single cigarettes by minors was more fre- quent in ethnic communities (71.2 percent of minors) than in white neighborhoods (34.4 percent of minors). Klonoff and colleagues (1997) used a factorial design to study the sale of cigarettes to minors in 72 stores in African American, Hispanic, and white com- munities. Purchase attempts (N = 1,296) were made in 24 stores in each community. There were two par- ticipants in each age (ages 10, 14, and 16 years), gender, and race/ethnicity category. Sales were made most often to 16-year-old African Americans, regardless of gender. A gender effect ex- isted for Hispanics, and more frequent sales occurred to Hispanic girls. Another report based on the same data analyzed purchase attempts by 14- and 16-year-old African American and white participants in African American and white communities (Landrine et al. 1997). Racial- and ethnic-specific sales rates were similar in white communities. In African American communities, however, sales rates were higher for African American youths than for white youths. Of the 41 packs of ciga- rettes sold to African American youths, only 7 percent were sold by African American vendors. The rest were sold by Asian (67 percent), white (13 percent), and His- panic (13 percent) vendors, according to participants’ reports. Unfortunately, vendor-specific sales rates and comparable sales data by vendor race/ethnicity for the white community were not provided. A limitation of this study is that the apparent age of the minors, an im- portant correlate of sales (DiFranza et al. 1996), was not assessed by independent raters. A community-based study conducted after pas- sage and enforcement of legislation limiting minors’ access to tobacco products showed a reduction in the proportion of merchants who sell cigarettes to minors and the proportion of adolescents who smoke (Jason et al. 1991; Jason et al. 1996). Nevertheless, many merchants—fully aware of legislation prohibiting sales 268 Chapter 5 of tobacco to minors—continue to sell these products to underage customers. For example, in a 1991 study of 156 tobacco retailers in central Massachusetts, 80 percent of the merchants who displayed state- mandated warning signs specifying that it was illegal for minors to purchase tobacco products were still will- ing to illegally sell cigarettes to youths (DiFranza and Brown 1992). Likewise, a 1994 Massachusetts study reported the ineffectiveness of the tobacco industry- sponsored “It’s the Law” voluntary compliance program for stores to prevent underage youths from purchasing tobacco (DiFranza et al. 1996). The results of surveys and sting operations conducted by com- munity action groups affiliated with such organiza- tions as Stop Teenage Addiction to Tobacco (STAT) show that before public awareness campaigns, 32 to 87 percent of U.S. adolescents who tried to buy ciga- rettes in various communities were able to do so. These figures decreased dramatically (by 10 to 93 percent) when merchants were informed of the law, fined for selling tobacco products to minors, or told that their behavior would be monitored by law enforcement agents (Altman et al. 1989; Feighery et al. 1991; Forster et al. 1992). Some of the campaigns aimed at increasing mer- chants’ awareness of the law’s provisions have con- centrated on small, urban convenience stores where many youths purchase their own cigarettes (Davis 1991). Asa result of amerchant public awareness cam- paign in San Diego County, tobacco sales to minors declined in Hispanic and Asian American neighbor- hoods but not in African American communities (Keay et al. 1993). Additional data are needed to determine the reasons that shopkeepers sell tobacco to minors (Landrine et al. 1994) and also the effectiveness of vari- ous approaches among youths of different racial/ ethnic minority groups and among owners of conve- nience stores located in racial/ethnic neighborhoods. Information about the tobacco-purchasing patterns among youths of various racial/ethnic groups also is limited; additional research in this area would be par- ticularly useful in designing programs to curtail youths’ access to tobacco products. Cigarette vending machines are another way minors obtain tobacco products, because the machines are rarely supervised by adults. Tobacco control ad- vocates have recommended banning cigarette vend- ing machines, locking them, or moving them to places where adults could check the ages of purchasers. Re- sults from the 1992 California Tobacco Survey showed that a large proportion of Hispanics (93.8 percent), African Americans (91.1 percent), Asian Americans and Pacific Islanders (87.9 percent), and whites (84.2 percent) were willing to ban cigarette vending ma- chines that are accessible to minors (Pierce et al. 1994a). Strong support for banning cigarette vending machines accessible to youths also was found in the 1994 Robert Wood Johnson Foundation (RWJF) Youth Access Survey, a national household survey to assess public attitudes about policy alternatives for limiting youths’ access to tobacco products. This survey of 2,345 adults, including 486 African Americans, 402 Hispanics, and 1,341 whites, showed that there was willingness to ban cigarette vending machines acces- sible to youths (Table 4) and strong support for ban- ning all cigarette vending machines (Nancy Kaufman et al., unpublished data). Although most adults believe that it is relatively easy for youths to obtain cigarettes, the RWJF Youth Access Survey found that African Americans (57.5 percent) were somewhat less likely than Hispanics (67.4 percent) and whites (70.0 percent) to believe that tobacco products were very or somewhat easy for youths to buy in their communities. Even so, African Americans and Hispanics were more supportive than whites of increasing retailing restrictions that would limit youths’ access to tobacco, with Hispanics being the most supportive. The retail measure with the broadest public support is the proposal to eliminate self-service tobacco displays, requiring retailers to keep tobacco products behind the counter. Hispanics and African Americans differ from whites in their beliefs about the potential results of raising the age at which tobacco products can be legally purchased. Sixty-five percent of Hispanics and 61.4 percent of African Ameri- cans, compared with only 44.3 percent of whites, be- lieve that raising the age of legal purchase to 21 would prevent smoking initiation. Similar results were observed when 19 was proposed as the legal age of purchase. School-Based Health Education Approaches In the past decade, numerous programs to pre- vent tobacco use have been developed for use in schools with a substantial number of white students (Lynch and Bonnie 1994). Rather than consider the specific cultural characteristics of targeted students, most of these programs have been theory-driven or intuitively designed and directed toward students at large. Although youths from various racial/ethnic groups have been included in numerous studies, their responses and behaviors have rarely been separately analyzed or reported in the literature. In a review of school-based smoking-prevention programs, an NCI Tobacco Use Among ULS. Racial/Ethnic Minority Groups panel of experts concluded that, in general, children from the major racial/ethnic groups and those of low- socioeconomic status were the least likely to have been reached by smoking-prevention programs in schools (Glynn 1989). In 1991, the NCI Advisory Panel on Tobacco-Use Reduction Among High-Risk Youth (Glynn et al. 1991) recommended that entire schools be the target of efforts to identify high-risk youth and that a broader approach (such as identifying a school with a large proportion of economically disadvantaged youth) may be more cost-effective and reach the great- est number of high-risk youth without detrimentally labeling individuals the way a more focused approach might. To support the development of effective school- based interventions, the CDC published a set of guide- lines for school health programs to prevent tobacco use and addiction (CDC 1994). These guidelines incorporate findings from a number of studies on tobacco use and addiction, call for school-based tobacco-use prevention programs to be provided for stu- dents from all racial/ethnic groups, and indicate that such programs should be “sensitive to, and representa- tive of, a student population that is multicultural, multiethnic, and socio-economically diverse” (p. 4). One significant challenge is the difficulty of implementing a targeted, culturally appropriate inter- vention ina typical urban classroom that includes stu- dents from many cultural and racial/ethnic groups. Another problem with school-based interventions is that teachers in most school districts are overworked and do not have the time, resources, or training to per- form these additional activities as part of their daily lessons (Perry et al. 1990). Teachers often have diffi- culty making tobacco control a high-priority area for instruction when they must also deal with basic edu- cational issues and serious community problems such as crime, illegal drug use, and substandard housing. In addition, high dropout rates in some racial/ethnic minority communities make it impossible for school- based programs to reach many children. For example, a recent analysis of 1990 census data (U.S. General Accounting Office [GAO] 1994) showed that a large proportion of Hispanic dropouts have abandoned for- mal schooling within the grades (sixth through ninth) when adolescents are vulnerable to cigarette smoking initiation (USDHHS 1994). The GAO report showed that among all Hispanic dropouts, 14 percent had left formal school by the fourth grade and 56 percent had left by the ninth grade. To overcome these challenges, new school-based tobacco control programs continue to be developed and implemented. ASSIST, the American Stop Smok- ing Intervention Study, for example, has a youth com- ponent, and at some sites such as North Carolina, the Tobacco Control and Education Efforts 269 Surgeon General's Report Table 4. Public support for and beliefs about policies regarding tobacco access and marketing, by selected characteristics, Robert Wood Johnson Foundation Youth Access Survey, 1994 African American* Hispanic White* (N = 486) (N = 402) (N = 1,341) Characteristic Jo +CIt % itl % xX! Favor banning the sale of cigarettes in vending machines 74.9 3.5 84.5 3.1 72.5 3.1 Favor banning cigarette vending machines that are accessible to youths 93.7 2.0 93.0 2.2 90.7 2.0 Think retailers should keep tobacco products behind the counter to prevent shoplifting by minors 82.6 3.0 88.9 2.7 75.5 3.0 Favor allowing the sale of cigarettes only in certain stores, just as is done with alcohol 46.9 4.0 72.9 3.9 43.1 3.4 Believe that restricting the sale of cigarettes to persons aged 21 years and older will help reduce the number of kids under 21 who begin smoking 614 3.9 65.4 4.2 44.3 3.4 Believe that restricting the sale of cigarettes to persons aged 19 years and older will help reduce the number of kids in high school who begin smoking 56.9 3.9 66.5 4.1 47.1 3.5 Favor banning tobacco product advertising on billboards 61.8 3.9 68.9 4.1 57.3 3.4 Favor banning tobacco product advertising in newspapers or magazines 574 39 62.3 43 49.1 3.5 Think tombstone advertising would make smoking less appealing to youths 72.1 3.6 74.9 3.8 72.8 3.1 Favor requiring plain packaging to make cigarettes less attractive to youths 48.0 4.0 61.8 43 44.9 3.5 Favor not allowing coupons in cigarette packs to obtain promotional items appealing to youths 765 3.4 82.1 3.4 67.8 3.3 Favor not allowing coupon promotions to obtain free cigarettes by mail 795 3.2 89.8 2.7 80.4 28 Favor not allowing tobacco companies to sponsor sporting or entertainment events in which their brand names are featured 65.1 3.8 71.7 3.9 51.9 3.5 Think that it is very or somewhat easy for youths to buy cigarettes 575 3.9 674 4.1 70.0 3.2 *Non-Hispanic. 95% confidence interval. Source: Nancy Kaufman et al., unpublished data. Ethnic differences in public attitudes about policy alternatives for limiting youth access to tobacco products: results of a national household survey, 1994. 270 = Chapter 5 program teaches students to serve as peer counselors who can provide information on smoking prevention and cessation to other high school students. However, little information is available on the counselors’ suc- cess in racial/ethnic communities. Some of the largest experimental school-based programs that have included children from racial/ ethnic minority groups are briefly described in this sec- tion. This listing is not exhaustive because previous reports have reviewed this type of program (Lynch and Bonnie 1994; USDHHS 1994). These interventions rep- resent the variety of school-based approaches used in racial/ethnic neighborhoods. Project SMART (Self-Management and Resistance Training) Project SMART is an in-school program designed to encourage junior high school students to resist pres- sure to use cigarettes and other drugs by teaching them stress-reduction skills, social-resistance skills, and personal decision-making skills. Implemented in 12 sessions, Project SMART provides the students with role-playing opportunities and offers specific tech- niques for resisting cigarettes, alcohol, marijuana, and other drugs. In an assessment of this program, Gra- ham and colleagues (1990) interviewed seventh grad- ers in 16 California schools between 1982 and 1986. Approximately 6 percent of the participants were Asian American, 20 percent were African American, 31 per- cent were Hispanic, and 43 percent were white. The program materials, dissemination channels, and evalu- ation procedures were not tailored specifically for any of these racial/ethnic groups. Differential effects for cigarette smoking on the basis of participants’ gender and racial/ethnic minority background were found. Overall, seventh-grade girls were more positively af- fected by the program than were seventh-grade boys, and Asian Americans were more likely than other racial/ethnic groups to be affected by the intervention. Hispanics and whites were marginally affected by the program, whereas African Americans did not appear to be affected at all. Life Skills Training Program The Life Skills Training (LST) Program is a tobacco-use prevention curriculum that teaches ado- lescents positive life options and social-resistance skills. The program aims to help students enhance their self- esteem, resist tobacco advertising appeals, cope with anxiety, and develop verbal and nonverbal communi- cation skills as well as social and assertiveness skills, including techniques to resist social pressures to smoke Tobacco Use Among U.S. Racial/Ethnic Minority Groups (Botvin et al. 1989a, 1992; Dusenbury and Botvin 1992). Program lessons focus on (1) tobacco information, (2) ‘social skills, (3) personal skills, and (4) self-improvement. Each program includes instruction, behavior model- ing and rehearsal, and group feedback. The LST cur- riculum was initially developed for use with white youths, but the curriculum was later modified for use with Hispanics and African Americans, following con- sultations with psychologists, educators, reading spe- cialists, and urban adolescents from various racial/ ethnic groups. To assess its feasibility, acceptability, and effectiveness in an urban African American popu- lation, the LST curriculum was tested in a pilot study involving 608 African American seventh-graders in New Jersey (Botvin et al. 1989a). The study found that the curriculum was acceptable to African American teachers and students and could be implemented with little difficulty in an urban setting. Three months after the intervention, investigators found a 56 percent re- duction in the proportion of adolescents who reported that they had smoked in the previous 30 days. In an earlier study, Botvin and colleagues (1989b) found that the use of the LST curriculum was feasible and accept- able among Hispanic seventh-graders attending urban schools in northern New Jersey and in New York City. More recently, researchers studied the LST curriculum’s effectiveness among Hispanic students in the New York City area and found significant changes in knowledge, smoking behavior, and norma- tive expectations concerning peer and adult smoking among students in the schools targeted by the inter- vention, compared with students in control schools that did not implement the curriculum (Botvin et al. 1992). Consistency in the findings varied, however, because of implementation difficulties across schools. General problems, such as limited resources and stress- ful conditions in urban schools, may have contributed to these difficulties. Project SHOUT (Students Helping Others Understand Tobacco) Project SHOUT was a three-year tobacco-use prevention program that began in 1988 and targeted San Diego students who were in the seventh grade at the beginning of the program (Sallis et al. 1990; Elder et al. 1993b). About 51 percent of the students who participated in the program for all three years were white, and 28 percent were Hispanic. The program consisted of lessons and activities, led by college un- dergraduate students, on such topics as the conse- quences of tobacco use, refusal and decision-making skills, and the antecedents and social consequences of tobacco use. Efficacy of the program was measured Tobacco Control and Education Efforts 271 Surgeon General’s Report with preintervention and postintervention question- naires administered to students at the end of grades seven, eight, and nine. In addition, the efficacy of the program was tested by using a physiological measure- ment to detect cigarette smoking and an audiotaped skills assessment of the students’ ability to refuse of- fers of cigarettes (Sallis et al. 1990). Follow-up telephone calls and mailings were made during the last year of the intervention to reinforce the program. The proportion of Project SHOUT students who re- ported smoking in the previous month increased from 8.3 percent at the end of the seventh grade to 13.2 per- cent at the end of the ninth grade. In comparison, 9.2 percent of control students reported smoking in the previous month at the end of the seventh grade, and 19.8 percent reported smoking in the previous month at the end of the ninth grade. When researchers used logistic regressions to analyze the prevalence of ciga- rette smoking during the previous month among ninth graders, comparing control and experimental groups, the results were statistically significant for whites but not for Hispanics (Elder et al. 1993b). When research- ers considered cigarette smoking during the previous week, they found statistically significant results for both Hispanic and white respondents. When offered a cigarette in a mock situation, students who received refusal skills training provided more appropriate re- sponses than those who did not receive the training (Sallis et al. 1990). Southwestern Cardiovascular Curriculum Project and Pathways to Health In 1990, the University of New Mexico began a series of projects designed to educate Navajo and Pueblo youths about cardiovascular health and the prevention of cancer. The Southwestern Cardiovas- cular Curriculum Project, founded by the National Heart, Lung, and Blood Institute, provides fifth-grade Navajo and Pueblo youths with information on the health effects of tobacco use and helps them develop skills to resist social pressures (Davis et al. 1995b). An evaluation of the program showed that among stu- dents who had tried cigarette smoking at baseline, boys who were randomly assigned to the program reported decreasing their cigarette smoking more than those not participating. The Pathways to Health program, developed with funding from the NCL, involves fifth and seventh graders in nine Navajo and Pueblo schools in rural northwest New Mexico (Davis et al. 1995a). This 16-lesson curriculum is designed to improve Navajo and Pueblo Indian children’s decision-making 272 Chapter 5 abilities regarding health (Cunningham-Sabo and Davis 1993). The curriculum includes skill acquisition, self-discovery, and class discussion, and it blends tra- ditions of Navajo and Pueblo Indians. Overall, the project promotes a diet low in fat and high in fiber, fruits, and vegetables, and it teaches students to avoid both cigarettes and smokeless tobacco (Cunningham- Sabo and Davis 1993). Results of the baseline testing showed that a large proportion of fifth (30.6 percent) and seventh (60.4 percent) graders had tried cigarette smoking (Davis et al. 1995a). Although 64.5 percent of fifth-grade girls and 41.0 percent of fifth-grade boys expressed intentions to never smoke, by the time they became seventh graders, only 37.8 percent of seventh- grade girls and 24.5 percent of seventh-grade boys re- ported intentions to never smoke. Tribal differences were also noted. Pueblo students reported higher use of cigarettes, and Navajos reported higher use of chewing tobacco and snuff. Other Primary Prevention and Intervention Efforts Other primary prevention and intervention pro- grams have been relatively small in scale and have directly targeted members of a given racial/ethnic minority group. For example, Cella and colleagues (1992) recently designed a smoking-prevention cur- riculum for 309 mostly African American (57 percent) and Hispanic (19 percent) sixth- and seventh-graders from the Chicago area. The program included two assemblies that were attended by all students. The first assembly featured a rap video developed by Af- rican American adolescents in Richmond, California, and a talk by an African American oncologist on the health risks of smoking and social pressures to smoke. The second assembly featured a rap contest in which students performed original rap songs they had writ- ten to convey messages about smoking prevention. After the first assembly, students who participated in small follow-up groups were found to have more nega- tive attitudes toward smoking, compared with stu- dents attending the larger assembly. There were no differences in attitudes towards smoking between stu- dents who decided to participate in the rap contest and those who did not. No data were collected on the intervention’s possible effects on rates of smoking ini- tiation or continuation. Another small-scale tobacco-use prevention effort targeted American Indian children from two Washington State reservations (Schinke et al. 1988). American Indian children participating in the project, who were an average of 11.8 years of age, received training in communication, coping, and cognitive decision-making skills from a bicultural perspective. At a six-month follow-up, children who participated in the program were less likely than children in a con- trol group to report that they had smoked tobacco or used smokeless tobacco within the previous 14 days. A prevention project now under way in Ameri- can Indian communities in the northeastern United States involves 260 American Indian adolescents in an after-school cancer education program (Schinke et al. 1996). The intervention merges tribal culture with an educational approach that uses storytellers and role models from the community. The curriculum provides students with information on problem-solving skills, the historical use of tobacco among northeastern In- dian tribes, and health and media literacy to show how lifestyle habits are heavily promoted through mass media. Problem-solving skills, the historical use of tobacco among northeastern Indian tribes, and Ameri- can Indians’ heritage are celebrated through such activities as making story bags (bags containing me- mentos that are reminders of the story) and dance sticks. A preliminary evaluation of the project has shown that American Indian youths who received the tobacco use curricula or the combined tobacco use and dietary curricula had more knowledge and under- standing of the health problems associated with to- bacco use. In addition, students receiving the tobacco use or the combined curricula were more aware of the role of peers, relatives, and the media in shaping people’s dietary and tobacco preferences (Schinke et al. 1996). In another program, involving American Indian children in the northwestern states, Moncher and Schinke (1994) have shown that a culturally appropriate skills-learning curriculum can be more effective when combined with community involve- ment in the prevention of tobacco use. Schinke and colleagues (1994) recently developed a program targeting American Indian youths. Based on a legend of the Seneca Nation, the program fea- tures an interactive software package entitled Boy and Woman Bear, which provides culturally appropriate information on how young people can reduce their risk of cancer via good nutrition and only very limited, nonhabitual use of tobacco. The effectiveness of the software was measured with 368 American Indian youths, aged 10-14 years, in the southeastern United States. As expected, the youths who participated in the program were more knowledgeable about nutrition and tobacco-related facts than were nonpar- ticipants. Further research by these authors (Schinke et al. 1996) has shown the strong effects of multitopic interventions with American Indians. Tobacco Use Among U.S. Racial/Ethnic Minority Groups The Alaska Area Native Health Service of the Public Health Service conducted a pilot study of a school-based intervention targeting 240 Alaska Native children in grades two through six in three Eskimo villages (Bruerd et al. 1994). The curriculum, a modi- fication of previously developed programs, was de- livered in 12-15 lessons and involved the children’s families in some of the activities. The evaluation of the program showed a decrease in cigarette smoking and in the use of snuff in two of the three villages that participated. The program was most effective when teachers attended training sessions and fully imple- mented the curriculum. Another program sponsored by the Alaska Area Native Health Service, the Great Alaska Spit-Out, educates Alaska Native schoolchil- dren and adults about the health risks associated with smokeless tobacco use (Burhansstipanov and Dresser 1993). Schoolchildren in rural Alaska communities prepare essays and public service announcements re- garding the health problems associated with tobacco use. All children who submit entries receive certifi- cates. Monetary awards are given for the best essays, and trips to Washington, D.C., are awarded to the first- place winners. As an adjunct to tobacco control curricula, ciga- rette smoking bans on school grounds have been im- posed in some states (recent federal legislation, Public Law 103-227, Part C, mandates that schools receiving federal monies be tobacco-free). Although some states and school districts have prohibited students from using tobacco on school campuses, they have excluded administrators, teachers, and volunteers from such policies, most likely because some adults are resistant to tobacco-use bans. Data from the 1992 California Tobacco Survey showed that a relatively low propor- tion of California adults and youths favored banning cigarette smoking on school grounds (Pierce et al. 1994a). Whites (22.3 percent) were the most willing to ban smoking on school grounds, followed by Asian Ameri- cans and Pacific Islanders (16.5 percent), African Ameri- cans (16.3 percent), and Hispanics (11.1 percent). Mass Media Efforts to Prevent Tobacco Use A few programs have developed mass media materials to prevent tobacco use among children in racial/ethnic minority groups. Most of these programs use television commercials and videotapes to present prevention messages in a targeted fashion. Stop Before You Drop, a 10-minute videotape developed by Afri- can American adolescents in Richmond, California (American Lung Association [ALA] 1990b), presents a Tobacco Control and Education Efforts 273 Surgeon General's Report preventive message through stories, rap songs, and dancing; this videotape is available through local af- filiates of the ALA. It’s No Joke, Don’t Smoke! is a 30-minute videotape that openly discusses tobacco use among children and young adolescents in racial/ ethnic minority groups (California Department of Health Services, Tobacco Control Section 1993). Other mass media prevention approaches include theatrical works presented at school assemblies or during com- munity events and the distribution of newsletters and newspapers in schools and through other community outlets. No data on the effectiveness of these and similar prevention efforts are available because these activi- ties are relatively new. Although these efforts incor- porate the musical preferences of young adolescents (for example, as reflected in programming on MTV {Music Television]) and feature actors from the racial/ ethnic groups being targeted, rarely do the messages properly reflect the attitudes, expectations, and nor- mative beliefs of the targeted children. Instead, most of these efforts have allowed untrained scriptwriters (often children from the targeted group) to produce the text. Although this approach benefits from the use of words and expressions that are familiar to the tar- geted children, it fails to incorporate attitudinal change strategies and the results of studies identifying pre- dictors of tobacco use (see Chapter 4). Also problematic is the lack of information re- garding the best media outlet to use in presenting smoking-prevention campaigns to youths in various racial/ethnic groups, both in terms of frequency of use and in their perceived credibility and motivating power. In a study of 349 Chicago youths aged 5-15 Smoking Cessation Programs years, Blosser (1988) found differences across racial / ethnic groups in the quantity, frequency, and access to various media. For example, 70.8 percent of African Americans in the sample reported watching television during dinner, compared with 64.6 percent of Puerto Ricans, 58.8 percent of whites, and 58.1 percent of Mexican Americans. Racial/ethnic group differences were also found for access to various media; large pro- portions of youths reported that they owned a televi- sion set (100 percent of whites, 99.0 percent of African Americans, and 97.7 percent of Hispanics), but vary- ing proportions of youths reported that they owned an audiocassette player (80.0 percent of whites, 77.1 percent of Mexican Americans, 62.5 percent of African Americans, and 54.8 percent of Puerto Ricans). Ina recent survey of Los Angeles children 8-12 years of age, Raymond J. Gamba (unpublished data) found that children perceived some media channels to be more believable than others when information on tobacco was presented. Overall, respondents perceived talks at school (63 percent), books and pamphlets (54 percent), television programs (54 percent), radio com- mercials (52 percent), and television commercials (52 percent) to be highly credible in presenting informa- tion about tobacco use. Students’ perceptions varied by ethnic group. For example, a large proportion of African Americans perceived books and pamphlets to be the most credible channels of information, followed by billboards, posters, newspapers, and television pro- grams and commercials. A large proportion of Asian Americans and Hispanics, however, perceived talks at school to be highly credible, followed by television and radio commercials. Most structured smoking cessation programs directed at members of racial/ethnic minority groups have emphasized a self-help approach with some sup- portive adjuncts, such as motivational messages in the mass media or the use of peers or relatives as motiva- tors and supporters (Stotts et al. 1991). This emphasis on self-help may be a direct result of the fact that most smokers quit on their own (Fiore et al. 1990). Some programs have successfully used materials developed 274 Chapter 5 for whites, with little or no adaptation for the racial/ ethnic group being targeted. Though there is currently little research on the development of culturally appro- priate smoking cessation programs, culture-specific tailoring or the development of culturally appropri- ate programs may be necessary in order to enhance effectiveness. Ata minimum, programs must be com- municated in a language understood by the target au- dience (Fiore et al. 1996). In this section, six major intervention approaches are described: (1) self-help programs, (2) group pro- grams, (3) community interventions, (4) programs in health care settings, (5) employer-sponsored programs, and (6) nontraditional provider interventions. When available, the results of outcome evaluations of the projects or strategies are mentioned. Because most of these projects are relatively new, there is a paucity of research measuring the effectiveness of the various strategies and programs. These descriptions provide an overview of the different approaches that have been used; the list is not complete and does not necessarily represent the most effective interventions or model programs. Future research efforts should consider the components of culturally appropriate interventions (Marin 1993) and conduct proper process and outcome evaluations to provide a better understanding of the effectiveness of various targeted intervention approaches. Self-Help Approaches In the United States, most people who quit smok- ing do so without the help of formal programs, therapy, or nicotine replacement (Pierce et al. 1989; Fiore et al. 1990; Stotts et al. 1991). Members of racial/ethnic mi- nority groups, however, generally seem to have less success with self-help approaches than whites. For example, recent analyses of the 1986 Adult Use of Tobacco Survey showed that African Americans tended to be less successful at quitting smoking than whites (Fiore et al. 1990). A number of self-help cessation materials and programs have been developed for members of racial/ ethnic groups who want to quit on their own. Some of these materials and programs are adaptations of materials and programs previously developed for whites, usually by federal agencies such as the NCI or voluntary associations such as the ALA. Other pro- grams and materials have been developed specifically for members of these racial/ethnic groups; however, only a few studies report on the success of these pro- grams in helping members of racial/ethnic groups quit smoking. Smokers from racial/ethnic minority groups tend to favor relying on willpower alone to quit smoking. In a 12-state survey of 1,163 low- to middle-income African American insurance policyholders aged 21-60 years, Orleans and colleagues (1989) found that 89.3 percent of those who were former smokers reported relying primarily on willpower to quit smoking and 21.7 percent reported relying primarily on prayer and medi- tation. These former smokers also reported seldom Tobacco Use Among U.S. Racial/Ethnic Minority Groups using cessation aids of any type, including smoking ces- sation groups (0.4 percent) or books and guides (3.2 per- cent). Likewise, Hispanic smokers surveyed in San Francisco perceived willpower as the most effective technique for quitting smoking (Marin et al. 1990a). Rompa Con el Vicio: Una Guia Para Dejar de Fumar (Break the Habit: A Guide to Stop Smoking) The first self-help manual designed specifically for a U.S. racial/ethnic group was developed in 1988 in San Francisco as part of the Programa Latino Para Dejar de Fumar (Hispanic Program to Quit Smoking). The manual was distributed by the NCI under the name Guia Para Dejar de Fumar (Sabogal et al. 1988) and was based ona significant number of studies that identified group-specific attitudes, norms, expectan- cies, and values related to cigarette smoking and smok- ing cessation among Hispanics and whites (Marin et al. 1990a,b). Initial versions of the manual (hereafter referred to as the Guia) were thoroughly pretested to identify optimal formats, designs, photographs, type- faces, and publication format and size. In 1991, a re- vised version, El Fumar, Un Juego Peligroso: Guia Para Dejar de Fumar, was published and distributed in Cali- fornia with funding from Proposition 99 tax revenues earmarked for tobacco control activities (Programa Latino Para Dejar de Fumar de San Francisco 1992). In 1993, the NCI published and distributed nationally the third edition, Rompa Con el Vicio: Una Guta Para Dejar de Fumar (Programa Latino Para Dejar de Fumar de San Francisco 1993). The Guia is a 24-page, 812-by-11-inch, full-color booklet printed on glossy paper and featuring photographs of numerous Hispanic individuals dem- onstrating various cessation techniques as well as their testimonials about quitting smoking. All text is in broadcast Spanish—that is, conversational Spanish used by television broadcasters and easily understood by all Spanish-speaking Hispanics. The first section of the Guia describes the short- and long-term effects of cigarette smoking, including health problems among smokers and their relatives and the negative social ef- fects, such as bad breath and bad-smelling clothes. The second section presents possible methods a smoker can follow to quit, particularly approaches that Hispanic smokers perceive to be effective (Marin et al. 1990a). In addition, this section offers suggestions and verbal scripts for dealing with social pressures to smoke as well as for dealing with stress or depression. The third section presents strategies to follow after a relapse. The final section lists ways relatives and friends can moti- vate and support smokers who are trying to quit. Tobacco Control and Education Efforts 275 Surgeon General's Report The effectiveness of the first edition of the Guta was evaluated ina study of 431 Hispanic smokers who volunteered to participate after they picked up the manual at community stores or clinics in San Francisco (Pérez-Stable et al. 1991). More than 21 percent of the participants reported that they had quit smoking 2.5 months after reading the Guia; however, this percent- age declined to 18.6 percent after more than 8 months and to 13.7 percent after 14 months. Pathways to Freedom Pathways to Freedom: Winning the Fight Against Tobacco is a self-help manual targeting African Ameri- cans (Robinson et al. 1992). The manual and a com- panion 12-minute videotape were developed by the Fox Chase Cancer Center in Philadelphia with fund- ing from the NCI and assistance from a number of African American churches and other community groups. The manual was designed to emphasize quit- ting and community mobilization. In the early stages of the manual’s development, focus group participants and community leaders who were interviewed sug- gested that the manual should include graphics de- picting African Americans representing everyday people of all ages, should provide strong visuals illus- trating the health consequences of cigarette smoking, and should target smokers and nonsmokers. Persons in the interviews and focus groups also suggested that the manual and videotape include information on tar- geted advertising and that they identify the tobacco industry as the enemy. The resulting manual, Pathways to Freedom, is a 36-page, 8'2-by-11-inch, glossy publication with nu- merous color photographs and line drawings. The first part of the manual discusses the characteristics of ciga- rette smoking among African Americans; the tobacco industry’s influence on the community through adver- tising and promotional campaigns; and the effects of stressors, such as unemployment and racism, that pro- mote cigarette smoking behavior. The second part pro- vides instructions on how to quit smoking and help smokers quit, and the third part shows how communi- ties can combat tobacco dependence by working together. The manual addresses the tobacco-related concerns of African American smokers as well as other community members. It covers such topics as cigarette-smoking patterns among African Americans, culturally appropriate strategies to quit smoking, messages that nonsmoking friends and relatives can use to help smokers quit, and the role of prayer and faith in helping people quit and avoid a relapse. The manual was distributed nationally as part of the 276 Chapter 5 Legends campaign carried out in 1993 and 1994 by CDC and the National Medical Association (NMA). As part of an American Cancer Society Pathways to Freedom Community Demonstration Project launched in 1992, 285 African American smokers who received the manual agreed to participate in postintervention evalu- ations. About 71 percent of respondents read some or all of the guide, and 56 percent of those who did re- ported trying to quit smoking. Approximately 75 per- cent of those who tried to quit reported being able to stay off cigarettes for at least 24 hours. Most respon- dents reported that the manual was easy to read, that the graphics were appropriate, and that it was useful overall (C. Tracy Orleans et al., unpublished data). For more information on the evaluation project, see the discussion later in this chapter under “Community Approaches.” Lam Thé’ Nao Dé Bo Hit Thud’c? (How to Quit Smoking) Lam Thé’ Nao Dé Bé Hut Thud’c? is a self-help, smoking cessation manual developed in 1990 to help Vietnamese smokers quit (Vietnamese Community Health Promotion Project 1990). The 30-page, 84-by- 11-inch manual was developed as part of the Vietnam- ese Community Health Promotion Project based at the University of California, San Francisco. The manual’s format is similar to that of the Guéa and covers topics such as reasons for quitting smoking, the health ef- fects of cigarette smoking, approaches to quitting, di- etary concerns while quitting, and suggestions for avoiding and coping with relapse. The manual, avail- able through the California Department of Health Ser- vices’ Tobacco Control Section, features full-color photographs. It’s Your Life—It’s Our Future It’s Your Life—tit’s Our Future is a 28-page smoking cessation, self-help manual targeting American Indian adults (American Indian Cancer Control Project 1991). The manual was developed by the American Indian Cancer Control Project in Berkeley, California, with NCI funding. The two-color, spiral-bound manual is printed on high-quality paper. The first section of the manual provides motivational information on quitting smoking, including the negative effects of smoking and the positive effects of quitting. The second section presents techniques to help smokers reduce the num- ber of cigarettes smoked per day and offers sugges- tions on what to do before and after quitting and how to deal with withdrawal symptoms. The last section of the manual provides suggestions on how to stay free of cigarettes, such as how to deal with pressure to smoke from family and friends, how to control stress, and how not to gain weight. The contents of the manual, the presentation of the materials, and the approach to quitting that is promoted in this manual reflect the values of American Indians and their em- phasis on the family and the community. The manual is formatted for easy reading; for example, the sections have bulleted headings, and the text is printed in large type. American Indian artwork and pictures are fea- tured thruughout the manual. A 16-minute videotape was produced to further motivate smokers to quit and to remain smoke-free (American Indian Cancer Con- trol Project 1991). Victory Over Smoking—A Guide to Smoking Cessation for You and Your Family The Chinese Community Smoke-Free Project of the Chinese Hospital in San Francisco produced a 46- page smoking cessation manual entitled Victory Over Smoking (Chinese Community Smoke-Free Project 1992) with funding from California’s Proposition 99 tobacco tax initiative. The 84-by-11-inch manual is printed on glossy paper and has black-and-white photographs of Chinese Americans and line drawings. The manual is written in Chinese, and it describes a number of suggested attitudes and behaviors that are specific to and consonant with Chinese culture. For example, “living long enough to see one’s grandchil- dren grow” is presented as a possible benefit to quitting, and martial arts is suggested as a possible alternative to smoking. The five-part manual was pre- tested with focus groups of San Francisco’s Chinese American residents. The first section describes ciga- rette smoking among Chinese Americans, and the second section describes common health effects of cigarette smoking. The third section presents steps smokers can take as they prepare to quit. The next section describes alternatives to smoking as well as techniques and activities for remaining smoke-free. The final section provides suggestions on how to main- tain abstinence, such as through physical exercise, deep breathing exercises, and diet. Smoking: Facts and Quitting Tips Series In 1992, the NCI produced two small brochures, Smoking: Facts and Quitting Tips for Black Americans (NCI 1992b) and Smoking: Facts and Quitting Tips for Hispanics (NCI 1992a). Despite the difference in titles, the brochures are basically identical in content. The Tobacco Use Among U.S. Racial/Ethnic Minority Groups major difference between the brochures is that the one targeting Hispanics includes text in both English and Spanish. No information is yet available on their effectiveness. Hot Lines Hot lines for smokers who want to quit provide callers with short-term counseling over the telephone and self-help materials via the mail. Probably the most prominent of these hot lines is the Cancer Information Service (CIS), funded by the NCI, which provides ser- vices and information to persons wishing to quit smok- ing. The CIS provides services in English as well as in Spanish in states with high concentrations of Hispan- ics. The CIS also provides Spanish-speaking counse- lors and callers with Spanish-language materials, including copies of the Guia. Some states have implemented their own smok- ing cessation hot lines. For example, California re- cently funded a hot line to help smokers quit by providing short-term telephone counseling. Between August 1992 and December 1993, the California hot line received calls from more than 18,000 smokers (Pierce et al. 1994b). Most of these calls came from whites (56.8 percent), followed by Hispanics (20.6 per- cent), African Americans (16.1 percent), and Asian Americans (2.4 percent). These figures show that the proportion of African American and Hispanic smok- ers reached by the California hot line was similar to or higher than the proportion of African American smok- ers (7.0 percent) and Hispanic smokers (18.6 percent) in the state, whereas the proportion of Asian Ameri- can smokers reached by the hot line was lower than the proportion of Asian American smokers in Califor- nia (5.0 percent). Group Approaches In general, smoking cessation programs that are group-based have had difficulty attracting participants, and attrition rates are often high. The scant data avail- able for racial/ethnic groups indicate that similar diffi- culties may exist to an even greater extent. For example, Hispanics and Asian Americans rarely participate in smoking cessation groups (Pérez-Stable et al. 1993). The same is true for African Americans (Hymowitz et al. 1996). The possible reasons are varied (Glynn 1989; Stotts et al. 1991; Lichtenstein and Glasgow 1992): ¢ They may have difficulty accessing primary health care facilities that offer smoking cessation services (because of eligibility criteria or physical distance). Tobacco Control and Education Efforts 277 Surgeon General's Report ¢ They may be unable to afford the high cost of some group interventions. ¢ They may perceive such efforts to be inconvenient (e.g., requiring transportation and child care) and time consuming. ¢ They may prefer to deal with personal problems alone or in the family rather than to seek profes- sional or other help outside of the home. ¢ They may lack access to linguistically appropriate services. ¢ They may distrust researchers and health care pro- viders who are not members of their racial/ethnic groups or who are unaware of their culture and behavioral expectations and traditions. * Ifthey have physically demanding jobs or heavy caregiving responsibilities, they may be too ex- hausted to attend program meetings. The difficulty in obtaining enough individuals to participate in smoking cessation groups or even to continue their participation after a few initial sessions has been a problem for many ethnic smoking cessa- tion programs, including those targeting Hispanics in San Francisco, California (Pérez-Stable et al. 1993) and Queens, New York (Nevid and Javier 1992), African Americans in Atlanta, Georgia (Ahluwalia and McNagny 1993), and Chinese restaurant workers in Boston, Massachusetts (Betty Lee Hawks, personal communication, 1993). As a result, many programs have stopped using cessation groups as a possible in- tervention strategy and as a way to deliver informa- tion personally. As an alternative to group approaches, interve- nors in San Francisco began offering personal consulta- tion over the telephone and face-to-face (Pérez-Stable et al. 1993). Trained individuals provide information and support to smokers who want more information than is provided in a self-help manual. This approach (labeled consultas, or personal consultations), although demanding in terms of time and personnel, is consid- ered culturally appropriate among Hispanics, who tra- ditionally value personal attention. This alternative also allows telephone advisors to tailor the information to each person’s needs. Another alternative program, which provides individual counseling to Southeast Asian smokers in their homes rather than in clinics, has been well received in Long Beach, California (Mary Anne Foo, personal communication, 1994). 278 Chapter 5 Community Approaches Most community smoking cessation programs targeting members of racial/ethnic groups have been conducted in fairly large urban communities and have used self-help materials together with mass media and outreach workers. Ina recent overview of community- wide programs targeting cardiovascular disease, Winkleby (1994) noted the need to conduct focused studies with populations that have not been reached successfully in the past with large-scale projects, as is the case with members of the four racial/ethnic minority groups considered in this report. Because so many racial/ethnic groups place a high value on the family and on the authority of older relatives (Sabogal et al. 1987), some community pro- grams have employed family-centered interventions, working under the assumption that a smoker’s chil- dren and other relatives can effectively intervene and that parents can be a child’s best source of informa- tion regarding smoking-prevention programs. In Boston, the South Cove Community Health Center involved more than 350 Chinese elementary school children in a poster contest to depict the hazards of tobacco. Many of these posters depicted the father smoking at home and motivated children to discuss cigarette smoking in their homes (Esther Lee, personal communication, 1993). In a Vietnamese Saturday lan- guage school program in Sacramento, California, youths have been mobilized to carry antismoking messages to their families and to encourage them to avoid using tobacco (Debra Oto-Kent, personal com- munication, 1993). In another project, Asian American and Pacific Islander children were asked to compete in a “letter to my parents” writing contest, asking them not to smoke (Irene Linayao-Putman, personal commu- nication, 1993). Anecdotal information about this and similar programs indicates that the children enjoy these activities and that their parents are seldom discomforted by the letters, particularly when they perceive the pro- grams to be sanctioned by the school system. Never- theless, the usefulness of such an approach may be limited in families that maintain strict patriarchal or ma- triarchal structures in which children’s interventions may be perceived as a lack of respect toward adults or as a challenge to the parents’ authority. As mentioned previously, large-scale community projects generally have used multiple strategies and channels to disseminate smoking cessation informa- tion and to motivate smokers to quit. Asample of pro- grams targeting members of the four racial/ethnic groups is presented below. This listing represents the variety of community approaches developed to help racial/ethnic smokers quit but should not necessarily be perceived as a list of model programs. Stanford Five-City Multifactor Risk Reduction Project Researchers at Stanford University developed the Stanford Five-City Multifactor Risk Reduction Project to examine cardiovascular disease and related risk fac- tors over a nine-year period in five small communi- ties in northern California. The project was based on behavior-change models and social-learning theory (Farquhar et al. 1985, 1990) and used television, mass- distributed print media, direct mailings, contests, cor- respondence courses, and school-based programs for youths. In the communities with very high concen- trations of Hispanics, Spanish-language radio and newspaper columns were chosen as the primary meth- ods of disseminating information. The decline of smoking rates was 13 percent greater in the treatment cities than in the control cities (Farquhar et al. 1990). Although researchers observed no differences in the proportion of experimental or control respondents who reported ever receiving advice from physicians on quitting smoking, whites (51.1 percent) were much more likely to report having received this advice than Hispanics (32.6 percent) (Frank et al. 1991). Researchers found that the project was fairly suc- cessful in promoting the use of self-help smoking ces- sation materials among whites. A greater proportion of smokers in the experimental communities (22.1 per- cent) than in the control communities (15.0 percent) reported using smoking cessation materials in the 12 months before the interview (Jackson et al. 1991). In the experimental communities, Hispanics and whites did not differ in their reported use of materials to re- duce cardiovascular risk. When asked about their use of tobacco control materials, 31.0 percent of Hispanic women and no Hispanic men reported using smok- ing cessation print materials during the previous 12 months, compared with 21.3 percent of white women and 13.7 percent of white men. The project was less effective in promoting smok- ing cessation programs; no Hispanic smokers reported using such programs, compared with 6.3 percent of white smokers. More recent analyses of and comment onrisk-reduction data from this and other community- based interventions suggest that such interventions can achieve more positive results by being coupled with policy initiatives, developing more focused studies, and broadening evaluation concepts (Winkleby et al. 1992; Fortmann et al. 1993; Winkleby 1994). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Programa Latino Para Dejar de Fumar (Hispanic Program to Quit Smoking) The Programa Latino Para Dejar de Fumar was a community-based, culturally appropriate intervention designed specifically for Hispanic smokers in San Fran- cisco (Pérez-Stable et al. 1993; Marin and Pérez-Stable 1995). Funded by the NCI for 1985-1995, the program was operated jointly by the University of California, San Francisco, and the University of San Francisco. To motivate Hispanic smokers to quit and to inform them of strategies to stop smoking, the program used mass media (primarily radio and television public service announcements), outreach efforts, and distribution of the Guia. Program planners developed the various versions of the Guia, implemented the consultas ap- proach to deal with individual needs for counseling, and used a periodic raffle to reward individuals who quit smoking within a given period of time (Pérez- Stable et al. 1993). Intervention messages were based on research that identified the attitudes, norms, expect- ancies, and values of Hispanic smokers (Marin et al. 1990a,b). The strategies incorporate significant cultural values such as familialism (the normative and behav- ioral influence of relatives) (Sabogal et al. 1987) and simpatia (a social mandate for positive social relation- ships) (Triandis et al. 1984). For example, a key mes- sage of the program was that smokers should quit to protect the health of their children and to avoid set- ting a bad example for children. To incorporate simpatia into the program, planners developed inter- vention materials that emphasized the positive aspects of quitting and avoid confrontational approaches. This latter approach was similar to that used in materials developed for American Indians (American Indian Cancer Control Project 1991). The Programa Latino Para Dejar de Fumar has been evaluated through a number of cross-sectional and longitudinal surveys as well as through smaller scale studies that have examined the effectiveness of specific strategies (Marin et al. 1990c, 1994; Pérez-Stable et al. 1993; Marin and Pérez-Stable 1995). The program has significantly increased Hispanics’ knowledge about the dangers of smoking, awareness of the pro- gram, and participation in the program. Most impor- tant, the program has decreased the prevalence of smoking among Hispanics in San Francisco (Marin and Pérez-Stable 1995). These changes have been observed primarily among the less acculturated Hispanic smok- ers who make up the targeted group. For example, during the first year of the program, 24.9 percent of the less acculturated Hispanics in San Francisco re- ported awareness of the program; two years later, that Tobacco Control and Education Efforts 279 Surgeon General's Report proportion had increased to 48.5 percent (Marin et al. 1990b; Marin and Pérez-Stable 1995). During the first year in which the Guia was available, 23 percent of the less acculturated Hispanic women and 12 percent of the less acculturated Hispanic men in San Francisco reported having a copy. One year later, the propor- tion of the less acculturated Hispanics who reported having a copy of the Guia had increased to 37.7 per- cent of the women and 34.1 percent of the men. Si Puedo (Yes, I Can) Si Puedo was an eight-week smoking cessation program designed specifically for Hispanic smokers in a largely Hispanic area of Queens, New York. The program used the Guia and other print materials, weekly bilingual group meetings, regular telephone calls to offer support to participants, and videotaped vignettes in which Hispanic actors conveyed smok- ing cessation messages. Persons were recruited through mass media advertising, direct mailings to Hispanic physicians and clergy, and fliers posted throughout the community. Most participants were from South America (57 percent); the rest were from the Caribbean (25.4 percent) or Central America (9 percent). Some people participated in all aspects of the program, whereas others used only the self-help materials. Preliminary figures show that 55.6 percent of the participants who took part in all components of the Si Puedo smoking cessation program stopped smoking by the end of the program (Nevid and Javier 1992). In comparison, 21.7 percent of those who used only the self-help materials abstained from smoking. Pathways to Freedom Community Demonstration Project The American Cancer Society (ACS) used the Pathways to Freedom manual and videotape as part of a demonstration project to lower the prevalence of ciga- rette smoking among African Americans (Robinson et al. 1992; Robinson and Sutton, in press). During the first phase (1992-1993), the ACS provided funds to eight of its local units in Long Beach and central Los Angeles, California; Philadelphia, Pennsylvania; Dela- ware; the District of Columbia; Georgia; Kansas; and Texas. The ACS units developed programs to recruit African American smokers to quit smoking using the Pathways to Freedom materials and to expand the ACS’s outreach into African American communities. Many of them planned their projects to coincide with the Great American Smokeout (GAS). In the second phase of the project (1993-1994), the ACS provided funding to seven more local units 280 Chapter 5 in Contra Costa and San Diego Counties, California; Maryland; Nebraska; Chattanooga and Memphis, Ten- nessee; and Utah. Cessation activities expanded to include efforts to mobilize African American commu- nities and to identify more individuals and groups willing to become tobacco control advocates. The process evaluation of the first phase showed that the program was easier to implement in commu- nities with a previous history of community-based outreach efforts (Robert G. Robinson et al., unpub- lished data). Dissemination of the self-help manual was most difficult in multiethnic communities and areas of a city. Most ACS agencies used a variety of distribution channels, including churches, health care organizations, and recreation centers. The program helped the ACS to approach African Americans and to gain support from African American volunteers. Even though the project emphasized self-help approaches, several ACS units incorporated Pathways to Freedom materials into smoking cessation groups conducted in African American communities. The outcome evaluation of the first phase con- sisted of telephone interviews with 763 smokers who returned a screening postcard that was attached to each Pathways to Freedom manual. Respondents reported a favorable impression of the manual and a 10 percent quit rate at 30 days. In addition, smokers who viewed the Pathways to Freedom videotape were significantly more likely than others to accept and use the self-help materials as well as to move from precontemplation to contemplation in the process of changes involved in smoking cessation. Quit Today! A two-part study funded by the NCI will evalu- ate the effectiveness of the Pathways to Freedom manual and videotape when incorporated into a community- based campaign targeting adult African American smokers. In the first phase of the project, the Pathways to Freedom videotape will be distributed communitywide, and paid radio announcements will be aired, encouraging smokers to call the CIS for help. In the second phase of the project, callers to the CIS will be randomly selected to receive either the Path- ways to Freedom manual and smoking cessation coun- seling related to the manual or an NCI manual and standard CIS smoking cessation counseling. Results of this study should produce important information about the effectiveness of targeted self-help smoking cessation materials for African Americans combined with established services such as the CIS. Chicago Lung Association’s Multifaceted Smoking Cessation Intervention In 1985, Warnecke and colleagues (1991) launched a multifaceted smoking cessation interven- tion on behalf of the Chicago Lung Association. Like a number of programs, this intervention used materi- als originally produced for whites to target members of other racial/ethnic minority groups. The program used televised messages on techniques for quitting smoking and avoiding relapse as well as the ALA self- help manual and smoking cessation groups. More than 325,000 smokers in the targeted population viewed televised messages featuring role models who encour- aged them to obtain a self-help manual, Freedom from Smoking in 20 Days, by mail or at one of three loca- tions—a local hardware store, an HMO, or the Chi- cago Lung Association. A total of 9,182 smokers (23 percent of whom were African American) registered to participate in the study and were followed for 24 months. The results showed that African American and white smokers responded differently to various smoking cessation strategies. For example, African Americans were more likely than whites to report see- ing the televised messages on a daily basis and were more likely to recall the messages. However, African Americans were less likely than whites to attend smok- ing cessation groups. As an adjunct to the Chicago Lung Association’s program, Jason and colleagues (1988) studied the ef- fects of a television program in the West Garfield Park neighborhood of Chicago, where 86 percent of the resi- dents were African American. Before the television program aired, individuals who reported smoking were randomly assigned to a control group (91 per- cent were African American) or to an experimental group (96 percent were African American). Members of the control group viewed the program or read the self-help manual at their leisure, whereas members of the experimental group received motivational calls prompting them to view the television program and inviting them to attend smoking cessation meetings at a community health center three times during the 20-day program. Eight percent of the smokers in the experimental group reported quitting at the end of the program, compared with 1 percent of those in the con- trol group. After four months, 20 percent of the smok- ers in the experimental group had quit, compared with 9 percent of those in the control group. Chicago Community-Based Interventions for Low-Income African Americans In conjunction with the smoking cessation television program sponsored by the Chicago Lung Tobacco Use Among U.S. Racial/Ethnic Minority Groups Association, Lacey and colleagues (1991) designed community-based interventions for low-income African Americans living in four subsidized housing projects in Chicago. Residents were trained as lay health advisors to deliver smoking cessation messages to their neighbors. They made weekly home visits during the 20 days in which the television program was aired, and they used reminder cards to support the positive behaviors outlined in the program. A subsample of women in the housing projects watched the televised program and participated in six smok- ing cessation classes, which used a curriculum similar to the one presented in the television program. Health educators gave the women supplemental materials ap- propriate for them and tips on sources of social sup- port for smoking cessation. Classes were held in the housing projects. Of the 235 residents who preregis- tered for the smoking cessation intervention, 141 at- tended at least one class or accepted at least one home visit. Of the 56 women who attended at least one class session, 11 percent quit smoking. About one-half of the 174 residents who registered for the home visita- tion accepted such a visit, but none quit smoking. Focus groups conducted in conjunction with the in- tervention indicated that residents of the housing projects perceived that they were not vulnerable to the negative health consequences of smoking, that smok- ing helped them to cope with stress, and that they had few environmental supports for quitting smoking. Freedom from Smoking® for You and Your Family on TV/Por Su Salud y Su Familia Like the Chicago Lung Association's interven- tion, the Freedom from Smoking® for You and Your Family Project in California featured role models in televised pieces and distributed self-help materials. In 1991, project planners produced special editions of the ALA Freedom from Smoking® for You and Your Family self-help manual and the Guia and placed them ina newspaper insert that was distributed throughout seven English-language television markets—Eureka, Fresno, Los Angeles, Sacramento, Santa Barbara, San Diego, and the San Francisco Bay area—and four Spanish-language television markets—Fresno, Los Angeles, Sacramento, and the San Francisco Bay area. In addition, locally produced television pieces in both English and Spanish were shown for seven days as part of the daily news. These news pieces included interviews with Hispanic and white experts on tobacco-use control and with four local residents who had volunteered to use the self-help materials to quit smoking. The program reached nearly 1.2 million Tobacco Control and Education Efforts 281 Surgeon General's Report smokers (C. Anderson Johnson et al., unpublished data). The newspaper insert was most frequently read by white (22 percent), Asian American and Pacific Is- lander (18 percent), and African American (16 percent) smokers; smaller proportions of English-speaking His- panics (14 percent) and Spanish-speaking Hispanics (10 percent) read the insert. The television pieces were viewed most frequently by Spanish-speaking Hispanics (25 percent), followed by African Americans (14 per- cent), Asian Americans and Pacific Islanders (9 per- cent), whites (9 percent), and English-speaking Hispanics (9 percent). A year after the intervention, 3.1 percent of the people who had read the English- language newspaper insert and had viewed the tele- vision piece were former smokers; this was true among all racial/ethnic minority groups except Spanish- speaking Hispanics. In comparison, 1.5 percent of the people who did not participate in the program were former smokers. By itself, neither the English-language television piece nor the newspaper insert was effec- tive in promoting smoking cessation. Viewers of the Spanish-language television program, which used cul- turally appropriate materials, were more successful; 9 percent of viewers were former smokers at 12 months, compared with 2 percent of smokers who did not view the program. A Su Salud (To Your Health) A Su Salud was a mass media health promotion program conducted from 1985 through 1990 to reduce smoking among Mexican Americans residing along the U.S.-Mexico border in Eagle Pass and Del Rio, Texas (Ramirez and McAlister 1988; Amezcua et al. 1990). This mass media campaign used role models, an ex- tensive media campaign, community volunteers, and behavioral modeling techniques grounded in the prin- ciples of Bandura’s (1977) Social Learning Theory. It was modeled after a similar program implemented in North Karelia, Finland (McAlister et al. 1982; Puska et al. 1987). ASu Salud recruited individuals who wanted to quit smoking, organized focus groups to determine their needs and levels of awareness about tobacco use, and then featured community role models in a series of informational programs that were televised on local Spanish-language stations. The media messages were reinforced through a network of community vol- unteers who personally contacted the targeted popu- lation individually or in small groups. The volunteers delivered calendars with community events and sto- ries about the role models. The program also produced fotonovelas—pictorial stories, presented in a comic-book format, which depicted smoking cessation behaviors. 282 Chapter 5 The program resulted in a modest but notable increase in smoking cessation rates among community mem- bers. Out of the 17 percent of smokers who reported that they had quit smoking, 8 percent were verified (McAlister et al. 1992). University of North Carolina/North Carolina Mutual Quit for Life Guide The Quit for Life program used lay leaders to pro- mote smoking cessation messages. The Quit for Life Guide was based on the ALA’s Freedom from Smok- ing® for You and Your Family Project and targeted poli- cyholders of the predominantly African American North Carolina Mutual Life Insurance Company (Schoenbach et al. 1988). The program was novel in that it was delivered by the company’s life insurance sales agents, who discussed the health consequences of smoking with their customers and provided social sup- port for quitting and avoiding relapse (Orleans et al. 1989). The Quit for Life program was moderately ef- fective in promoting smoking cessation among the targeted low- to middle-income smokers. Over a two-year period, 2,042 smokers enrolled in the program. About 14.9 percent of the participants who received self-help materials, telephone counseling, and agent support quit smoking at 12 months, compared with 14.1 percent of the participants who received just self-help materials and agent support, and 12.3 percent of the control subjects, who received agent support only. Veri- fying these self-reported quit rates was impossible, how- ever, because few respondents agreed to provide saliva samples for a cotinine test, which would have provided biochemical verification (Schoenbach et al. 1988). In an eight-week follow-up study, the Quit for Life program targeted the insurance company’s cor- porate employees in a large urban center. Preliminary results regarding policyholders in one sales district and lasting eight weeks showed that 8 of the 126 African American smokers enrolled in the program (6 percent) were nonsmokers six months after enrollment (Sandra W. Headen et al., unpublished data). Legends Beginning in 1993, the NMA and CDC began co- sponsoring the Legends campaign. Legends is the only national-level, mass media motivational campaign di- rected at African Americans who want to quit smok- ing. The campaign consists primarily of public service television and radio announcements that use famous African American leaders and historic figures, such as Martin Luther King, Jr., and Malcolm X, to motivate smokers to quit. Individuals interested in quitting can request the Pathways to Freedom cessation guide by call- ing a toll-free telephone number; the Legends campaign generated more than 7,500 calls for the Pathways to Free- dom guide within the first 18 months. The NMA has supported the campaign at the local level by promot- ing media and community outreach activities, includ- ing billboard advertisements, in 14 NMA-sponsored “Healthy People 2000” cities across the country. Great American Smokeout GAS is an annual ACS-sponsored event that en- courages smokers to quit. The results of a 1991 Gallup poll indicated that smokers of various racial/ ethnic minority groups may respond favorably to the GAS (CDC 1992). Fewer African Americans and His- panics than whites reported being aware of the Smokeout. However, 25 percent of African Americans and Hispanics who were aware of the GAS reported participating in the project, and 14 percent of those who participated reported that they were not smok- ing cigarettes one to three days after the GAS (CDC 1992). The same poll estimated that during the 1991 GAS, approximately one-third of smokers in the United States participated, either by not smoking or by reduc- ing the number of cigarettes they smoked (CDC 1992). Lieberman Research Inc. (1993) found that 26 percent of smokers from racial/ethnic communities (i.e., African Americans, Asian Americans, Hispanics, and others) participated in the 1993 GAS, compared with only 19 percent of white smokers. In interviews conducted 1 to 10 days after the GAS, however, similar proportions of racial/ethnic group members (18 per- cent) and whites (17 percent) reported that they had quit or that they were smoking less than before the GAS. Suc Khoe La Vang! (Health is Gold!) From 1990 to 1992, Suc Khoe La Vang! (Health is Gold!), the Vietnamese Community Health Promotion Project, conducted media-led smoking reduction cam- paigns targeting Vietnamese men in San Francisco and Alameda Counties and in Santa Clara County, Cali- fornia (McPhee et al. 1993, 1995; Jenkins et al. 1997). Both interventions used materials that were produced in Vietnamese. The programs included antitobacco counteradvertising campaigns that used billboard, print, and television advertisements; published articles in Vietnamese-language newspapers; a videotape that aired on Vietnamese-language television stations; health education materials such as brochures, a quit kit, posters, bumper stickers, and a calendar; a Tobacco Use Among U.S. Racial/Ethnic Minority Groups continuing medical education course on smoking cessation counseling methods for Vietnamese physi- cians; and the distribution of printed “no smoking” signs and ordinances. Unlike the Santa Clara inter- vention, the San Francisco campaign was preceded by a 15-month pilot antitobacco media program and in- cluded a component for students and their families. The evaluation of the programs showed that the Santa Clara intervention did not influence cigarette smoking prevalence or recent quitting status (quitting during the prior two years) (McPhee et al. 1995). How- ever, a program effect was observed in the San Fran- cisco trial, such that the odds of being a smoker were significantly lower and the odds of quitting recently were significantly higher in San Francisco than in a comparison community (Jenkins et al. 1997). The au- thors explained the difference in two ways, the longer duration of exposure to the antitobacco campaign in San Francisco (39 months) than in Santa Clara (24 months) and the added school- and family-based component of the San Francisco campaign. Involvement of Health Care Providers A number of successful smoking cessation ap- proaches use health care providers, primarily physi- cians and dentists, to inform patients about the urgency of quitting smoking and to suggest quitting strategies (Health and Public Policy Committee 1986; Flay et al. 1992; Reid et al. 1992; NCI 1994; Fiore et al. 1996). Al- though this approach may be effective with members of the four racial/ethnic minority groups studied in this report—particularly those groups that exhibit high power distance (i.e., the respect for and deference to authority figures such as physicians, teachers, and older people) (Hofstede 1980)—a number of structural characteristics limit the usefulness of this approach. The most important limitation is that a large propor- tion of members of these racial/ethnic minority groups lack access to primary care providers. This problem has been widely documented among adult members of racial/ethnic groups (Aday et al. 1993) and adoles- cents (Lieu et al. 1993), such as among African Ameri- cans (Hopkins 1993) and Hispanics (Trevijio et al. 1991; GAO 1992; Pierce et al. 1994b). Data from the 1990 California Tobacco Survey showed that 46.9 percent of Hispanic smokers had not visited a physician in the 12 months before the survey, compared with 42.0 percent of Asian Ameri- cans and Pacific Islanders, 26.7 percent of African Americans, and 33.4 percent of whites (Burns and Pierce 1992). According to the 1992 NHIS data on Tobacco Control and Education Efforts 283 Surgeon General’s Report cigarette smokers, 37.6 percent of Hispanics, 26.1 per- cent of African Americans, and 29.2 percent of whites had not visited a physician during the year preceding the survey (Tomar et al. 1996). Data from the 1989 NHIS on the number of annual visits per person to the dentist showed that African American men (1.0 visits) and women (1.4 visits) made fewer visits than Hispanic men (1.5 visits) and women (1.7 visits) and white men (2.1 visits) and women (2.4 visits) (Bloom et al. 1992). Among smokers, national data collected in 1992 showed that 42.6 percent of African Americans, 39.3 percent of Hispanics, and 54.4 percent of whites had visited a dentist during the preceding year (Tomar et al. 1996). In addition, because many health care providers lack linguistic skills and training in cultural sensitivity, they tend to be ineffective advocates of smoking cessation among members of ethnic groups. Equally problematic is the fact that few physicians have the necessary training, feel qualified and supported, or express interest in recom- mending quitting to smokers (Kottke et al. 1994). Available data indicate that a large proportion of health care providers, primarily physicians, do not take advantage of office visits to encourage smokers to quit. In general, members of racial/ethnic groups are less likely than whites to receive advice on quit- ting smoking from their physicians, and they are even less likely to receive such advice from their dentists (e.g., Kogan et al. 1994; Winkleby et al. 1995; Hymowitz et al. 1996). According to data from the 1992-1993 CPS, about 42.4 percent of Hispanics and 45.4 percent of African Americans who had visited a physician dur- ing the previous year reported that within that year they had received a physician’s advice on quitting smoking, compared with 50.4 percent of whites (Table 5) (U.S. Bureau of the Census, NCI Tobacco Use Supple- ment, public use data tapes, 1992-1993). In general, women reported receiving a physician’s advice in greater proportions than men. When asked if they had ever received a physician’s advice on quitting smok- ing, only 39.8 percent of Hispanics said they had, com- pared with 47.2 percent of African Americans, 45.7 percent of Asian Americans and Pacific Islanders, 54.5 percent of American Indians and Alaska Natives, and 58.1 percent of whites. Results of the 1991 NHIS show that whereas 38.2 percent of whites reported receiv- ing advice to quit from a physician or other health care professional at any visit during the preceding 12 months (CDC 1993a), a percentage significantly higher than for Hispanics (30.6 percent), such advice was re- ceived by 34.4 percent of African Americans, 41.4 per- cent of American Indians and Alaska Natives, and 34.4 percent of Asian Americans and Pacific Islanders. According to the 1992 NHIS data on cigarette smok- 284 Chapter 5 ers who had visited a physician during the previous year, 55.5 percent of whites, 50.2 percent of African Americans, and 35.1 percent of Hispanics reported that a physician had advised them to quit smoking during the preceding year; among smokers who had visited a dentist during the previous year, 23.4 percent of whites, 26.3 percent of African Americans, and 27.2 percent of Hispanics reported that a dentist had advised them to quit during the preceding year (Tomar et al. 1996). Be- cause questions were worded differently about advice from health care providers on quitting smoking, esti- mates based on data from the 1991 NHIS and the 1992 NHIS are not directly comparable and cannot be in- terpreted as indicating a secular trend. Findings from other surveys show that among African Americans, pregnant women are the most likely to receive smok- ing cessation advice and services in a health care set- ting (O’Campo et al. 1992; Tiedje et al. 1992). Results from the 1992 California Tobacco Survey showed that among smokers who visited a physician in the previous year, 60.9 percent of Hispanics did not receive advice on quitting smoking, compared with 56.0 percent of African Americans and 47.8 percent of whites (Pierce et al. 1994b). These figures are comparable to those found in the Stanford Five-City Multifactor Risk Reduction Project, in which 63.4 percent of Hispanic smokers reported never being advised to quit smoking by their physician, compared with 45.9 percent of whites (Frank et al. 1991). These differences seem to be particularly notable among less educated Hispanics (Winkleby et al. 1995). Despite these limitations, the use of health care providers to promote smoking cessation can have promising results (Royce et al. 1995). The CDC has funded the design of protocols that will prescribe strat- egies health care providers can use when counseling patients in smoking cessation, using the Guia for His- panics and the Pathways to Freedom program for Afri- can Americans. In addition, the NCI has produced a number of publications reviewing this approach (NCI 1994) as well as training materials to teach health care personnel how to promote smoking cessation (Glynn and Manley 1992), and a recent publication has evalu- ated the effectiveness of various smoking cessation approaches available to primary care clinicians (Fiore et al. 1996). For You and Your Family The For You and Your Family project provides tobacco-use prevention services to racial/ethnic com- munities in health care settings. The project, sponsored by California’s Department of Health Services, was Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 5. Percentage of adult smokers who have received advice to quit smoking from either a medical doctor or a dentist, by race/ethnicity and gender, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +r % +cl % +Cl % +Cl % +CI Received advice from a medical doctor in past yeart Total 454 1.7 48.3 6.2 49.6 5.3 424 2.6 504 0.7 Men 42.5 2.6 45.2 9.0 50.1 6.8 396 3.6 488 1.0 Women 473 2.2 51.0 8.5 48.8 8.6 45.5 3.8 51.7 09 Received advice from a medical doctor ever | Total 47.2 14 54.5 5.3 45.7 41 39.8 2.0 58.1 0.6 Men 405 2.1 50.4 7.5 43.7 4.8 33.2 2.5 53.1 0.8 Women 53.1 2.0 58.6 7.4 50.4 7.9 50.0 3.3 63.1 0.8 Received advice from a dentist in past year? Total 20.6 18 - 21.1 6.3 30.5 5.0 226 2.6 19.6 0.6 Men 22.0 28 28.5 10.1 36.3 6.4 23.3 3.6 214 09 Women 19.6 23 14.2 7.5 19.3 7.3 21.7 3.7 18.0 08 Received advice from a dentist ever Total 14.7. 1.0 18.2 4.1 24.9 3.5 16.7. 16 18.6 04 Men 154 15 21.2 6.1 26.7 4.3 15.7 2.0 194 0.6 Women 141 14 15.2 54 20.8 6.1 18.2 2.6 178 0.6 *95% confidence interval. *Among persons who visited a medical doctor during the past year. +Among persons who visited a dentist during the past year. Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes, 1992-1993. developed recently by a team of California research- ers. This multicultural perinatal project seeks to re- duce cigarette smoking among pregnant women and to limit their exposure to ETS. The project includes a trainer’s guide, a health care provider’s guide, and targeted client education materials for African Americans, American Indians, Hispanics, and Asian Americans (i.e., Cambodians, Chinese, Koreans, and Laotians). Materials for clients differ in their content and format, depending on the racial/ethnic group be- ing targeted; the materials range from a brochure for African Americans entitled Hey, Girlfriend, Let's Talk About Smoking and You to a four-color magazine entitled La Mujer: La Familia y el Cigarrillo, which motivates Hispanic women to quit and provides sug- gestions and techniques for quitting and maintaining abstinence (Otero-Sabogal and Sabogal 1991). The importance of developing smoking cessation programs for pregnant women of various races/ ethnicities has been documented recently among American Indians (Bulterys et al. 1990). By using sta- tistical models with information on the health status of American Indians in the Aberdeen IHS area, Bulterys and colleagues found that by quitting smoking, Ameri- can Indian pregnant women would prevent 2.6 per- cent of all infant deaths, 3.7 percent of postneonatal deaths, and 1.2 percent of neonatal deaths. Tobacco Control and Education Efforts 285 Surgeon General’s Report American Indian Cancer Control Project The American Indian Cancer Control Project in California used self-help techniques, individual coun- seling, and cultural interventions to help American Indian smokers quit. Access to American Indians over the age of 18 years was facilitated through 18 north- ern California clinics owned and operated by Ameri- can Indians. Fourteen rural clinics located on or near reservations and four urban clinics participated in the project. The project has been testing a clinic-based, physician-initiated message enhanced by using Ameri- can Indian community health representatives who also provide outreach support. Recent data indicate that the clinic-based procedures were an acceptable and accessible means of reaching the American Indian population in northern California (Hodge et al. 1995, 1996). Evidence from this project suggests the need for culturally appropriate smoking cessation programs (Hodge et al. 1995). Involvement of Employers Employer-provided smoking cessation programs could help to lower the prevalence of smoking, yet very few individuals report having such programs avail- able to them. Data from the 1992-1993 CPS showed that 23.6 percent (95 percent confidence interval [CI] = + 0.9 percent) of African Americans reported having such services at work, compared with 22.4 per- cent (CI + 0.3 percent) of whites, 21.8 percent (CI + 1.8 percent) of Asian Americans and Pacific Islanders, 18.8 percent (CI + 3.6 percent) of American Indians and Alaska Natives, and 15.8 percent (CI + 0.9 percent) of Hispanics (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). Among smokers, 25.0 percent (CI + 1.8 percent) of Af- rican Americans, 19.7 percent (CI + 0.6 percent) of whites, 18.4 percent (CI + 4.1 percent) of Asian Ameri- cans and Pacific Islanders, 17.7 percent (CI + 5.8 per- cent) of American Indians and Alaska Natives, and 14.3 percent (CI + 1.9 percent) of Hispanics reported hav- ing access to employer-provided smoking cessation services (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). Involvement of Nontraditional Providers Community members who traditionally have not been perceived as health promoters also have become involved in tobacco control efforts. For example, Af- rican American religious leaders have been involved 286 Chapter 5 in tobacco control efforts as well as in other health promotion activities, such as the National High Blood Pressure Education Program (1992). These ministers and pastors carry great influence among African Americans and are responsible for dictating social and moral values. In addition, the church often has been central in mobilizing African American communities around issues of social justice. Examples of tobacco control efforts involving community members, includ- ing religious leaders, are presented in this section. Unfortunately, little evidence is available about the success or effectiveness of this type of intervenor. Heart, Body, and Soul is a church-based intervention in east Baltimore, Maryland, a predominantly (88 per- cent) African American community (Stillman et al. 1993; Voorhees et al. 1996). Focus groups conducted before the intervention revealed that African American smok- ers were knowledgeable of the health risks of smoking but knew few strategies beyond quitting cold turkey. The smokers perceived little support for quitting from their friends and family, with the exception of their children, who tended to be strong motivators to quit smoking. The smokers participating in the focus groups did not approve of nicotine replacement and viewed it as substituting one addiction for another. The intervention phase of the study emphasized the impor- tance of self-efficacy to promote behavior change and social actions that promote large, systemic, social changes as a strategy for affecting individual behav- ior. The project was carried out through a partnership with the local ministerial alliance. Of 130 churches in the area, 22 participated in the intervention. After introductory activities, which included a health fair, churches were randomly assigned to re- ceive either an intensive smoking cessation interven- tion or the minimal level of activity, which involved distribution of the ALA educational brochure Don’t Let Your Dreams Go Up in Smoke (ALA 1990a). Churches participating in the intervention received the same brochure but also were involved in the following ac- tivities: (1) training of smoking cessation specialists, who conducted weekly support groups with a spiri- tual overtone; (2) a kickoff service that included an inspirational sermon, distribution of One Day at a Time (a Scripture-based book of inspirational messages for smokers), and an inspirational audiocassette on quit- ting smoking; and (3) reinforcement of successful quit- ting through recognition during church services and the provision of certificates to volunteers participat- ing in the program. The program is now being extended to churches in 13 cities throughout the coun- try. As a result of this program, a number of African American clergy have formed a coalition, Black Clergy for Substance Abuse Prevention, to implement tobacco control programs and other substance abuse preven- tion efforts. The coalition is affiliated with the National Association of African Americans for Positive Imagery (NAAAPI). A recent study showed that church-based programs can be effective in moving in- dividuals along the continuum of change toward quitting smoking (Schorling et al. 1997). Innovative programs are also under way in California. In San Diego, the Union of Pan Asian Com- munities of San Diego County delivers antismoking messages through fortune cookies (Irene Linayao- Putman, personal communication, 1993). The St. Mary Medical Center and the United Cambodian Commu- nity, Inc., in Long Beach, California, developed audiocassettes that feature traditional Laotian and Cambodian music as well as antismoking messages. These audiocassettes are distributed through racial/ Tobacco Use Among ULS. Racial/Ethnic Minority Groups ethnic shops, health fairs, and other community events. Barbers and beauty parlor operators also have been trained to provide antismoking messages to their cli- ents in small community programs in California and other states. Although not all of these smoking cessation in- terventions are culturally appropriate, preliminary figures on the overall effectiveness of these massive interventions show that progress is being made in a number of areas. In California, for example, the over- all prevalence of smoking has declined, more smok- ing cessation services are available, people are more aware of the dangers of cigarette smoking, and in- creases in adolescent smoking appear to have stopped (Breslow and Johnson 1993; Pierce et al. 1994b; Elder et al. 1996). These results are true for members of racial/ethnic minority groups as well as for whites. Environmental Tobacco Smoke and Clean Indoor Air Policies A large number of individuals from racial/ ethnic groups work in the service industry (e.g., res- taurants) and in blue-collar jobs (e.g., factories and repair shops)—areas of employment where cigarette smoking usually is allowed. Thus, they are probably heavily exposed to ETS. Although the data are incomplete, a few studies indicate the extent to which nonsmokers, particularly those who are members of racial/ethnic groups, are exposed to ETS. Data from the 1993 California Tobacco Survey showed that 32.0 percent of nonsmoking His- panics were exposed to ETS at indoor workplaces, compared with 19.1 percent of African Americans and 19.0 percent of whites (Pierce et al. 1994b). Exposure to ETS at home is also a concern among members of racial/ethnic groups. Data from the 1992- 1993 CPS (Table 6) showed that a majority of Asian Americans and Pacific Islanders (60.6 percent) and His- panics (56.6 percent) did not allow cigarette smoking in their homes (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992— 1993). In comparison, smaller proportions of whites (41.3 percent), African Americans (38.9 percent), and American Indians and Alaska Natives (35.6 percent) reported that they prohibited smoking at home. Mi- nor gender differences were observed in the reporting of such restrictions. Other surveys indicate that expo- sure to tobacco smoke at home is a valid concern. An analysis of data from the Hispanic Health and Nutrition Examination Survey indicates that 31 to 62 percent of Mexican American nonsmoking women had household exposure to ETS (Pletsch 1994). In addi- tion, 22 to 59 percent of Puerto Rican women and 40 to 53 percent of Cuban American women had such ex- posure. In recent years, businesses and governments have adopted policies, laws, and ordinances that limit ciga- rette smoking in public places and in workplaces (Rigotti and Pashos 1991). The effects of these policies can be expected to benefit all U.S. residents, including members of racial/ethnic minority groups. In addi- tion, systemwide antismoking policies are being pro- mulgated. For example, no-smoking policies have been implemented in a number of federal workplaces, including IHS hospitals and clinics and Department of Defense installations. States have also been restrict- ing smoking at a fairly rapid pace by banning smok- ing on public transportation vehicles as well as in health care offices and facilities, airports, other public buildings, and elevators (O’Connor 1992). A number of states also restrict smoking in indoor cultural and recreational facilities, including libraries, museums, Tobacco Control and Education Efforts 287 Surgeon General's Report Table 6. Percentage of adults who reported that no one is allowed to smoke anywhere inside the home,” by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +CIt % +CI % +ClI % +CI % +l Overall Total 38.9 0.7 35.6 3.2 60.6 1.6 56.6 0.9 41.3 0.3 Men 37.7. 1.1 34.1 4.7 57.9 2.3 54.3 13 41.2 0.4 Women 39.6 0.9 36.8 4.3 63.2 2.2 58.5 1.2 41.4 0.4 Nonsmokers Total 499 0.9 53.4 4.2 67.3 1.6 64.5 1.0 51.7 0.3 Men 50.22 1.4 54.1 6.6 66.7 2.5 63.6 1.5 51.6 0.5 Women 498 1.1 52.9 5.5 67.8 2.2 65.2 1.2 51.8 0.4 Smokers Total 74 08 7.9 2.9 25.2 3.5 21.6 1.7 10.1 0.3 Men 9.2 12 8.7 4,2 28.5 4.4 26.7 2.4 12.4 0.5 Women 59 = =60.9 7.1 3.9 17.5 5.7 13.9 2.3 7.8 0.4 *Includes persons who reported having a rule that no one is allowed to smoke anywhere inside the home. *95% confidence interval. Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes, 1992-1993. theaters, galleries, shopping malls, sports arenas, and auditoriums. An ever-increasing number of states have restricted smoking in schools and on school grounds for students, school personnel, and other persons with access to the school; 27 states restrict smoking in child day-care centers. As of December 31, 1997, 41 states have some kind of restriction on smoking in govern- ment worksites, 21 have restrictions on smoking in pri- vate worksites, and 31 restrict smoking in restaurants (CDC, Office on Smoking and Health, State Tobacco Ac- tivities Tracking and Evaluation System, unpublished data). An increasing number of employers are also re- stricting cigarette smoking. In the 1992-1993 CPS, a substantial proportion of respondents reported that their employers had policies prohibiting cigarette smoking in work areas and in indoor public areas, such as lobbies, rest rooms, and lunch rooms. Gerlach and colleagues (1997) used data from the 1992-1993 NCI Tobacco Use Supplement to the CPS to document the prevalence and restrictiveness of workplace smoking policies reported by African Americans, Asian Ameri- cans and Pacific Islanders, Hispanics, and whites who were employed in indoor workplaces. Their data 288 Chapter 5 showed that 43.3 percent of African Americans, 51.4 percent of Asian Americans and Pacific Islanders, 45.1 percent of Hispanics, and 46.2 percent of whites worked for employers who provided smoke-free policies. In all four groups, women were more likely than men to be protected by smoke-free policies. Over- all, about one-third of employees worked in places that either had no policy on smoking or allowed smoking in private work areas. These minimal policies were reported by 33.9 percent of African Americans, 29.7 percent of Asian Americans and Pacific Islanders, 37.3 percent of Hispanics, and 35.6 percent of whites. This report did not present data on American Indians and Alaska Natives. Members of the racial/ethnic minority groups considered in this report tend to favor restrictions on tobacco smoking (see Royce et al. 1993 for data on African Americans). In the 1992-1993 CPS, Asian Americans and Pacific Islanders and Hispanics were generally more likely to support the total restriction of cigarette smoking in restaurants, hospitals, indoor workplaces, and indoor shopping malls (Table 7) (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). Smokers were more likely to agree with partial restrictions of cigarette smoking (limiting smoking to some areas within each enclosed space) than to support the total restriction of cigarette smoking in each of the public places included in the CPS. Results of an ABC News/The Washington Post poll conducted in February 1993 showed that larger proportions of African Americans (54.3 percent) and Hispanics (52.9 percent) favored banning smok- ing in public places, compared with whites (48.3 per- cent) (Roper Center for Public Opinion Research 1993). The same poll showed that fairly similar proportions of Hispanics (87.9 percent), African Americans (84.3 percent), and whites (84.1 percent) felt that ETS was a health risk. However, Hispanics (50.8 percent) and African Americans (44.2 percent) reported worrying more about ETS than whites (34.4 percent). Data from the 1992 California Tobacco Survey showed that members of racial/ethnic groups had lim- ited support for the complete ban of cigarette smok- ing in restaurants and in workplaces (Pierce et al. 1994a). For example, smoking bans in restaurants drew support from 53.5 percent of Hispanics, 41.9 percent of African Americans, 35.0 percent of Asian Americans and Pacific Islanders, and 34.7 percent of whites. The data on smoking bans in the workplace were similar. Hispanics (54.5 percent) were more likely to support banning cigarette smoking in the workplace than were Asian Americans and Pacific Islanders (43.5 percent), African Americans (40.2 percent), and whites (34.4 percent). More recently, findings from a 1993 survey indi- cate that residents of eight California cities (Fresno, Hercules, Indio, Los Angeles, Paradise, Sacramento, San Bernardino, and San Diego) significantly sup- ported strong ETS controls (Sherwood et al. 1994). In this 1993 survey, 78 percent of whites supported a com- plete ban on smoking in restaurants, compared with 91.4 percent of Asian Americans, 89.5 percent of His- panics, 82.6 percent of American Indians, and 82.5 per- cent of African Americans. In addition, 84.5 percent of whites strongly supported a complete ban on smok- ing in the workplace, compared with 93.5 percent of Asian Americans, 92.0 percent of Hispanics, 87.9 per- cent of African Americans, and 85.6 percent of Ameri- can Indians. The degree to which existing no-smoking poli- cies are enforced in racial/ethnic communities is unknown. In a recent survey of 39 American Indian tribes, Glasgow and colleagues (1995) found signifi- cant intertribal variations in the types of policies and places covered by clean indoor air policies. For Tobacco Use Among U.S. Racial/Ethnic Minority Groups example, 64 percent of the tribes reported having a no- smoking policy that designated tribal schools, council meeting areas, and private offices as nonsmoking ar- eas, but none banned smoking in bingo halls. Those tribes that received a specially developed policy work- book and direct consultation on ways to implement tobacco control policies were found to have adopted stringent policies within two years of having received the intervention materials (Lichtenstein et al. 1995). A recent observational study of American Indian facili- ties in California, Idaho, New Mexico, New York, Or- egon, and Washington found that smoking policies and practices varied considerably across settings (Hall et al. 1995). Tribal schools and Indian health care fa- cilities had the most restrictive policies. Tribal council meeting areas and private offices were less likely to be designated nonsmoking areas. No-smoking signs were observed most frequently in clinics (46 percent) and tribal offices (37 percent); no-smoking posters also were prominent in clinics (49 percent). Evidence of smok- ing (e.g., persons smoking, cigarette stubs, and ash- trays) was observed most frequently in tribal offices and cultural centers or community buildings (Hall et al. 1995). A number of programs have tried to promote clean indoor air policies and practices among mem- bers of the racial/ethnic minority groups included in this report, but little information is available on their effectiveness. For example, Asian Americans for Com- munity Involvement of Santa Clara County, based in San Jose, California, has targeted 400 Asian American restaurants and businesses to encourage them to have smoke-free areas. However, the researchers had diffi- culties assuring Asian American merchants that pro- viding smoke-free areas would be good for business (Jung 1993). Among American Indians, efforts have been made to help various tribes develop comprehensive smoke-free programs. For example, Glasgow and col- leagues (1995) worked with 39 tribes in Washington, Oregon, and Idaho to review, modify, and develop tobacco-use policies that would protect tribal mem- bers from ETS. Tobacco policy committees were es- tablished to advise tribes during the policymaking process. A tobacco policy workbook also was devel- oped to guide the tribes. Although tribal leaders expressed support for more stringent tobacco-use policies, changes in tobacco policies were not produced through the tobacco policy committees as the project had originally planned. Tobacco Contrel and Education Efforts 289 Surgeon General's Report Table 7. Percentage of adults who think that smoking should be allowed in some areas or not allowed at all in selected public locations,* by race/ethnicity and smoking status, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +CIt % +Cl % +Cl % x+CI % +cI Restaurants (allowed in some areas) Total 50.8 0.7 52.4 3.3 42.1 1.6 38.1 0.9 52.9 0.3 Nonsmokers 44.3 0.9 39.1 4.1 37.6 1.7 33.5 0.9 44.4 0.3 Smokers 69.5 1.3 73.4 4.7 66.4 3.9 58.8 2.1 78.6 0.5 Hospitals (allowed in some areas) Total 22.8 0.6 26.6 29 12.8 1.1 12.9 0.6 25.8 0.2 Nonsmokers 18.5 0.7 15.6 3.1 11.2 11 10.5 0.6 19.0 0.3 Smokers 35.0 14 44.3 5.3 21.7 3.4 234 1.8 46.3 0.6 Indoor work areas (allowed in some areas) Total 39.3 0.7 43.9 3.3 24.7 1.4 25.8 0.8 40.7 0.3 Nonsmokers 32.6 0.8 30.1 3.9 21.0 1.4 216 0.8 32.4 0.3 Smokers 58.5 14 65.8 5.0 44.3 4.1 44.1 2.1 65.5 0.5 Restaurants (not allowed) Total 45.3 0.7 42.5 3.3 54.5 1.6 58.8 0.9 43.1 0.3 Nonsmokers 53.0 0.9 58.7 4.2 59.8 1.7 64.2 1.0 52.9 0.3 Smokers 23.5 1.2 16.9 4.0 25.9 3.6 34.9 2.0 13.6 0.4 Hospitals (not allowed) Total 75.3 0.6 71.3 3.0 85.1 1.1 85.7 0.6 72.5 0.3 Nonsmokers 80.0 0.7 83.5 3.2 86.9 1.2 88.3 0.6 79.9 0.3 Smokers 62.0 1.4 51.8 5.3 75.8 3.5 74.2 18 50.6 0.6 Indoor work areas (not allowed) Total 57.0 0.7 52.2 3.3 71.8 1.4 70.9 0.8 55.7 0.3 Nonsmokers 64.6 0.8 68.3 4.0 75.8 15 75.7 0.9 65.1 0.3 Smokers 35.6 1.4 26.5 4.7 50.5 4.1 50.3 2.1 27.6 0.5 *In response to the question about each place, “Do you think that smoking should be allowed in all areas, in some areas, or not allowed at all?” *95% confidence interval. Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes, 1992-1993. 290 Chapter 5 Table 7. Continued Tobacco Use Among U.S. Racial/Ethnic Minority Groups African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +Cl % +cl % +Cl % H+CI % +Cl Bars and cocktail lounges (allowed in some areas) Total 44.2 0.7 36.6 3.2 45.7 1.6 38.8 0.9 440 03 Nonsmokers 44.2 0.9 38.5 4.1 46.4 1.8 39.0 1.0 44.9 0.3 Smokers 443 14 33.3 5.0 42.2 4.0 37.8 2.0 413 0.6 Indoor sporting events (allowed in some areas) Total 30.3 0.7 25.8 2.9 23.0 14 22.4 0.7 28.7 03 Nonsmokers 27.1 0.8 17.9 3.3 21.1 1.4 20.2 0.8 23.9 0.3 Smokers 39.2 14 38.2 5.2 32.8 3.8 31.9 19 43.3 0.6 Indoor shopping malls (allowed in some areas) Total 39.9 0.7 40.8 3.3 32.3 15 28.2 0.8 416 03 Nonsmokers 35.7 0.8 31.7 4.0 29.1 1.6 25.2 0.9 35.2 0.3 Smokers 51.7 14 54.8 5.3 49.5 4.1 4430 2.1 61.2 0.6 Bars and cocktail lounges (not allowed) Total 25.6 0.6 22.2 2.8 29.8 1.5 31.3 08 22.6 0.2 Nonsmokers 318 0.8 33.2 4.0 33.5 1.7 35.6 1.0 288 03 Smokers 8.1 0.8 5.2 2.4 9.6 2.4 12.1 14 4.0 0.2 Indoor sporting events (not allowed) Total 64.5 0.7 68.2 3.1 72.3 14 72.9 0.8 65.9 03 Nonsmokers 68.9 0.8 79.3 3.4 74.8 15 75.8 0.9 72.3 0.3 Smokers 52.5 14 50.5 5.3 59.5 4.0 60.0 2.0 46.5 0.6 Indoor shopping mails (not allowed) Total 544 0.7 52.3 3.3 62.7 1.6 67.2 0.8 52.6 0.3 Nonsmokers 59.7 08 65.2 4.0 66.5 1.7 70.8 0.9 60.6 0.3 Smokers 39.7 14 32.3 5.0 42.7 4.0 513 2.1 28.6 0.5 Tobacco Control and Education Efforts 291 Surgeon General's Report Economic Efforts to Reduce Tobacco Use Numerous efforts have been made to reduce the use of cigarettes through excise and sales taxes. Be- cause these taxes increase the price of cigarettes, higher tax rates generally curb the demand for cigarettes, and ultimately, tobacco consumption (Grossman 1989; Peterson et al. 1992; Keeler et al. 1993; Townsend et al. 1994). Peterson and colleagues (1992) evaluated the effects of state cigarette tax increases on cigarette sales in the 50 states from 1985 through 1988. The research- ers found that state cigarette tax increases were associated with an average decline in cigarette con- sumption of three cigarette packs per capita (a decline of about 2.4 percent). Likewise, larger tax increases were associated with larger declines in consumption. Ina recent study in Britain, Townsend and colleagues (1994) found that individuals of low-socioeconomic status were more responsive to changes in the price of cigarettes than those who were more affluent. As of June 30, 1996, all states, the District of Co- lumbia, and 451 localities currently impose taxes on cigarettes in addition to the federal tax (Tobacco Insti- tute 1997). As of December 31, 1997, state taxes ranged from a low of 2.5 cents in Virginia to a high of $1 in Alaska; the average state tax was 37.76 cents per pack (CDC, Office on Smoking and Health, State Tobacco Activities Tracking and Evaluation System, unpub- lished data). Members of some racial/ethnic minority groups have supported increases in taxes for tobacco prod- ucts. In a 1990 survey of California smokers, 29.1 per- cent of African American smokers and 34.5 percent of Hispanic smokers reported that they would support a cigarette tax increase (Burns and Pierce 1992). Amuch smaller proportion of whites who smoke (20.0 percent) supported such an increase. Recently, larger propor- tions of California adults have supported an increase in cigarette taxes. The 1992 California Tobacco Sur- vey among both smokers and nonsmokers found that cigarette tax increases were supported by 60.2 percent of Asian Americans and Pacific Islanders, 50.4 percent of Hispanics, 49.5 percent of African Americans, and 49.8 percent of whites (Pierce et al. 1994a). Further- more, a 1993 nationwide survey conducted for the ACS found that Hispanics (71 percent) and African Ameri- cans (63 percent) supported an increase of $2 per pack to pay for a national health insurance program (Marttila & Kiley, Inc. 1993). These proportions were fairly similar to those found among whites (66 percent). 292 Chapter 5 Although tobacco taxes are effective in discour- aging smoking, some people consider increases in excise taxes to be regressive because the poorer members of society pay a higher proportion of their income in taxes. Wasserman (1992), for example, states: With respect to excise tax increases, however, we must be mindful of the distributional conse- quences of higher taxes. More precisely, because low-income smokers do not appear to be any more responsive to higher cigarette prices than high- income smokers, higher excise taxes will result in disproportionate economic harm, and, in some cases, could lead poorer smokers to forgo food, shelter, and needed health care to fulfill the per- sistent and pernicious demands of their smoking habits. As a result, higher cigarette taxes should be accompanied by measures to compensate the poor for the larger burden that they will necessar- ily have to bear. For example, federal and state income tax structures could be modified to facili- tate such compensation (p. 20). A 1990 federal government report supported this argument by presenting data from the 1984-1985 Consumer Expenditure Survey Interview showing that families in the lowest income quintile spent 4 percent of their posttax income on tobacco products, compared with families in the highest quintile, who spent 0.5 percent of their posttax income on tobacco products (U.S. Congressional Budget Office 1990). On the other hand, some argue that the hardship of increased taxes on the poor is outweighed by the fact that smoking- related health costs and suffering decline among persons who smoke fewer cigarettes or stop smoking because of the higher taxes on tobacco. A group of economists meeting in 1995 concluded that additional research on costs is needed before an optimal cigarette excise tax from an economic perspective can be deter- mined (Warner et al. 1995). These economists agreed that the strongest argument currently for increasing cigarette taxes is the protection of children. The actual effects of excise tax initiatives on mem- bers of racial/ethnic minority groups are difficult to ascertain. Nevertheless, reductions in the consumption of tobacco products resulting from increases in excise taxes should ultimately benefit members of U.S. racial/ethnic groups by lowering their prevalence of cigarette smoking and by limiting or lowering their exposure to ETS. California’s experience after increas- ing the tax on cigarettes shows that a number of community-based projects, school-based interventions, and research activities, which directly benefit members of the racial/ethnic groups and could not have been funded from other sources of tax revenue, can be Tobacco Use Among ULS. Racial/Ethnic Minority Groups funded through the revenue generated by the increased taxes (Breslow and Johnson 1993). In addition, given the need to help community-based programs and or- ganizations rely less on tobacco industry support (Satcher and Robinson 1994), earmarked tax revenues may prove to be a viable alternative. Efforts to Control Tobacco Advertising and Promotion Tobacco products are heavily advertised in racial/ethnic publications and in racial/ethnic com- munities. Efforts to restrict the effects of advertising and promotion of tobacco products in racial/ethnic communities have been limited by various factors, including the communities’ reliance on the tobacco industry (see Chapter 4), difficulties in mobilizing com- munities that are faced with problems perceived to be in need of more immediate attention (e.g., affordable housing, unemployment, unequal education, and racial/ethnic minority discrimination), the lack of trained community leaders interested in health issues, and possibly the lack of infrastructure for tobacco pre- vention and control initiatives in racial/ethnic com- munities (Robinson et al. 1995). As a result, persons residing in racial/ethnic communities are continually exposed to the advertising and promotion of tobacco products. A recent study in Los Angeles County, for example, examined the risk of exposure to outdoor advertising of cigarettes among residents of various communities (Ewert and Alleyne 1992). The results suggest that persons residing in the city of Los Angeles were more likely to be exposed to cigarette and alcohol billboard advertisements than residents of nearby sub- urbs. Cigarettes were advertised on 59 of the 299 bill- boards (19.7 percent) surveyed on 46.2 miles of streets. The number of cigarette advertisements was 4.6 times greater in the city of Los Angeles than in its suburbs. Members of some racial /ethnic minority groups tend to be more likely than whites to support a ban on tobacco product advertisements (Table 8). Data from the 1992-1993 CPS showed that 37.5 percent of whites supported a ban on advertising tobacco products, com- pared with 44.7 percent of Hispanics, 39.5 percent of Asian Americans and Pacific Islanders, and 38.3 per- cent of African Americans (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). In each racial/ethnic group, women and nonsmokers were more supportive of a total ban on tobacco advertising than were men and smokers. The 1992 California Tobacco Survey found that adult Cali- fornians supported the banning of such advertising in newspapers and magazines as well as on billboards (Table 9) (Pierce et al. 1994a). The same survey also showed support for banning tobacco companies from sponsoring cultural events. Hispanics tend to show the greatest level of support for these measures, whereas whites support them the least. Data from the 1992-1993 CPS also showed that fairly large percent- ages of racial/ethnic group members would support a ban on the free distribution of tobacco samples (Table 10) (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). Hispanics (59.4 percent) and Asian Americans and Pacific Islanders (57.5 percent) were the most likely respondents to state that they supported such a ban. In all groups, women and nonsmokers were more likely than men and smokers to favor the ban. The 1994 RWJF Youth Access Survey (Table 4) found varying support for restricting or banning dif- ferent types of tobacco advertising. Hispanics and African Americans were more likely than whites to support such proposals (Nancy Kaufman et al., un- published data). Hispanics were more supportive of bans on billboard, newspaper, and magazine adver- tising than were African Americans and whites. Re- quiring plain packaging of tobacco products (brand name and warning label in black letters on white background) was supported substantially more by Hispanics than by African Americans or whites. In recent years, the tobacco industry has shifted expenditures for advertising to promotional market- ing, with 89 percent of 1995 expenditures devoted to nonadvertising promotions (Federal Trade Commis- sion 1997). The RWJF Youth Access Survey found that broad-based support exists for eliminating coupon Tobacco Control and Education Efforts 293 Surgeon General's Report Table 8. Percentage of adults who think that the advertising of tobacco products should be always allowed or not allowed at all,* by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +CIt % +c] % +cl % +ClI % 25 cigarettes per day, overall and by gender, age, and education, National Health interview Surveys, United States, 1978-1995 aggregate data 68 Percentage of adult Hispanic ever smokers who have quit, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 70 Percentage of Hispanic women of . reproductive age who reported being current cigarette smokers, overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 71 Percentage of self-reported cigarette brand use among adult current cigarette smokers, overall and by race/ethnicity and gender, National Health Interview Surveys (NHIS) 1978-1980 combined, Adult Use of Tobacco Survey (AUTS) 1986, and NHIS 1987 80 Percentage of self-reported cigarette brand use among adolescent current cigarette smokers, by race/ethnicity, Teenage Attitudes and Practices Survey (TAPS), 1989 and 1993 82 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 34. Table 35. Table 36. Table 37. Table 38. Table 39. Table 40. Table 41. Relationship between smoking status and race/ethnicity among adults, before and after controlling for education, National Health Interview Surveys, United States, 1987, 1988, 1990, and 1991 aggregate data 84 Percentage of all adults and nonsmokers who reported levels of exposure to environmental tobacco smoke in the home, by race/ethnicity and gender, National Health Interview Surveys, United States, 1991-1993 aggregate data 87 , Age-adjusted prevalence of current cigarette smoking among adults, overall and by race/ethnicity and gender, National Health Interview Surveys, United States, 1994 and 1995 aggregate data 88 Cigarette smoking status and number of ’ cigarettes smoked per day among adults, overall and by race/ethnicity and gender, National Health Interview Surveys, United States, 1987; 1988, 1990, and 1991 aggregate data 90 Percentage of adults who reported using cigars, pipes, chewing tobacco, snuff, or any form of tobacco, overall and by race/ethnicity and gender, National Health Interview Surveys, United States, 1987 and 1991 aggregate data 92 Percentage of white adults who reported being current cigarette smokers, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 98 Percentage of adult white smokers who reported smoking <1 5, 15-24, and 225 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 100 Percentage of adult white ever smokers who have quit, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 104 List of Tables and Figures 313 Surgeon General's Report Table 42. Table 43. Table 44. Table 45. Table 46. Table 47. Table 48. Table 49. Table 50. Percentage of white women of reproduc- tive age who reported being current cigarette smokers, overall and by education, National Health Interview Surveys, United States, 1965-1995 106 Percentage of white adults who reported being current cigarette smokers, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 107 Percentage of adult white smokers who reported smoking <15, 15-24, 225 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 108 Percentage of adult white ever smokers who have quit, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 110 Percentage of white women of reproduc- tive age who reported being current cigarette smokers, overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 111 Percentage of adult African Americans who reported being current cigarette smokers, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 112 Percentage of adult African American smokers who reported smoking <15, 15-24, or 225 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 114 Percentage of adult African American ever smokers who have quit, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 118 Percentage of African American women of reproductive age who reported being current cigarette smokers, overall and by education, National Health Interview Surveys, United States, 1965-1995 120 314 List of Tables and Figures Table 51. Table 52. Figure 1. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Figure 7. Figure 8. Sample sizes for birth cohorts, by gender, race/ethnicity, and education, National Health Interview Surveys, 1978-1980, 1987 and 1988 combined, and Hispanic Health and Nutrition Examination Survey, 1982-1984 122 Comparison of current smoking preva- lence between reconstructed estimates from National Health Interview Surveys (NHISs), 1987 and 1988 combined, NHIS cross-sectional survey estimates, and Gallup poll estimates 124 Trends in the prevalence of cigarette smoking among African American and white men and women, National Health Interview Surveys, United States, 1965-1995 23 Trends in daily smoking among African American and white high school seniors, by gender, United States, 1977-1996 30 Trends in daily smoking among African American, Hispanic, and white high school seniors, United States, 1977-1996 31 Trends in smoking among African Americans and whites aged 20-34 years, United States, 1978-1995 35 Use of cigarettes and alcohol among African American and white high school seniors, United States, 1976-1979 and 1990-1994 38 Use of cigarettes and illicit drugs among African American and white high school seniors, United States, 1976-1979 and 1990-1994 39 Cigarette smoking prevalence among successive birth cohorts of African American men, by education, National Health Interview Surveys, United States, 1978-1980, 1987, and 1988 75 Cigarette smoking prevalence among successive birth cohorts of African American women, by education, Na- tional Health Interview Surveys, United States, 1978-1980, 1987, and 1988 76 Figure 9. Figure 10. Figure 11. Figure 12. Figure 13. Figure 14. Figure 15. Figure 16. Cigarette smoking prevalence among successive birth cohorts of Hispanic men, by education, Hispanic Health and Nutrition Examination Survey, 1982- 1984 77 Cigarette smoking prevalence among successive birth cohorts of Hispanic women, by education, Hispanic Health and Nutrition Examination Survey, 1982-1984 77 Reconstructed prevalence of smoking among African American adults aged 20-29 years, by gender and education, National Health Interview Surveys, United States, 1910-1988 78 Reconstructed prevalence of smoking among Hispanic adults aged 20-29 years, by gender and education, His- panic Health and Nutrition Examination Surveys, 1920-1984 79 Trends in the age-adjusted prevalence of current cigarette smoking among African American, American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white adults, National Health Interview Surveys, United States, 1978-1995 aggregate data 88 Trends in the age-adjusted prevalence of current cigarette smoking among African American, American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white men, National Health Interview Surveys, United States, 1978-1995 aggregate data 89 Trends in the age-adjusted prevalence of current cigarette smoking among African American, American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white women, National Health Interview Surveys, United States, 1978-1995 aggregate data 89 Comparison of smoking prevalence estimates from selected U.S. surveys, 1910-1991 123 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Chapter 3 Health Consequences of Tobacco Use Among Four Racial/Ethnic Minority Groups Table 1. Death rates per 100,000 U.S. residents for malignant diseases of the respiratory system, by race/ethnicity and gender, United States, 1950-1995, selected years 139 Table 2. Age-adjusted death rates for selected smoking-related causes of death, by race/ethnicity and gender, United States, 1992-1994 141 Table 3. Death rates for lung cancer among American Indians and Alaska Natives, by Indian Health Service (IHS) area, 1984-1988 146 Table 4. Age-adjusted death rates for selected smoking-related causes of death among Mexican Americans, Puerto Rican Americans, and Cuban Americans, United States, 1992-1994 148 Table 5. | Odds ratios for the risk of lung cancer, by gender, race/ethnicity, and smoking status, case-control study, New Mexico, 1980-1982 149 Table 6. Age-adjusted incidence and death rates for selected smoking-related cancers, by race/ethnicity and gender, National Cancer Institute’s Surveillance, Epidemi- ology, and End Results (SEER) Program, 1988-1992 150 Table 7. Age-adjusted cancer death rates among American Indians and Alaska Natives at all 12 Indian Health Service areas, United States, 1984-1988 155 Table 8. Odds ratios and 95% confidence inter- vals for the risk of oral cancer associated with cigarette smoking, by race/ ethnicity and smoking status, 1984— 1985 156 Table 9. Odds ratios for the risk of urinary bladder cancer associated with smoking, by gender, race/ethnicity, and smoking status 157 Table 10. Rates of selected infant outcomes, by mother’s race/ethnicity, United States 168 List of Tables and Figures 315 Surgeon General's Report Table 11. Table 12. Table 13. Table 14. Table 15. Table 16. Table 17. Table 18. Figure 1. Figure 2. Figure 3. Risk of sudden infant death syndrome associated with smoking, by race/ ethnicity, selected studies, United States 170 Exposure to household smoke among children 5 years of age and younger and percentage distribution, by level of exposure since birth and selected characteristics, United States, 1988 173 Criteria for drug dependence 176 American Psychiatric Association diagnostic criteria for substance dependence 177 Human pharmacology of nicotine 178 Incidence of nicotine withdrawal symptoms, United States 179 Percentage of adult smokers who reported that they smoked their first cigarette within 10 minutes and within 30 minutes of awakening, by race/ ethnicity and number of cigarettes smoked per day, National Health Interview Survey, United States, 1987 182 Percentage of men and women who considered smoking a habit or addiction, overall and by smoking status, Current Population Survey, United States, 1992- 1993 184 Incidence of cancer of the lung and bronchus, by race/ethnicity and gender, National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program, 1973-1994 138 Age-adjusted lung cancer death rates among American Indian and Alaska Native men in selected states compared with rates among all U.S. men, 1968-1987 144 Age-adjusted lung cancer death rates among American Indian and Alaska Native women in selected states com- pared with rates among all U.S. women, 1968-1987 145 316 List of Tables and Figures Figure 4. SEER cancer incidence and U.S. death rates, 1988-1992, ratio of African American rate to white rate for all ages, by cancer site 154 Figure 5. Serum cotinine levels by number of cigarettes smoked daily for African Americans, Mexican Americans, and whites, National Health and Nutrition Examination Survey, United States, 1988-1991 180 Chapter 4 Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups Table 1. High school seniors’ perceptions about the risks associated with cigarette smoking, Monitoring the Future sur- veys, United States, 1980-1989 230 Chapter 5 Tobacco Control and Education Efforts Among Members of Four Racial/Ethnic Minority Groups Table 1. Percentage of adult smokers who would like to stop smoking, by race/ethnicity and gender, National Health Interview Survey, United States, 1993 261 Table 2. Adults’ beliefs about the health effects of smoking, by race/ethnicity, gender, and smoking status, National Health Inter- view Survey, United States, 1992 264 Table 3. Adults’ beliefs about minors’ ease in purchasing cigarettes and other tobacco products, by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993 267 Table 4. Public support for and beliefs about policies regarding tobacco access and marketing, by selected characteristics, Robert Wood Johnson Foundation Youth Access Survey, 1994 270 Table 5. Percentage of adult smokers who have received advice to quit smoking from either a medical doctor or a dentist, by race/ethnicity and gender, Current Population Survey, United States, 1992- 1993 285 Table 6. Table 7. Table 8. Percentage of adults who reported that no one is allowed to smoke anywhere inside the home, by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 1992— 1993 288 Percentage of adults who think that smoking should be allowed in some areas or not allowed at all in selected public locations, by race/ethnicity and smoking status, Current Population Survey, United States, 1992-1993 290 Percentage of adults who think that the advertising of tobacco products should be always allowed or not allowed at all, by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993 294 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 9. Table 10. Table 11. Figure 1. Percentage of Californians who support curtailment of tobacco advertising and promotion efforts, by race/ethnicity, 1992 295 Percentage of adults who think that giving away free tobacco samples should be always allowed or not al- lowed at all, by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993 296 Public beliefs about and support for policies related to nicotine and tobacco product regulation, Robert Wood Johnson Foundation Youth Access Survey, 1994 298 Billboard used by the California Depart- ment of Health Services in targeting Hispanics to quit smoking 261 List of Tables and Figures 317 . Tobacco Use Among U.S. Racial/Ethnic Minority Groups Glossary ACS American Cancer Society DSM-IV™ Diagnostic and Statistical Manual oo, . of Mental Disorders, Fourth Edition AIDS acquired immunodeficiency syndrome ETS environmental tobacco smoke ALA American Lung Association FAO Food and Agriculture Organization . . . of the United Nations APA American Psychiatric Association . . FDA Food and Drug Administration ASSIST American Stop Smoking Intervention Study FEV, forced expiratory volume after one second AUTS Adult Use of Tobacco Survey . . . FTC Federal Trade Commission BRFSS Behavioral Risk Factor Surveillance System G6PD glucose-6-phosphate dehydrogenase CARDIA Coronary Artery Risk Development GAO U.S. General Accounting Office in (Young) Adults . GAS Great American Smokeout CDC Centers for Disease Control and . . , Prevention HHANES Hispanic Health and Nutrition Examination Survey CES-D Center for Epidemiological . , Studies Depression Scale HMO health maintenance organization CHD coronary heart disease HRSA Health Resources and Services Administration cI confidence interval . —_ ICD Manual of the International Statistical CIS Cancer Information Service Classification of Diseases, Injuries and : . ; Causes of Death COMMIT Community Intervention Trial for Smoking Cessation ICD-9 International Classification of Diseases, . . Ninth Revision COPD chronic obstructive pulmonary disease IHD ischemic heart disease COSSMHO __ National Coalition of Hispanic IHS Indian Health Service Health and Human Services . . Organizations LBW low birth weight COST Churches Organized to Stop Tobacco LST Life Skills Training CPS Current Population Survey MTF Monitoring the Future surveys CPS-I Cancer Prevention Study I MTV Music Television DNA deoxyribonucleic acid NAAAPI National Association of African Americans for Positive Imagery DOC Doctors Ought to Care . — NAACP National Association for the DSM-HT™ Diagnostic and Statistical Manual Advancement of Colored People of Mental Disorders, Third Edition . . . NBLIC National Black Leadership Initiative on Cancer Glossary 319 Surgeon General's Report NCHS NCI NHANES I NHANES II NHANES III NHEFS NHIS NHSDA NIDA NMA NMES NMIHS OR PUSH RFLP RWJE 320 Glossary National Center for Health Statistics National Cancer Institute National Health and Nutrition Examination Survey I National Health and Nutrition Examination Survey II National Health and Nutrition Examination Survey II] NHANES I Epidemiologic Follow-up Study National Health Interview Survey National Household Survey on Drug Abuse National Institute on Drug Abuse National Medical Association National Mortality Followback Survey National Maternal and Infant Health Survey odds ratio People United to Save Humanity restriction fragment length polymorphism The Robert Wood Johnson Foundation SAIAN SEER SESUDAAN SHOUT SIDS SMART STAT SUDAAN TAPS TAPS-II UNCF USDHEW USDHHS YRBS Survey of American Indians and Alaska Natives Surveillance, Epidemiology, and End Results Program Standard Errors Program for Computing of Standardized Rates from Sample Survey Data Students Helping Others Understand Tobacco sudden infant death syndrome Self-Management and Resistance Training Stop Teenage Addiction to Tobacco Professional Software for Survey Data Analysis Teenage Attitudes and Practices Survey Teenage Attitudes and Practices Survey II United Negro College Fund U.S. Department of Health, Education, and Welfare U.S. Department of Health and Human Services Youth Risk Behavior Survey Index A ASuSalud 282 Absorption of nicotine. See Nicotine pharmacology Abstinent smokers, effects of nicotine administration 177 Academic performance and smoking initiation 36, 228 , Access of minors to tobacco products ease of access 266-269 enforcement of legislation 266, 268 over-the-counter sales of cigarettes 266, 269 perception of ease by adult members of ethnic groups 267 vending machines 268-269 Acculturation effectiveness of warning labels 299 factor in coronary heart disease incidence 163 Hispanics 228, 237 initiation of tobacco use 234-235 smoking cessation 235, 237 smoking prevalence 61, 65, 235 tobacco advertising and promotion 227, 229 Actors, appearance in tobaccoads 243 Addiction, nicotine. See Nicotine dependence and addiction Adolescent African American mothers and use of tobacco 27-28 Adolescent Health Survey 49 Adolescents cigarette brand preference 80-83 risk factors to predict cigarette smoking 228-229, 230-231 smoking initiation 40, 225-229 smoking prevalence 28-44 use of smokeless tobacco 44, 49-50, 174-175 See also Youth Adult literacy programs tobacco industry support 217 Adult Use of Tobacco Survey (AUTS) 21, 79, 80, 96 (description) Adults, psychosocial factors of use 225-238 Advertising, tobacco products bans, ethnic group support 293-297 billboards 215, 221, 222, 244, 293 convenience stores 222 endorsements 242 ethnic targeting 13, 220-224, 240-244 ethnicity of models 240-242 immigrants 223, 241 Tobacco Use Among ULS. Racial/Ethnic Minority Groups impact on youth 220 in-store advertising displays 222 print advertisements 214-215, 221 revenues 214-215 role models 242 stimulation of cigarette consumption 207, 220-223 targeting youth 207 television ban 214 African American Tobacco Control Network of California 297 Age airflow obstruction and smoking, Japanese men 159 and stroke incidence, Asian Americans 165 at smoking onset 36 differences in smoking prevalence, by ethnicity African Americans 22-23 American Indians and Alaska Natives 46 Asian Americans and Pacific Islanders 61-63 Hispanics 66-67 Aggregation problems in data collection. See Data collection and analysis Alameda County Low Birth Weight Study Group 168 Alcohol use and smoking among youth 37-38 Alpha Kappa Alpha Sorority 216 American Cancer Society (ACS) 280, 292, 295 American Health Foundation study 156 American Indian Cancer Control Project of California 276, 286 American Lung Association (ALA) 274, 275, 295 American Psychiatric Association (APA) diagnostic criteria for drug dependence 177 American Stop Smoking Intervention Study (ASSIST) 269 Anemia and smoking, effects on birth weight 171 Angina. See also Coronary heart disease (CHD) incidence and mortality Antismoking campaigns. See Mass media; School- based health education approaches Antismoking policies. See Smoking bans in public places Arts, tobacco industry support of. See Tobacco industry, support for arts Asian Americans for Community Involvement 289 Asian American Health Forum 297 Asian Pacific Islander Tobacco Education Network 297 Asthma 160 Index 321 Surgeon General's Report Athletes, appearance in tobacco ads 214, 243 Athletic events. See Sponsorship by tobacco industry; Cigarette promotion campaigns Attempts to quit smoking. See Smoking cessation programs Attention. See Nicotine, physiological effects Attitudes toward tobacco use among adults 264-265 among youth 36, 38, 41 belief that smoking is addictive 183-184 immigrants to the United States 262 parental attitudes 40 smoking in public places 287-291 See also Cultural values Attrition rates in group approaches to cessation. See Smoking cessation, attrition rate B Barbers /beauty parlor operators, involvement in cessation efforts 287 Behavioral Risk Factor Surveillance System (BRFSS) American Indians and Alaska Natives 45, 46, 50, 51-56, 144 Asian Americans and Pacific Islanders 56, 58, 59, 61, 62-64 description of 21,95 ethnic differences in quitting smoking 183 Hispanics 164 measures of tobacco use 97, 98 Behavioral alternatives to cigarette smoking 260 Bill of Rights touring exhibition 218, 222 Billboard advertising. See Advertising, tobacco control, tobacco products Biochemical markers of tobacco use ethnic differences 179-181 measurements among pregnant women 167 smokeless tobacco users 183 youth 32-34 Birth weight. See Infant outcomes, effects of smoking during pregnancy Black Clergy for Substance Abuse Prevention 286 Black History Month 222, 296 Bladder cancer. See Urinary bladder cancer Blood pressure. See Hypertension Boston, marketing of X brand cigarettes 295-296 Boy and Woman Bear culturally appropriate software package 273 Brain function. See Nicotine, physiological effects Brand preference 79-83. See also Cigarette brands Brand recognition. See also Cigarette promotion campaigns; Cigarette brands 322 Index Bronchitis 141,158, 160 Bureau of the Census 187 Bureau of Vital Statistics 187 Cc California “Proposition 99” 217,275 smoking cessation hot lines 277 smoking cessation efforts 297 use of revenue from cigarette taxes 277 California Department of Health Services 284 California Tobacco Survey 68, 182, 268, 283-284, 289, 292 Cancer. See specific types of cancer Cancer Information Service (CIS) hot line, National Cancer Institute 277 Cancer Prevention Study I(CPS-I) 161 cancer registries 138, 147 Carbon monoxide as an indicator of smoking 33, 34 Cardiovascular disease. See also Coronary heart disease (CHD) incidence and mortality Cardiovascular effects of nicotine. See Nicotine, physiological effects Center for Epidemiological Studies Depression Scale 234, 237 Centers for Disease Control and Prevention (CDC) 282, 284 Cerebrovascular disease African Americans 165 American Indians and Alaska Natives 165 Asian Americans and Pacific Islanders 165-166 Hispanics 166 Ceremonial and religious rites involving tobacco 44, 209 Cervical cancer 152 Cessation of smoking. See Smoking cessation programs Charleston Heart Study 161 Chewing tobacco. See Smokeless tobacco use Chicago Community Based Interventions for Low-Income African Americans 281 Chicago Lung Association’s multifaceted smoking cessation intervention 281 Child Health and Development Studies 167 Children as motivators to quit smoking among Hispanics 260 exposure to environmental tobacco smoke inhome 173 involvement in smoking cessation campaigns 269,271 lung function and environmental tobacco smoke 172 Chinese Community Smoke-Free Project 277 Cholesterol and cardiovascular disease risk 162 Chronic obstructive pulmonary disease (COPD) African Americans 158 American Indians and Native Americans 158-159 Asian Americans and Pacific Islanders 159 Hispanics 159-160 Churches Organized to Stop Tobacco (COST) 296 Cigar smoking 91-94 Cigarette brands 555 State Express 218 Alpine 242 American Spirit 223 Belair 242 Benson & Hedges 79, 80, 82 Camel 79, 80, 82, 220, 224, 243 Chesterfield 242 Dorado 220 Eve 243 Kent 79, 80, 243 Kool 79, 80, 82, 243 L&M 243 Lucky Strike 243 Marlboro 79, 80, 82, 83, 218, 220, 224, 242, 243 Merit 79, 81, 82 Mild Seven 223 More 219 Newport 79, 81, 82, 220-221, 224, 242 Oasis 242 Old Gold 241 Pall Mall 79, 81 Parliament 219 Richmond 242 Rio 220 Riviera 242 Salem 79, 81, 224, 242 Salem Extra 244 Spring 242 Spud 242 SuperM 244 Uptown 222, 224, 294 Vantage 79,81 Viceroy 243 Virginia Slims 79, 81, 223-224 Winston 79, 81, 82, 243 X 224, 295-296 See also Brand preference; Brand recognition; Cigarette promotion campaigns Tobacco Use Among U.S. Racial/Ethnic Minority Groups Cigarette consumption among ethnic groups African Americans 22-28, 41-43, 74-78, 112-121 American Indians and Alaska Natives 44-55 Asian Americans and Pacific Islanders 56-66 Hispanics 66-74, 75-77 targeted ads as external cues to smoke 223-224 Cigarette manufacturers. See Tobacco companies Cigarette prices. See Revenues Cigarette promotion campaigns Chesterfield film campaign 242 coupons 223,294 cultural events 213, 218-219, 297. See also Tobacco industry, support for ethnic communities, pride, and culture Marlboro Man 243 Marlboro Tour ‘93 211 samples 296 sports events 294 Viceroy race car driver 243 See also Advertising, tobacco products; Brand recognition; Cigarette brands Cigarettes, hand-rolled, lung cancer death rate 149 Civil rights movement 243 Clean air policies. See Smoking bans in public places Coalition Against Billboard Advertising of Alcohol and Tobacco 297 Coalition Against Uptown Cigarettes 295 Cocaine use in conjunction with cigarette smoking 37 Cognition. See Nicotine, physiological effects Committee to Prevent Cancer Among Blacks 295 Communication skills training for youth 278 Community approach to smoking cessation 278-283 dependence on tobacco industry 213-219 loyalty to tobacco industry 213 meeting of community leaders in Greensboro 297 mobilization /involvement in antitobacco campaigns California 297 Uptown cigarettes 294-295 X cigarettes 295-296 projects, limitations of 263, 265, 293 volunteer health representatives 282 Community Intervention Trial (COMMIT) for Smoking Cessation 181, 183, 236, 260 Congressional candidates, campaign support from tobacco industry 217 Index 323 Surgeon General's Report Congressional Hispanic Caucus 215 Consumer Expenditure Survey Interview Survey 292 Coping mechanism, cigarette smoking 275 Coronary Artery Risk Development in (Young) Adults (CARDIA) 172, 181, 186 Coronary heart disease (CHD) incidence and mortality African Americans 160-161 American Indians and Alaska Natives 161-162 Asian Americans and Pacific Islanders 162-163 Hispanics 163-164 Cotinine. See Biochemical markers of tobacco use Cultural events, tobacco industry support of. See Tobacco industry, support for cultural events Cultural values as depicted in tobaccoads 222-224 cigarettes as indicator of affluence 222-224 Hispanic attitudes toward smoking 223 tobacco as a gift 210 See also Attitudes toward tobacco use; Social influences Current Population Survey (CPS) attitudes concerning minors’ ease of access to tobacco products 267 ban on tobacco samples 293 classification of ethnicity 186, 187 CPS-I 161 efforts to restrict youth access to tobacco 266 employer-provided smoking cessation programs 286 ethnic differences in prevalence 87 ethnic differences in quitting smoking 183, 184 Hispanics and coronary heart disease 163 quitting behavior 25, 48,57, 70 workplace/ public place smoking restrictions 288, 289, 290-291 Current smokers, definition of 97 D Dance troupes, tobacco industry support of 219 Data collection and analysis accuracy of findings on youth smoking prevalence 31-36 aggregation problems 239 bias against Asian Americans with low English skills 61 bias in selection for studies 61 bias of findings 31 324 Index differential misclassification bias 30-32, 34 differential school dropout rates, African American youth 31,32, 228 multivariable logistic regression technique 83, 85 noncomparability of tobacco use studies 238 nongeneralizability of tobacco use studies 238 nonreporting problems in tobacco use studies 238 reporting bias 31, 239 retrospective analysis methodology 74 sources of data 95-96 tobacco smoke exposure, infant outcomes 168-171 unavailability of data on specific ethnic groups 44, 56,259,277 Death rates by cancer cervix/uteri 148, 150,152, 153,155 esophagus 148, 150,153 kidney/renal pelvis 148,150,155 larynx 148,155 lung/bronchus 144, 146, 148, 150 oral/pharynx 148, 153-155 pancreas 152 stomach 155 urinary/bladder, 152,156 by ethnicity 139, 144, 146 Decision-making skills training for youth 271 Decline in smoking. See Smoking prevalence, decline in smoking Definitions cigarette smoking and cessation 97 number of cigarettes smoked daily 97 use of cigars, pipes, and smokeless tobacco 97 Dentists, advice to patients 285 Depressive symptoms and smoking 234 See also Center for Epidemiological Studies Depression Scale Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV™) 179, 181 Doctors, in cigarette ads 243 Doctors Ought to Care (DOC) 215 Don’t Let Your Dreams Go Up in Smoke 286 Dropouts, high school 228 Drug use and smoking. See type of drug E Economics dependency on tobacco sales, American Indian reservations 213 efforts to reduce tobacco use 292-293 expenditures on tobacco promotion in ethnic communities 213-219 Education by ethnic group African Americans 83, 84 American Indians and Alaska Natives 83, 84 Asian Americans and Pacific Islanders 83, 84 Hispanics 83, 84 levels of, and smoking 25, 26, 28 Educational materials, smoking intervention. See Smoking cessation programs Elimination of nicotine. See Nicotine pharmacology Emphysema 158, 160 Employment employer antismoking policies 287-288 employer-provided smoking cessation programs 286 labor force composition of tobacco factories 208-209 English proficiency. See Language/linguistics Environmental Protection Agency assessment of environmental tobacco smoke risks 287-289 Environmental tobacco smoke (ETS) exposure and ethnicity 86-87, 172-173, 287, 289 exposure in public places 287-291 exposure to household smoke 288 fetalexposure 167 infant outcomes 167-171 nonsmokers’ exposure 172-173 perceived dangers of 261-263 pregnant women 285 Sudden Infant Death Syndrome 169-171 workplace exposure 287-288 See also Smoking bans in public places Esophageal cancer 151-153 Ethnic groups , definition of 7-8, 186-187 demographic characteristics 8-11 exclusion from tobacco studies 61 health outcomes 187 Ethnic labels, see Ethnic groups, definition of Ever smokers, definition 97 F Fagerstr6m dependence questionnaire 179 Familialism 212 Federal Trade Commission 140, 181 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Federal workplace antismoking policies 287-288 Fetal morbidity and mortality. See Infant outcomes, effects of smoking during pregnancy Filters, packaging of Uptown cigarettes 224 Focus groups 40, 286 Food and Agriculture Organization of the United Nations 211 Food and Drug Administration 207, 266, 297 Food, Tobacco, Agriculture, and Allied Workers Union 209 For You and Your Family 284 Forced expiratory volume as a measure of pulmonary function 159 Former smokers, definition 97 Freedom from Smoking® for You and Your Family 281 Freedom from Smoking in 20 Days 281 Funding initiatives for public health 6 G Gateway Program 217 Gender differences smoking prevalence African Americans 22-24, 41 American Indians and Alaska Natives 44-48, 50-56 Asian Americans and Pacific Islanders 56-59 Hispanics 66-69 smoking trends national data 23-28, 78-81 General Social Survey 233 Genetic risk, lung cancer and CYP1A1 gene 142 Gingival bleeding and recession 174 See also Periodontal disease Government regulation of cigarettes, support for 298-299 Great American Smokeout 280, 283 Great Alaska Spit-Out 273 Group approaches to smoking cessation 277-278 Guide to Black Organizations 217 H Harlem Dowling-West Side Center for Children and Family Services 216 Harlem Hospital 221 Health care facility access 277, 283-284 Health care providers 283-284, 285 Health consequences/risks of tobacco use knowledge of among adults 235, 264-265 among blue collar workers 263 Index 325 Surgeon General's Report among ethnic groups 12, 265 among pregnant women 171 Health insurance 216, 263 Health Status of Minorities and Low-Income Groups 6 Healthy People 2000 5 Heart, Body, and Soul 286 Heart attack. See Myocardial infarction Hey, Girlfriend, Let's Talk About Smoking and You 285 Hispanic Health and Nutrition Examination Survey (HHANES) chronic obstructive pulmonary disease 159 cigarette smoking prevalence among adults 66-67, 79 among successive birth cohorts 122 among women of reproductive age 71 among young people 72 description of 21,95 environmental tobacco smoke and clean indoor air policies 287 long-term trends in cigarette smoking 78 methodological issues 186 quitting behavior 183 Hispanic/Latino Tobacco Control Network 297 History of tobacco use by ethnic group African Americans 208-209 American Indians and Alaska Natives 209-210 Asian Americans and Pacific Islanders 211~212 Hispanics 212 Honolulu Heart Program 159 Housing projects 236, 263 Hypertension 160, 162, 163 74,76, I Immigration, impact on smoking prevalence 61, 234 In-store advertising displays. See Advertising, tobacco products Income and increases in cigarette taxes 292 Indian Health Service (IHS) cancer death rates age-adjusted 155 lung cancer 143-146 cervical cancer 152 classification of smoking status 186 regional differences in cancer death 144 smokeless tobacco use 49-50 326 Index smoking cessation programs for pregnant women 285 Infant outcomes, effects of smoking during pregnancy birth weight 166-169 morbidity and mortality 169-171 Sudden Infant Death Syndrome 169-171 International Multicultural Partnership 297 Interviewing methods. See Data collection and analysis It’s No Joke, Don’t Smoke! 274 It’s the Law voluntary compliance program 268 It’s Your Life—It’s Our Future 276 J Jackie Robinson Foundation Awards Dinner 219 Jargon, use in cigarette ads 242-243 K Kaiser Permanente 61, 161 Kool Achiever Awards 218 L Labor unions 208-209 Lim Thé Néo Dé Bé Hit Thudc? 276 Language/ linguistics proficiency, as barrier to knowledge of health consequences 234 proficiency, as barrier to tobacco control messages 262 proficiency as measure of acculturation smoking prevalence 234 translation of smoking cessation materials 274, 281 use of non-English words in tobacco product materials 222 Law abidance 228, 232 Leadership Conference on Civil Rights 216 League of United Latin American Citizens 216 Legends Campaign 282-283 Legislation sale of tobacco to minors (Synar Amendment) 266 FDA tobacco product regulations 297 Liberalism, factor in smoking status 232 Life Skills Training (LST) Program 9 271 Lifestyle factors and decline in smoking by ethnic group African American youth 36-38 Low birth weight. See Infant outcomes, effects of smoking during pregnancy, birth weight Lung cancer 137-135 African Americans 138-143 American Indians and Alaska Natives 143-145 Asian Americans and Pacific Islanders 145-147 Hispanics 147-149 M Magazines, ethnic African Americans 218, 241-243 portrayal in tobaccoads 241 American Indians’ portrayal in tobacco ads 223,241 Hispanics 214 perception as trustworthy information source 241,274 See also Advertising tobacco products; Mass media; Newspapers Manual of the International Classification of Diseases, Injuries and Causes of Death (ICD) 187 Marijuana use in conjunction with smoking 37, 44 Mass media radio 274 television 241, 274 See also Advertising, tobacco products; Magazines, ethnic; Newspapers Maternal smoking. See Pregnancy and smoking Media literacy 241 Medicinal usage of tobacco. See Religious use of tobacco Memory. See Nicotine, physiological effects Menthol cigarettes 79, 142, 224, 242, 243, 244 Metabolism of nicotine. See Nicotine pharmacology Milwaukee County Youth Initiative 217 Minors’ access to tobacco. See Access of minors to tobacco products Misconceptions about causes of cancer 263 Monitoring the Future (MTF) surveys description of 21, 96 perceptions of risks of cigarette smoking 230-231 predictors of cigarette smoking in African American youth 226 smoking cessation 97 smoking prevalence American Indian and Alaska Native high school seniors 49 decline 36 young people 28, 30, 32, 37, 42, 44, 72-74 Tobacco Use Among U.S. Racial/Ethnic Minority Groups MTV 274 Muscle relaxation. See Nicotine pharmacology Musical events, ethnic targeting by tobacco industry 218-219 Myocardial infarction 160, 164 N National Association for the Advancement of Colored People (NAACP) 213, 216 National Association of African Americans for Positive Imagery (NAAAPI) 224, 287, 296, 297 National Association of Black Social Workers 216 National Association of Negro Business and Professional Women’s Clubs 216 National Black Caucus of State Legislators 215 National Black Leadership Initiative on Cancer (NBLIC) 295 National Black Police Association 216 National Cancer Institute (NCI) 25, 74, 265, 277,279 National Cancer Institute Advisory Panel on Tobacco-Use Reduction Among High-Risk Youth 269 National Center for Health Statistics (NCHS) 147, 154, 163 National Coalition of Hispanic Health and Human Services Organizations (COSSMHO) 215, 218 National Directory of Asian Pacific American Organizations 217 National Directory of Hispanic Organizations 217 National Coalition of 100 Black Women 216 National Conference of Black Lawyers 216 National Death Index 163 National Health and Nutrition Examination Surveys (NHANESL IL, 0D 71,86, 161, 164, 181 National Health Interview Survey (NHIS) adults beliefs about health effects of smoking 264-265 cigarette brand preferences 79 cigarette smoking frequency 182 current cigarette smoking 87-90 effects of education and race/ethnicity on smoking behavior 83 ethnic differences in quitting smoking 183 exposure to environmental tobacco smoke 86-87, 172 involvement of health care providers 283-286 information needs 262-263 lung cancer death rates 146 Index 327 Surgeon General's Report measures of tobacco use 97 pipe and cigar use 91-92 prevalence of smoking 35, 92-93, 98-121, 122-124 quitting behavior 261 smoking prevalence estimates 124 smoking status and ethnicity 84 use of smokeless tobacco 94 African Americans and chronic obstructive pulmonary disease 158 prevalence among successive birth cohorts 74-75, 76, 140 prevalence of cigarette smoking 22, 23-24 quitting behavior 25-26 women of reproductive age 26-28 young people 30-44 American Indians and Alaska Natives prevalence of cigarette smoking 44-45 quitting behavior 46, 48 women of reproductive age 48-49 young people 49-50 Asian Americans and Pacific Islanders prevalence of cigarette smoking 56 quitting behavior 57 women of reproductive age 57,59 young people 59-60 Hispanics prevalence among successive birth cohorts 77 prevalence of cigarette smoking 66-69 quitting behavior 70, 237 women of reproductive age 71-72 young people 72-74 National Heart, Lung, and Blood Institute 272 National High Blood Pressure Education Program 286 National High School Senior Surveys. See Monitoring the Future survey National Hispanic Scholarship Fund 217 National Household Survey on Drug Abuse _ ’ (NHSDA) 28, 36, 72, 182 National Institute on Drug Abuse (NIDA) 28, 72 National Longitudinal Mortality Study 186 National Maternal and Infant Health Survey (NMIHS) 27, 28, 49, 170 National Medical Association (NMA) 276, 282, 283 National Medical Expenditure Survey 44 National Minority AIDS Council 216 National Mortality Followback Survey (NMFS) 161 National Natality Survey 27 National Pregnancy and Health Survey 28, 72 National Research Council 172 328 Index National Survey of Family Growth 27,71 National Survey of Oral Health in U.S. School Children 174 National Urban League 215, 216 National Vital Statistics System 138 Native American Indians, by region and tribe (smoking survey) 50-56 Neighborhood tobacco product advertising 221-222, 293-297 Neural actions of nicotine. See Nicotine, physiological effects Neurotransmitter release, changes caused by nicotine See Nicotine, physiological effects New York City, proposed ban on public smoking 218 Newsletters, smoking prevention campaigns 274 Newspapers 214,218. See also Magazines, ethnic Nicotine dependence and addiction 181-184 Nicotine pharmacology 175-184 Nicotine, physiological effects 175-179. See also Withdrawal symptoms, nicotine Nicotine replacement therapy 286 Nicotine yield 179 Nonsmokers exposure to environmental tobacco smoke 137 support for bans on tobacco ads 293-298 O 100 Black Men of America, Inc. 216 One Day ata Time 286 Operation PUSH (People United to Save Humanity) 213, 216 Opportunities Industrialization Centers of America 216 Oral cancer 153-155,174 Orallesions 174-175 Oral leukoplakia 174 Outdoor advertisements. See Advertising, tobacco products Over-the-counter sales of cigarettes. See Access of minors to tobacco products Oxygen-carrying capacity, maternal, and effects of smoking 171 P Packaging 224 Parental attitudes toward smoking 40 Parental cigarette smoking, as risk factor for initiation 229 Passive smoke exposure. See Environmental tobacco smoke Pathways to Freedom Community Demonstration Project 280 Pathways to Freedom: Winning the Fight Against Tobacco 276 Patterns of tobacco use. See Cigarette consumption Peace pipe 210 Peer tobacco use 231-233 Perinatal mortality 166 Periodontal disease 174 Personal consultation for smoking cessation face-to-face 278 telephone 278 Pew Charitable Trusts 217 Pharyngeal cancer 174 Philadelphia Mayor’s Commission on Literacy 217 Physicians advice to patients regarding smoking 283-285 appearance in tobacco advertisements 243 Physiological measurement of cigarette smoking. See Biochemical markers of tobacco use Pipe smoking definition for surveys 92 history of 91-92 prevalence of 91-92 Point-of-sale displays. See Advertising, tobacco products Political campaign contributions by tobacco companies 217 Portland Life Center 216 Power distance 283 Predictors of tobacco use and initiation 231-233 Pregnancy and smoking abruptio placentae 171 African American vs. white 167-169 and other drug use 168 birth weight 166, 167-169, 171, 185 ectopic pregnancy 171 intention to breast-feed as predictor of smoking cessation 260 intrauterine growth retardation 166 preterm delivery 169 reduction of cigarette consumption 27,71, 167, 169 Sudden Infant Death Syndrome (SIDS) 167, 169-171 See also Infant outcomes, effects of smoking during pregnancy; Smoking prevalence, during pregnancy Prevalence of cessation 8 Prevalence of smoking. See Smoking prevalence Preventing Tobacco Use Among Young People: A Report of the Surgeon General 44,220 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Prevention programs. See Mass media; School-based health education approaches Product endorsements. See Advertising, tobacco products Product targeting American Spirit cigarettes, American Indians 223 Dorado cigarettes, Hispanics 220, 222 Mild Seven cigarettes, Asian Americans 223 Rio cigarettes, Hispanics 220, 222 Uptown cigarettes, African Americans 222, 223-224, 294 Project SHOUT = 271-272 Project SMART 271 Programa Latino Para Dejar de Fumar 279-280 “Proposition 99” tobacco tax initiative 217,277 Psychosocial risk factors 225-233 Public health objectives 5. See also Healthy People 2000 Public places, antismoking policies. See Smoking bans in public places Public service announcements 279 Q Quit attempts. See Smoking cessation programs, quit attempts Quit for Life, employer-provided program 282 Quit Today! 280 R Race. See Ethnic groups Racial discrimination 214, 260 Radio. See Mass media Rappers/Pick It antismoking message 221 Rates of smoking. See Cigarette consumption Recidivism. See Relapse Regular smoking, definition of 97 Reinforcing effects of smoking tobacco 176 Relapse 25, 122, 261-262 Religion as protective factor 42, 226, 232 Religious use of tobacco 210 Reporting bias. See Data collection and analysis Reproductive health. See Pregnancy and smoking; Smoking prevalence, during pregnancy Resource guides for ethnic groups, tobacco industry support of 216-217 Retrospective analysis methodology. See Data collection and analysis Revenues. See Advertising, tobacco products, revenues Index 329 Surgeon General's Report Risk-taking behavior, factor in tobacco use 44,7 3, 95 Robert Wood Johnson Foundation (RWJF). See Youth Access Survey Role models. See Advertising, tobacco products Rompa Con El Vicio. Una Guia Para Dejar de Fumar 275 S Salem Freshside™ Salute 218 Salem Open tennis tournament 211 Sales to minors. See Access of minors to tobacco products San Antonio Heart Study 164 School-based health education approaches 269-273 School performance. See Academic performance and smoking initiation Schools, antismoking policies 289 Second-hand smoke. See Environmental tobacco smoke Self-help approach to smoking cessation 275-277 willpower 275 Self-reports of nicotine addiction, by ethnicity 181-183 Self-service tobacco displays, elimination of 266, 269 Sex differences. See Gender differences Sharing cigarettes 211, 212 SiPuedo 280 Sickle cell trait and smoking, effects on birth weight 171 Sidestream smoke. See Environmental tobacco Smoke Smokefree policies. See Smoking bans in public places Smokeless tobacco addiction 183 Smokeless tobacco use by ethnic group African Americans 44, 94,174 American Indians and Alaska Natives 49-50, 55, 94,174 Asian Americans and Pacific Islanders 60, 94, 174 Hispanics 74, 94 cessation programs 234 effects of 174-175 factors associated with initiation 232-233 prevalence 233-235 Skoal Bandit promotion 218, 219 use by adolescents 174, 232-233 Smokers, acceptance of. See Attitudes toward tobacco use; Cultural values; Social influences 330 = Index Smokers, definitions 97 Smoking abstinence, overnight, and loss of nicotine tolerance 178 Smoking: Facts and Quitting Tips for Black Americans 277 Smoking: Facts and Quitting Tips for Hispanics 277 Smoking bans in public places 287-292 enforcement in ethnic communities 289 Smoking cessation programs ageatcessation 46 among members of ethnic groups 14, 274-283, 286-287 approaches 259 attrition rate 277 culturally appropriate 259-262, 273, 274-283, 286, 287 desire to quit 260-262 education and ethnicity as factors 85 employer-provided programs 286 family-centered interventions 260 Freedom from Smoking in 20 Days 281 health benefits of 263-265 home visits 278 information needs 262-263 motivation to quit 260 nontraditional providers and 286-287 perceived ability to quit 286 pregnant women 285 prevalence of former smokers African Americans 25 American Indians and Alaska Natives 46 Asian Americans and Pacific Islanders 57 Hispanics 70 quit attempts, African Americans 25-26, 236 See also Community; Group approaches to smoking cessation; Self-help approach to smoking cessation Smoking initiation adolescents 225 by ethnic group African Americans 40, 78,226 American Indians and Alaska Natives 227 Asian Americans and Pacific Islanders 227 Hispanics 40, 78-79, 228-229 long-term trends, birth cohort analysis 78-79 multiple group studies 229 targeted advertising 223, 240-244 Smoking prevalence among adults 21-23, 26-28 among ethnic groups 12 among young people African Americans 28-31, 44 American Indians and Alaska Natives 49 Asian Americans and Pacific Islanders 59-60 Hispanics 72-73 See also Monitoring the Future surveys by ethnic group African Americans 22-25, 35, 74-75, 233 American Indians and Alaska Natives 44-46, 50-56, 233 Asian Americans and Pacific Islanders 56-59, 234 Hispanics 66-70, 75-77, 234-235 comparisons among ethnic groups 87-91 decline in smoking African Americans 27, 30, 31, 36, 38, 41, 74-75, 78 American Indians and Alaska Natives 49 Asian Americans and Pacific Islanders 56-57, 59, 61 Hispanics 69,71, 75-76, 78-79 decreased by cigarette taxes 292-293 during pregnancy African Americans 26-28, 29, 285 American Indians and Alaska Natives 29, 49, 285 Asian Americans and Pacific Islanders 29,59, 285 Hispanics 29, 71-72, 285 education and ethnicity as factors in smoking status 83-86 in Asian countries 65-66 in Latin American countries 69 in women of reproductive age African Americans 26-28 American Indians and Alaska Natives 48-49 Asian Americans and Pacific Islanders 57,59 Hispanics 71-72 regional and tribal tobacco use 50-56 retrospective analysis and assessment of African Americans 74-75 Hispanics 75-76 See also Gender differences Smoking prevention programs. See Mass media; School-based health education approaches Smoking recidivism. See Relapse Smoking reduction during pregnancy. See Pregnancy and smoking Snuff use. See Smokeless tobacco use Tobacco Use Among U.S. Racial/Ethnic Minority Groups Social influences smoking prevalence in Latin America 212 status-seeking behavior 224, 240-241 tobacco use at American Indian social gatherings 210 See also Cultural values Social Learning Theory 282 Social skills/ peer pressure resistance training for youth 271 Sociodemographic factors and decline in smoking by African American youth 36 Socioeconomic status coronary heart disease deaths 161 exposure to school-based smoking prevention programs 269 factor in the response to changes in cigarette price 292 smoking prevalence 83 targeting ofads 240-244 Software, interactive learning programs 273 Sponsorship by tobacco industry. See Tobacco industry Stages of change 225 Stanford Five-City Multifactor Risk Reduction Project 279, 284 Stomach cancer 155 Stop Teenage Addiction to Tobacco (STAT) 268 Stress. See Coping mechanism, cigarette smoking Strong Heart Study 45 Stroke as the major form of cerebrovascular disease 164 Suc Khoe La Vang! 283 sudden infant death syndrome (SIDS) 169-171 Surveillance, Epidemiology, and End Results (SEER) Program 138, 146, 149, 151, 152, 156, 186 Surveys. See specific survey: Adult Use of Tobacco Survey (ALTS) Behavioral Risk Factor Surveillance System (BRFSS) Current Population Survey (CPS) Hispanic Health and Nutrition Examination Survey (HHANES) Monitoring the Future (MTF) surveys National Health and Nutrition Examination Surveys (NHANES) National Health Interview Survey (NHIS) Surveillance, Epidemiology, and End Results (SEER) Program Teenage Attitudes and Practices Survey (TAPS) Youth Access Survey, Robert Wood Johnson Foundation (RWJF) Youth Risk Behavior Survey (YRBS) Synar Amendment. See Legislation Index 331 Surgeon General's Report T Task performance. See Nicotine, physiological effects Taxes on tobacco products excise taxes 292-293 sales taxes 292-293 Teach For America 217 Teenage Attitudes and Practices Survey (TAPS) 21, 32, 36, 73, 81, 83, 96, 228, 266, 267 Terms related to tobacco use 8 Television. See Mass media Tobacco, alternative uses. See Religious use of tobacco Tobacco companies American Tobacco Co. 242, 244 British American Tobacco Co. 212 China National Tobacco Corporation 211 Brown & Williamson Tobacco Corp. 217, 224, 242 Japan Tobacco Inc. 223 Liggett & Myers 242, 243 Lorillard 223, 241, 242, 243 Parliament 219 Philip Morris 216, 217, 218, 222, 241, 242 RJR Nabisco (R. J. Reynolds) 215, 216, 217, 219, 223, 224, 244 Sante Fe Tobacco Co. 223 Tobacco Institute 216 United States Tobacco Co. 219 Tobacco control. See Smoking cessation programs Tobacco industry African American involvement 208-209, 213-214 Asian production 211 community loyalty 213 funding of community agencies and organizations 215-217 Latin American production 212 shift of expenditures to promotional marketing 293 support for arts 218-219 support for cultural activities 218-219 support for education 217 support for ethnic communities, pride, and culture 213,216 Tobacco Use. See Smokeless tobacco use; Smoking prevalence Tobacco-Use Reduction Among High-Risk Youth, NCI Advisory Panel 269 Tobacco Workers International Union 208 Tumor suppressor gene p53 143 332 Index U Union of Pan Asian Communities 287 United Cambodian Community, Inc. 287 United Negro College Fund (UNCF) 215, 216, 217, 219 United Tobacco Workers 209 Urinary bladder cancer 156-157 Vv Values, used as a means of smoking cessation and health promotion effort 260 Vending machines 268-269 Victory Over Smoking—A Guide to Smoking Cessation for You and Your Family 277 Vietnamese Community Health Promotion Project 283 Virginia Slims fashion show 211 Ww Warning labels 298 Warning signs mandated by state, prohibition of sales to minors 268 Weight control and cigarette smoking 38-39, 277 Withdrawal symptoms, nicotine 178-179 Women. See Gender differences; Smoking prevalence Workplace environmental tobacco smoke exposure 287-288 See also Environmental tobacco smoke Y Young Men’s Christian Association 216 Youth advertising, effectiveness of 41 alcohol use 37, 38 attitudes toward tobacco use 38-41 knowledge of health consequences of smoking 227 skills training 271 See also Adolescents; Mass media; School-based health education approaches; Smoking initiation; Smoking prevalence Youth Access Survey, Robert Wood Johnson Foundation (RWJF) 269, 293, 298 Youth access to tobacco. See Access of minors to tobacco products Youth Risk Behavior Survey (YRBS) 74,96 29, 36, 44, 73,