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