UCLA CENTER FOR &, Bla NW age A137 \ NO BR healthpolicy.ucla.edu California Native Hawaiian and Pacific Islander Adult Health Behaviors and Attitudes on Tobacco Use A report based on the California NHPI Tobacco Survey UCLA Center for Health Policy Research Funded by the California Tobacco Control Program, California Department of Health california aterelian interview OA] CALIFORNIA NATIVE HAWAIIAN AND PACIFIC ISLANDER ADULT HEALTH BEHAVIORS AND ATTITUDES ON TOBACCO USE A report based on the California NHPI Tobacco Survey June 2022 UCLA CENTER FOR ::. LTH POLICY RESEARCH. o-: UCLA Center for Health Policy Research Funded by the California Tobacco Control Program, California Department of Public Health About Author Sean Tan, MPP is the senior public administration analyst at the UCLA Center for Health Policy Research. Suggested Citation Tan, S. California NHPI adult health behaviors and attitudes on tobacco use. 2022. Los Angeles, Calif.: UCLA Center for Health Policy Research. The UCLA Center for Health Policy Research (CHPR) is part of the UCLA Fielding School of Public Health and is affiliated with the UCLA School of Public Affairs. The views expressed in this report are those of the authors and do not necessarily represent those of the UCLA Center for Health Policy Research, the Regents of the University of California, or collaborating organizations or funders. Copyright © 2022 by the Regents of the University of California. All rights reserved. Editor-in-Chief: Ninez A. Ponce, PhD Phone: 310-794-0909 Fax: 310-794-2686 Email: chpr@ucla.edu healthpolicy.ucla.edu UCLA CENTER FOR HEALTH POLICY RESEARCH 05 e Ait Table of Contents BackGrounnd ...............cccccccscccecceseccceeeeesseaseceseueeeseaseceesueeeeeaceeessgeeeeeaeeeesageeees 9 Executive SUMIMALPY.................:cccccccccccssssseecceeeseeeeseeeaeseeceseeaeeeesessaeseeeessaeas 4 Methodology ...............cccccseccccssscccceecececeaseeeeeseeeeeasecessueeeseaeeeessaseessaesessaaaes 10 Demographic Characteristics .....................ccccccccceeccessseeeseeeeeeeeesseaaeeseeees 12 Tobacco USE ............. cece eee eee eee eee e eee ease aaeeeeeeee sees 14 Cessation 0.0.0... ee eeeeeeeeeeeeeeeeeeeeeeeeetes 23 Secondhand Smoke Exposure ................ccccccssccceceseeecssseeeeeeseeeeeeeetseseees 30 Attitudes On Tobacco Use and Tobacco Control Policies .................. 35 Acknowledgements UCLA Center for Health Policy Research (CHPR) would like to express its gratitude and give special recognition to the Native Hawaiian and Pacific Islander community-based organizations, leaders, experts, service providers, and community members for their support of the California Native Hawaiian and Pacific Islander (NHPI) Tobacco Survey. The California NHPI Tobacco Survey would not have been possible without them. UCLA CHPR is truly grateful for the tireless efforts and guidance that community members have provided toward this survey and in advancing the health and well-being of Native Hawaiian and Pacific Islander communities across California. UCLA CHPR would also like to express its appreciation to all of the respondents of the California NHPI Tobacco Survey. The California Native Hawaiian and Pacific Islander Adult Health Behaviors and Attitudes on Tobacco Use report was funded and supported by the California Department of Public Health. The findings in this report are those of the author and do not necessarily represent the views or opinions of the California Department of Public Health and the California Health and Human Services Agency. UCLA CHPR and the author would like to thank Xueying Zhang, Chief of Surveillance Unit, and Tam Vuong, Project Coordinator, at the California Tobacco Control Program for their support in the development of the California NHPI Tobacco Survey and the report. UCLA CHPR and author would like to give special thanks to the members of the subject matter expert group for providing invaluable insights to and support for this project: Sefa Aina Corina Penaia Randall Akee Sora Park Tanjasiri Natalie T. Ah Soon Karla Thomas Richard Chang 'Alisi Tulua Toluk Ito Ami Shah Sunghee Lee Emilia Simeonova Jonathan Tana Lepule Winston Tseng Paula Palmer Taunu'u Ve'e Sela Panapasa This project was also designed and conducted with significant contributions from the following staff at the UCLA Center for Health Policy Research: Ninez Ponce, PhD, MPP, Director of UCLA Center for Health Policy Research & Principal Investigator of California Health Interview Survey (CHIS) Todd Hughes, Director of California Health Interview Survey Royce Park, MA, Associate Director of Survey Planning and Operations YuChing Yang, PhD, Director of Statistical Unit Andrew Juhnke, MPH, Compliance Officer and Data Product Manager Jason Frost, Statistician UCLA CHPR also thanks SSRS for conducting data collection for the California NHPI Tobacco Survey. 4 UCLA CENTER FOR HEALTH POLICY RESEARCH .e se Health behaviors and attitudes about tobacco among Native Hawaiian and Pacific Islander adults in California then The California Native Hawaiian and Pacific Islander Tobacco Survey* was developed by the UCLA Center for Health Policy Research and community partners to understand how certain health behaviors and attitudes regarding tobacco affect Native Hawaiian and Pacific Islander (NHPI) communities in California a ee NHPI adults reported 2 in 3 current use of tobacco (64.3%) products of any kind Among NHPI smokers... Cessation methods used: . ( . | delaved - ) ; used NHPI-serving did not try to quit have never tried to elayed or did not : cessation services programs smoking in the past quit smoking in get FDA-approved 12 months their lifetime cessation medicine' due to cost : used vaping products ET s2.2%) PARED 65.2) 37.4% | 'oe t. would rather receive would be more delayed or did not cessation services at likely to quit if more seek cessation BSEe FD pur NHPI-serving health tobacco cessation services because of _ _: Css organizations than services were perceived race-based : general health tailored to NHPI discrimination _- e organizations communities used a cessation hotline NHPI adults were exposed in places such as.. : Among NHPI adults... : More than \* Aa sidewalk | 3 in 4 | (76%) 4in 5 | (83.2%) : agree or strongly agree or strongly \= bet home : agree ona agree that : tobacco sales apartment units ELA workotace : ban to anyone should be smoke- : born after 2025 and vape-free *The California Native Hawaiian and Pacific Islander Tobacco Survey is a study that used non-probability Read the full report: recruitment methods, therefore data estimates may not be entirely represent NHPI populations in California. https: . s://ucla.in/3NmgNJ7 tNicotine replacement therapy or prescription cessation medication (e.g. Chantix or Zyban) attp g Executive Summary The California Native Hawaiian and Pacific Islander Health Behaviors and Attitudes on Tobacco Use is a report based on the California Native Hawaiian and Pacific Islander (NHPI) Tobacco Survey. This report provides estimates on tobacco use, other health behaviors associated with tobacco such as smoking cessation and exposure to tobacco secondhand smoke (SHS) or secondhand vape (SHV) as well as attitudes regarding tobacco use and tobacco control policies among surveyed NHPI adults in California. This report also provides estimates on marijuana use and co-use among surveyed NHPI adults in California. Estimates presented in this report are disaggregated by NHPI subgroups, sex, age groups, education level, and regions in California to support examination of health disparities that exists among and within the NHPI adult population in California. Key Findings Below are the key findings gathered from the California NHPI Tobacco Survey: Tobacco Use A large proportion of NHPI adults in this sample use tobacco products as 64.3% of NHPI adults surveyed reported use of tobacco products of any kind in the past 30 days: e Over three-quarters (77.8%) of Native Hawaiian adults and a majority (54.3%) of Pacific Islander adults reported being a current smoker. e A majority (52.2%) of NHPI adults reported ever use of vaping products (lifetime), and close to 2 in 5 (38.4%) of NHPI adults reported current use of vaping products (past 30 days). e Among NHPI adults, 22.4% reported use of big cigars, 21.4% reported use of little cigars, 22.1% reported use of smokeless tobacco (chewing tobacco, snuff or snus), 20.8% reported use of heated tobacco products, 18.3% reported use of hookah, and 16.9% reported use of nicotine pouch in the past 30 days. e A majority (54.6%) of NHPI adults reported current use of flavored tobacco products. e Over three-quarters (77.4%) of NHPI adults wno chewed betel nut had reported current use of betel nut with tobacco. A large proportion of NHPI young adults (ages 18 to 24) in this sample use tobacco products such as cigarettes, vaping products, and flavored tobacco products: 5 About 3 in 5 (59.3%) NHPI young adults reported being a current smoker. 45.2% of NHPI young adults reported current use of vaping products and 62.0% of NHPI young adults reported ever use of vaping products. 57.7% of NHPI young adults reported current use of flavored tobacco products. A larger proportion of NHPI male adults in this sample reported tobacco use than NHPI female adults: 83.6% of NHPI male adults compared to 45.9% of NHPI female adults reported use of tobacco products. 81.7% of NHPI male adults compared to 37.9% of women reported being current smokers. A majority (51.5%) of NHPI male adults compared to a quarter (25.9%) of women reported current use of vaping products. In addition, 63.4% of NHPI male adults compared to 41.6% of NHPI female adults reported ever use of vaping products. 71.0% of NHPI male adults compared to 38.9% of NHPI female adults reported current use of flavored tobacco products. Cessation NHPI smokers indicated greater level of comfort and likelihood of quitting smoking with NHPI specific organizations and services, but continue to face many obstacles: A majority (52.3%) of current NPHI smokers in this sample indicated that they were more comfortable receiving tobacco cessation services at health organizations that serve NHPI communities than health organizations that serve the general population. About two-thirds (65.8%) of current smokers also indicated that they were more likely to quit if more tobacco cessation services were tailored to NHPI communities. A larger proportion of Guamanian (91.9%) and Fijian smokers (83.7%) indicated that they would be more likely to quit if cessation services were tailored to NHPI communities than any other NHPI smoker comparing by NHPI subgroups. Withdrawal symptoms (31.7%), relapse or unable to quit (23.6%), and decrease in social interaction with peers (15.7%) were the biggest fears that NHPI smokers had when quitting smoking for good. Around 2 in 5 (40.4%) NHPI smokers delayed or did not get nicotine replacement therapy (NRT) or prescription cessation medications due to cost and 37.4% of NHPI smokers delayed or did not seek cessation services because of perceived unfair treatment based on their race or ethnicity. About 9 in 10 (92.6%) NHPI adults with less than a high school diploma in this sample reported being a current smoker and many face substantial barriers to cessation, despite indicating a clear need for cessation programs: NHPI smokers with a bachelor's degree (92.5%) are more likely to report having attempted to quit in their lifetime than NHPI smokers with less than a high school diploma (66.5%), but NHPI smokers with less than a high school diploma (97.7%) were more likely to report having attempted to quit in the past 12 months when comparing by education level. 67.7% reported that they were more comfortable receiving cessation services from health organizations that serve NHPI communities. Also, almost all (93.5%) indicated that they would be likely to quit if cessation services were specific to NHPI communities. Among NHPI smokers with less than a high school diploma who had attempted to quit: 86.2% used cessation services programs at a NHPI specific organization, 73.0% used a cessation helpline, and 72.4% used nicotine replacement therapy (NRT) or prescription cessation medications. A majority (56.4%) of current NHPI smokers with less than high school a diploma delayed or not get NRT or prescription cessation medications due to cost. Tobacco Secondhand Smoke and Vape Exposure Over two-thirds (67.0%) of NHPI adults in this sample reported being exposed to tobacco secondhand smoke (SHS) or secondhand vape (SHV), while 48.9% of NHPI adults reported exposure to marijuana secondhand smoke (SHS), a lower percentage of reported exposure compared to NHPI adults exposed to tobacco SHS or SHV. e NHPI adults with less than a high school diploma (92.8%) were more likely to report being exposed to tobacco SHS or SHV than any other NHPI adult when comparing across education level. e Larger proportions of NHPI adults reported being exposed to tobacco SHS or SHV on the sidewalk (72.5%) and at home (71.2%) than in the workplace (58.7%). e A larger proportion of NHPI adults in Northern and Sierra Counties (88.7%), Central Coast (86.7%), and Sacramento area (82.3%) indicated being exposed to tobacco SHS or SHV in the past two weeks than other regions in California. Attitudes Around Tobacco-Related Statements Many NHPI adults in the sample agreed that tobacco negatively impacts their community: e About two-thirds (66.4%) of NHPI adults agree or strongly agree that the tobacco industry advertising targets the NHPI community. e 76.2% of NHPI adults agree or strongly agree that vaping, juuling, and e-cigarettes are a health threat to NHPI communities. Agreement to this statement among NHPI young adults (aged 18 to 24) was at 76.1% and 66.4% among NHPI older adults (aged 65 and over), and overall percentages of agreement were similar across age groups. e Over two-thirds (67.6%) of NHPI adults agree or strongly agree that flavored e- cigarettes and other flavored tobacco products are intentionally designed to appeal to youth. Agreement to this statement among NHPI young adult was at 74.9% compared to 57.1 among NHPI adults aged 50 to 64. There was strong agreement among NHPI adults on tobacco control policies: e There was strong agreement (76.6%) among NHPI adults that the sale of tobacco should be banned to anyone born after 2025. Despite a large percentage (77.3%) of Fijian adults in this sample reporting being a current smoker, 91.2% of Fijian adults agree or strongly agree to the tobacco control policy. On the other hand, 77.8% of Native Hawaiian adults reported being a current smoker and only 62.2% of Native Hawaiian adults agree or strongly agree to the tobacco control policy. e Over 4 in 5 (83.2%) NHPI adults agree or strongly agree to having smoke- and vape-free apartment units. Background Data collection on Hawaiian and Part Hawaiian as a separate race category on the U.S. Census began in 1960, a year after Hawaii became the 50' state of the United States. Starting in the 1970s, Hawaiian was included in the Census for all states except Alaska." In 1997, under the Office of Management and Budget Directive 15, Native Hawaiian and Pacific Islanders (NHPI) were considered their own category, replacing the racial category "Asian or Pacific Islander". Since then, the 2010 Census counted around 540,000 Native Hawaiians and Pacific Islanders alone and an additional 685,000 NHPIs were two or more races with a majority of NHPIs living in either Hawaii or California.' According to the latest Census, NHPIs are one of the fastest growing population groups in the U.S. from 2000 to 2019. The NHPI population in the U.S. grew by 72.7%, second only to the Asian Americans (alone) population at 82.2%, while the general U.S. population grew only about 16.3% within the same time period." Despite the growing Asian American and NHPI populations in the U.S., data collection efforts and availability of AA and NHPI population data remain sparse.* In addition, population data on NHPIs are systematically conflated with Asians or Asian Americans as "Asian or Pacific Islander (API)", which often masks disparities on a variety of sociodemographic and health indicators between Asian Americans and NHP'Is as well as within Asian American and NHPI communities.* Tobacco companies have heavily targeted NHPI communities with advertising campaigns, which have led to disproportional use of tobacco products as well as disparate health outcomes among NHPI individuals.° However, because of small sample sizes, lack of in-language surveys, and aggregation of Asian/Asian American and NHPI data as a standard practice, research on tobacco use among NHPI communities are all the more limited.® These limitations make it difficult to track trends on tobacco use and evaluations on tobacco use disparities statewide and at the national level. Given the disproportionate use of tobacco among NHPI individuals, NHPI community organizations in California and in the United States have long engaged in vast anti-tobacco coalition building and participated with various stakeholders to enact tobacco control policies.® Comprehensive data collection and reporting on NHPI communities and their health are critical to decreasing health disparities and achieving health equity. This report aims to provide population health and health behaviors data among NHPI communities in California with hopes of providing NHPI community stakeholders with the tools to strengthen research on tobacco and further improve the health and wellbeing of all NHPI community members. Methodology About The California Native Hawaiian and Pacific Islander (NHPI) Tobacco Survey (referred to in respondent materials as the "California Pacific Islander Health Attitudes and Behavior Survey" or CPIHABS is a follow-on study that contacted adults residing in California who identify as Native Hawaiian or Pacific Islander). The survey sample consists of re-contacted respondents from the 2019-2020 main California Health Interview Survey (CHIS), referrals from 2019-2020 CHIS respondents and community- based organizations (CBOs) serving NHPI communities, respondents referred by CBO recruits as well as respondents from CBOs and community leaders' social media and e- mail contacts. This survey employed a convenience or non-probability-based sampling design, which differs from the probability-based sampling utilized in the development of CHIS data. Data table estimates in this report are not entirely representative of the NHPI populations in the state of California. UCLA CHPR cautions readers when interpreting the results of the data estimate tables pertaining to its generalizability to the overall NHPI populations in California. A total of 1,267 respondents were collected between July 2020 and June 7, 2021. The survey was made available via telephone and web, but all responses were web-based. Further information regarding the study methodology including sample design, data collection, data processing and preparation, data collection results, survey weights and variance estimation can be found on a separate document entitled, California Pacific Islander Health Attitudes and Behaviors Survey -- Methodology Report: January 2022. Interpretation and Limitations Statistically unstable estimates symbolized by an exclamation point (!) reflect percentages based on a small sample size that may not accurately reflect the behaviors, health conditions, or health services issues of the population. The coefficient of variation (CV) is defined as the ratio between the standard error of the point estimate and the point estimate. The CV is calculated for each estimate to assess statistical stability. A point estimate with a CV larger or equal to 0.30 is considered a statistically unstable estimate. If an estimate table has values followed by an exclamation point (!), the UCLA Center for Health Policy Research and CHIS do not recommend using these values for purposes of policy development, program planning, or advocacy. Statistically unstable estimates are shown in the report to illustrate completeness of data collected and analyzed. 10 Statistical testing was not conducted to assess differences in estimates between subgroups. In lieu of statistical testing, 95% confidence intervals for estimates are provided in this report. Construction of NHPI as a Race Category and Detailed Race Categories In constructing the Native Hawaiian and other Pacific Islander categories, respondents who identified as Native Hawaiian and Pacific Islander were randomly selected to either be included in the Native Hawaiian or Pacific Islander category. For example, if a respondent is Native Hawaiian and Fijian, the respondent was randomly selected and treated as Native Hawaiian or Fijian. Therefore, Native Hawaiians and Pacific Islanders are treated as mutually exclusive in this report. For a respondent who is Native Hawaiian and have multiple Pacific Islander identities, the respondent was also randomly selected as either Native Hawaiian or Pacific Islander. If the respondent was categorized as Pacific Islander (e.g. respondent who is Tongan and Samoan), responses are recorded under "Other Pacific Islander'. 11 Demographic Characteristics The sample consists of Native Hawaiian and other Pacific Islander adult respondents totaling 1,267. The survey recorded 713 responses from Native Hawaiian alone adults, which is a larger proportion of the sample compared to the proportion of Native Hawaiians among the NHPI population in California. After weighting calibrations using American Community Survey (ACS) 5-year estimates as benchmarks, 21.2% of the sample are Native Hawaiian, 28.9% are Samoan, 12.8% are Guamanian, 14.5% are Tongan, 5.4% are Fijian, and 17.2% are considered Other Pacific Islanders. A majority (57.9%) of the sample are adults ages 25 to 49, 18.0% of the sample are young adults (aged 18 to 24), 16.7% are adults aged 50 to 64, and 7.4% are older adults (aged 65 and over). A majority of the sample respondents are female (51.2%) and 48.8% are male based sex assigned on birth certificate. About 2 in 5 (40.8%) in the sample are adults with "some college, university, or community college", which includes completion of an Associate's degree or 2-year equivalent degree, 27.0% are adults with a bachelor's degree or higher, about a quarter (24.0%) have a high school diploma, and 8.2% have less than a high school diploma. Regionally, 26.6% of the sample are from the Larger Bay Area, followed by Southern California counties other than Los Angeles (25.3%), Los Angeles county (21.2%), San Joaquin Valley (11.3%), Sacramento (10.3%), Northern or Sierra Counties (2.8%) and Central Coast (2.5%). Close to half of respondents (44.4%) are homeowners in a single-unit building, 18.4% are renters in a single-unit building, 16.9% are renters in a multi-unit building, 16.1% are homeowners in a multi-unit building and 4.2% had other arrangements. Table 1. Demographic characteristics of sample Percent (%) 95% Confidence Interval NHPI Native Hawaiian 21.2 17.9 - 24.5 Samoan 28.9 24.1 - 33.6 Tongan 14.5 10.4 - 18.5 Guamanian 12.8 8.3 - 17.2 Fijian 5.4 3.2-7.6 Other Pacific Islander 17.2 13.2 -21.3 Sex Male 48.8 43.5 - 54.1 12 Female Age 18 to 24 25 to 49 50 to 64 65 and over Education Less than high school High school graduate Some college or community college Bachelor's degree or higher Region North/Sierra Counties Larger Bay area Sacramento area San Joaquin Valley Central Coast Los Angeles Other Southern California Housing Status Rent in multi-unit building Rent in single-unit building Homeowners in multi-unit building Homeowners in single-unit building Other arrangements 51.2 45.9 -56.5 18.0 14.2-21.8 57.9 52.4 - 63.3 16.7 12.2-21.2 7.4 3.8 - 11.0 8.2 5.1-11.3 24.0 19.4 - 28.6 40.8 35.8 - 45.7 27.0 22.3 - 31.8 2.8 (!) 11-44 26.6 22.3 - 30.9 10.3 7.0 - 13.6 11.3 8.0 - 14.6 2.5 1.0-3.9 21.2 17.6 - 24.9 25.3 20.5 - 30.1 16.9 13.0 - 20.8 18.4 14.5-22.4 16.1 12.0 - 20.3 44.4 39.3 - 49.5 4.2 1.9-6.5 13 Tobacco Use Current Use of Tobacco Products Table 2 shows that about 64.3% of NHPI adults in this sample indicated current use of tobacco products of any kind. Current tobacco use is defined as the use of one of the following tobacco products in the past 30 days: cigarettes, vaping products, smokeless (chewing tobacco, snuff or snus), big cigars, cigarillos or little cigars, hookah, heated tobacco products, or nicotine pouches. This study found that a larger proportion of Native Hawaiians (78.8%) and Fijians (77.3%) reported current use of tobacco than any other NHPI subgroups. NHPI male adults reported higher current use of tobacco products than NHPI female adults (83.6% vs. 45.9%). In addition, current use of tobacco products decreases across adult age groups. Larger proportion of adults with some college or community college reported current tobacco use than adults who are high school graduates as well as adults with a bachelor's degree (70.3% vs. 62.2% and 46.4%). About 9 in 10 (90.8%) NHPI adults in the Sacramento area reported current use of tobacco followed by 84.3% of NHPI adults in the Northern or Sierra counties and 84.0% of NHPI adults in the Central Coast, which are among the highest across regions in California. Table 2. Percentages of sample reporting current use of tobacco products by NHPI subgroups, sex, age, education level and regions in California Use of Tobacco (%) 95% Confidence Interval Overall NHPI Population 64.3 59.2 - 69.5 NHPI subgroups Native Hawaiian 78.8 73.4 - 84.2 Samoan 62.3 53.4 - 66.6 Tongan 56.1 40.9 - 84.2 Guamanian 39.7 21.7 - 57.7 Fijian 77.3 56.2 - 98.4 Other Pacific Islander 57.7 46.4 -- 68.9 Sex Male 83.6 77.8 - 89.5 Female 45.9 38.6 - 53.2 Age 18 to 24 72.2 61.8 - 82.6 25 to 49 67.5 61.5 - 73.5 50 to 64 59.9 44.4 -75.4 65 and over 30.6 (!) 6.8 - 54.4 Education Less than high school 100.0 (!) 100.0 - 100.0 High school graduate 62.2 50.8 - 73.6 Some college or community college 70.3 62.8 - 77.8 14 Bachelor's degree or higher 46.4 37.1 - 55.7 Region North/Sierra Counties 84.3 63.3 - 100.0 Larger Bay area 55.7 46.0 - 65.4 Sacramento area 90.8 82.4 - 99.2 San Joaquin Valley 68.0 53.0 - 83.0 Central Coast 84.0 61.9 - 100.0 Los Angeles 56.7 46.7 - 66.6 Other Southern California 63.4 53.3 - 73.3 ! = Statistically Unstable Estimate Current Smokers Table 3 shows that around 3 in 5 (59.3%) NHPI adults reported being a current smoker. A current smoker is defined as someone who has had 100 or more cigarettes in their lifetime and smokes cigarettes some days or every day. Larger proportions of Native Hawaiians (77.8%) and Fijians (77.3%) reported being current smokers than any other adult comparing across NHPI subgroups. A higher percentage of NHPI male adults reported being a current smoker than NHPI female adults (81.7% vs. 37.9%). A higher percentage of NHPI adults aged 25 to 49 (62.5%) reported being current smokers than NHPI older adults or adults aged 65 and over (30.6%). NHPI adults with less than a high school diploma (92.6%) reported a higher percentage of being a current smoker than any other adult compared by education level. Larger proportions of adults in North or Sierra counties (84.3%), Sacramento area (90.5%), and Central Coast (84.0%) reported being current smokers compared to all other California regions. Table 3. Percentages of sample reporting current smoking by NHPI subgroups, sex, age, education level and regions in California Current Smoker (%) 95% Confidence Interval Overall NHPI Population 59.3 54.1 - 64.5 NHPI subgroups Native Hawaiian 77.8 72.3 - 83.2 Samoan 55.0 46.0 - 64.0 Tongan 42.3 28.2 - 56.5 Guamanian 38.8 20.9 - 56.8 Fijian 77.3 56.2 - 98.4 Other Pacific Islander 67.5 55.5 - 79.6 Sex Male 81.7 75.7 - 87.8 Female 37.9 30.9 - 45.0 Age 18 to 24 60.3 49.7 - 70.8 25 to 49 62.5 56.1 - 69.0 50 to 64 59.9 44.4 -75.4 65 and over 30.6 6.8 - 54.4 15 Education Less than high school 92.6 77.3 - 100.0 High school graduate 58.3 46.9 - 69.7 Some college or community college 64.3 56.7 -71.9 Bachelor's degree or higher 42.6 33.5 - 51.7 Region North/Sierra Counties 84.3 63.3 - 100.0 Larger Bay area 52.3 42.3 - 62.3 Sacramento area 90.5 82.1 - 98.9 San Joaquin Valley 67.8 52.9 - 82.8 Central Coast 84.0 61.9 - 100.0 Los Angeles 46.5 37.0 - 56.0 Other Southern California 55.8 45.5 - 66.1 ! = Statistically Unstable Estimate Current and Lifetime Use of Vaping Products Table 4 shows that 38.4% of NHPI adults in this sample reported current use of vaping products (past 30 days) and a majority (52.2%) reported having ever used vaping products (lifetime use). A larger proportion of Fijians (66.2%) reported current use of vaping products than any NHPI group. NHPI male adults reported both higher percentages of current use and ever use of vaping products than NHPI female adults. A higher percentage (62.0%) of NHPI young adults reported having ever used vaping products than older adults (24.0%). Table 4 also shows that percentages of NHPI adults reporting current and ever use of vaping products decreases across education levels, but with an uptick among NHPI adults with some college or community college. About 7 in 10 (70.7%) NHPI adults in the Sacramento region reported current use of vaping products, a larger proportion than any other region in California, while 17.0% of NHPI adults in the Central Coast reported current use of vaping products, the smallest proportion across regions in California. Larger proportions of NHPI adults in the Sacramento region (76.6%) and in the Central Coast (64.3%) reported having ever used vaping products than any other region in California. Table 4. Percentages of sample reporting current and ever use of vaping products by NHPI subgroups, sex, age, education level and regions in California Current Use of Ever Use of Vaping Vaping Products 95% Confidence Products 95% Confidence (%) Interval (%) Interval Overall NHPI Population 38.4 34.0 - 42.7 52.2 47.7 -56.8 NHPI subgroups 16 Native Hawaiian 52.5 45.1 -60.0 60.9 53.4 - 68.4 Samoan 32.8 24.2 - 41.3 49.6 40.3 - 58.9 Tongan 24.3 11.8 - 36.9 44.1 28.8 - 59.3 Guamanian 21.8 6.2 - 37.4 34.8 17.1-52.5 Fijian 66.2 43.9 - 88.5 68.7 46.1 --91.3 Other PI 45.7 33.6 - 57.7 60.6 47.9 -- 73.2 Sex Male 51.5 44.6 - 58.3 63.4 55.9 - 70.9 Female 25.9 20.5 - 31.3 41.6 35.3 - 47.97 Age 18 to 24 45.2 33.8 - 56.6 62.0 50.2 - 73.8 25 to 49 39.5 34.7 - 44.3 55.4 49.7 - 61.1 50 to 64 34.8 20.7 - 48.9 43.3 28.2 - 58.4 65 and over 21.3 0.0 - 42.6 24.0 (!) 2.5- 45.5 Education Less than high school 59.4 36.0 - 82.8 68.9 47.4--90.5 High school graduate 34.6 24.5 --44.6 43.7 32.9 - 54.4 Some college or community colleae 40.2 33.4 - 47.0 59.8 52.8 - 66.9 Bachelor's degree or higher 32.7 23.9 - 41.4 43.4 34.0 - 52.8 Region North/Sierra 50.2 23.0 -77.4 58.0 28.4 - 87.5 Larger Bay area 25.5 18.4 -32.6 37.9 29.2 - 46.5 Sacramento 70.7 55.3 - 86.0 76.6 62.2 - 91.0 San Joaquin Valley 51.2 36.9 - 65.6 58.9 44.0 - 73.9 Central Coast 17.0 0.0 - 36.9 64.3 29.3 - 99.4 Los Angeles 35.5 27.1 - 43.9 49.9 40.2 - 59.6 Other Southern California 36.3 26.2 - 46.4 54.7 44.0 - 65.4 ! = Statistically Unstable Estimate Current Use of Other Tobacco Products Tobacco products other than cigarettes and vaping products include big cigars, little cigars or cigarillos, snokeless tobacco (i.e., chewing tobacco, snuff or snus), hookah, heated tobacco products, and nicotine pouch. Among NHPI adults in this sample 17 reported current of use tobacco products were: big cigars (22.4%), little cigars (21.4%), smokeless tobacco (22.1%), heated tobacco products (20.8%), hookah (18.3%), and nicotine pouch (16.9%). Larger proportions of Native Hawaiian adults reported current use of other tobacco products compared to the general NHPI adult population. NHPI male adults were more likely to report use of other tobacco products than NHPI female adults. Current use of other tobacco products was similar across age groups. NHPI adults with less than a high school diploma were more likely to use other tobacco products than any other NHPI adult compared across education level. Smaller proportions of NHPI adults in the Bay Area, Los Angeles, and other Southern California regions reported use of other tobacco products than other regions in California (See Appendix Table 1). Current Use of Flavored Tobacco Products Table 5 shows that a majority (54.6%) of NHPI adults in this sample reported current use of flavored tobacco products. NHPI male adults reported higher current use of flavored tobacco products than NHPI female adults (71.0% vs. 38.9%). Current use of flavored tobacco products was similar across age groups. Larger proportions of NHPI adults with less than a high school diploma reported current use of flavored tobacco products than NHPI adults with a bachelor's degree (76.0% vs. 42.1%). A larger proportion of NHPI adults in the Sacramento area (88.3%) reported current use of flavored tobacco products than any other NHPI adult across regions in California. Table 5. Percentages of sample reporting current use of flavored tobacco products by NHPI subgroups, sex, age, education level and regions in California Use of Flavored Tobacco (%) 95% Confidence Interval Overall NHPI Population NHPI groups Native Hawaiian Samoan Tongan Guamanian Fijian Other Pacific Islander Sex Male Female Age 18 to 24 25 to 49 50 to 64 65 and over Education Less than high school 54.6 49.7 - 59.5 66.4 58.9 - 73.9 51.0 41.6 -60.4 45.6 30.5 - 60.7 34.6 16.8 - 52.3 16.8 55.6 - 97.9 61.4 48.7 - 74.0 71.0 64.8 -77.3 38.9 32.0 - 45.8 97.7 46.0 - 69.5 59.2 53.4 - 64.9 46.0 30.6 - 61.3 30.6 (!) 6.8 - 54.4 76.0 56.4 - 95.7 18 High school graduate 49.8 38.2 - 61.3 Some college or 61.4 53.9 - 68.8 Bachelor's degree or 42.1 32.7 - 51.4 Region North/Sierra Counties 79.1 58.0 - 100.0 Larger Bay area 42.2 32.9-51.5 Sacramento area 88.3 79.5 - 97.1 San Joaquin Valley 65.0 49.9 - 80.0 Central Coast 53.0 (!) 20.8 - 85.2 Los Angeles 46.3 36.9 - 55.6 Other Southern 53.6 42.7 - 64.5 ! = Statistically Unstable Estimate Current Use of Betel Nut with Tobacco Betel nut is a fruit from the tropical areca palm. In some cultures, betel nut is consumed with other ingredients such as tobacco. Table 6 shows that about over three quarters (77.4%) of NHPI adults who chewed betel nut used it with tobacco in the past 30 days. Larger proportions of Samoans (81.3%) and other Pacific Islanders (91.6%) reported current use of betel nut with tobacco across NHPI subgroups. NHPI young adults (86.0%) and adults aged 25 to 49 (84.6%) reported higher current use of betel nut with tobacco than adults aged 50 to 64. Almost all (99.5%) of NHPI adults who have less than a high school diploma reported current use betel nut with tobacco compared across education level. The Central Coast (99.1%), Northern and Sierra Counties (95.8%), and Bay Area (94.8%), were among the regions with the largest proportions od NHP! adults reporting current use of betel nut with tobacco. Table 6. Percentages of sample reporting current use of betel nut with tobacco by NHPI subgroups, sex, age, education level and regions in California Current Use of Betel Nut with Tobacco (%) 95% Confidence Interval NHPI Adults who Chewed Betel Nut 17.4 69.8 - 85.0 NHPI subgroups Native Hawaiian 75.1 66.2 - 83.9 Samoan 81.3 64.6 -- 98.1 Tongan 68.3 28.1 - 100.0 Guamanian 69.5 29.1 - 100.0 Fijian 58.9 31.0 - 86.7 Other Pacific Islander 91.6 85.0 -- 98.2 Sex Male 76.9 68.2 - 85.5 Female 78.9 64.1 - 93.7 Age 18 to 24 86.0 72.9 - 99.0 25 to 49 84.6 77.2 - 92.0 19 50 to 64 65 and over Education Less than high school High school graduate Some college or community college Bachelor's degree or higher Region North/Sierra Counties Larger Bay area Sacramento area San Joaquin Valley Central Coast Los Angeles Other Southern California Current Marijuana Use 47.0 22.7 -71.3 51.6 (!) 0.0 - 100.0 99.5 98.5 - 100.0 69.1 50.7 - 87.6 78.1 68.8 - 87.4 70.8 52.3 - 89.3 95.8 85.9 - 100.0 94.8 89.5 - 100.0 65.9 43.7 - 88.2 73.0 56.6 - 89.4 99.1 96.5 - 100.0 81.2 71.4-91.0 69.5 52.1 - 86.9 ! = Statistically Unstable Estimate Table 7 shows that 34.4% of NHPI adults reported current use of marijuana. Marijuana is used in this report instead of cannabis due to how the survey question was presented to respondents. A larger proportion of Native Hawaiians (50.6%) reported current marijuana use than any other NHPI group. The proportions of NHPI adults reporting current use of marijuana were similar across sex and age groups. A larger proportion of adults with less than a high school diploma (65.0%) reported current use of marijuana than other NHPI adults comparing by educational level. Larger proportions of NHPI adults in the Sacramento region (55.1%) and San Joaquin Valley (57.0%) region reported current use of marijuana than any other region in California. Table 7. Percentages of sample reporting current use of marijuana by NHPI subgroups, sex, age, education level and regions in California Use of Marijuana (%) 95% Confidence Interval Overall NHPI Population NHPI subgroups Native Hawaiian Samoan Tongan Guamanian Fijian Other Pacific Islander Sex Male Female Age 34.4 33.1 - 42.2 50.6 43.2 - 58.0 41.0 32.3 - 49.7 31.9 18.1 - 45.8 18.6 (!) 4.7 - 32.5 32.5 13.8 - 51.2 39.3 26.9 - 51.6 43.5 36.7 - 50.3 32.1 25.8 - 38.3 20 18 to 24 40.2 28.8 - 51.5 25 to 49 39.1 33.9 - 44.3 50 to 64 34.6 20.3 - 48.8 65 and over 27.3 (!) 2.8 -- 51.7 Education Less than high school 65.0 44.4 - 85.6 High school graduate 34.4 24.8 - 43.9 Some college or community college 32.7 26.6 - 38.9 Bachelor's degree or higher 39.7 29.8 - 49.6 Region North/Sierra Counties 31.0 (!) 6.9 - 55.1 Larger Bay area 29.9 21.1 - 38.8 Sacramento area 55.1 37.2 - 73.0 San Joaquin Valley 57.0 42.6 --71.4 Central Coast 53.3 (!) 21.1 - 85.5 Los Angeles 34.1 25.4 - 42.8 Other Southern California 32.3 23.6 - 40.9 ! = Statistically Unstable Estimate Co-Use and Poly-Use of Tobacco Products Table 8 shows that about 33.3% of NHPI adults reported current co-use of cigarettes and vaping products, 28.4% reported co-use of cigarettes and marijuana, and 22.8% reported poly-use of cigarettes, vaping products, and marijuana. Larger proportions of NHPI male adults reported co-use of cigarettes and vaping products (48.2% vs. 19.0%), co-use of cigarettes and marijuana (40.1% vs. 17.2%), and poly-use of cigarettes, vaping products and marijuana (34.4% vs. 11.8%) than NHPI female adults. Percentages of co-use of tobacco products and marijuana were similar across age groups. Larger proportions of NHPI adults with less than a high school diploma reported co-use of cigarettes and vaping products (51.0%), cigarettes and marijuana (63.9%), as well as poly-use of cigarettes, vaping products and marijuana (44.7%) than any other NHPI adult by educational level. Table 8. Percentages of sample reporting co-use of tobacco products and marijuana by NHPI subgroups, sex, age, and education level Use Both Use Both Use Cigarettes, Cigarettes & Cigarettes & Vaping Products & Vaping Products Marijuana Marijuana % (95% Confidence % (95% Confidence % (95% Confidence Interval) Interval) Interval) Overall NHPI 33.3 28.4 22.8 Population (29.0 - 37.5) (23.8 - 32.9) (19.1 - 26.6) NHPI subgroups Native Hawaiian 50.4 49.2 41.4 (43.1 - 57.8) (41.7 - 56.6) (34.6 - 48.3) 21 Samoan Tongan Guamanian Fijian Other Pacific Islander Sex Male Female Age 18 to 24 25 to 49 50 to 64 65 and over Education Less than high school High school graduate Some college or community college Bachelor's degree or higher 26.4 22.8 16.9 (18.6 - 34.2) (15.5 - 30.2) (10.8 - 23.0) 14.0 (!) 14.6 (!) 8.7 (!) (5.1 - 22.9) (4.1 - 25.0) (1.3 - 16.1) 17.1 (!) 9.9 (!) 6.8 9 (!) (4.0 - 30.1) (0.0 - 21.2) (0.0 - 16.1) 64.9 32.0 31.2 (1) (42.8 - 87.0) (13.4 - 50.6) (12.7 - 49.7) 41.9 36.2 31.0 (30.6 - 53.2) (24.3 - 48.0) (20.0 - 42.1) 48.2 40.1 34.4 (41.3 - 55.2) (33.4 - 46.8) (28.1 - 40.7) 19.0 17.2 11.8 (14.4 - 23.6) (12.2 - 22.2) (8.5 - 15.2) 34.0 28.0 22.6 (23.3 - 44.6) (18.6 - 37.5) (13.8 - 31.5) 35.2 30.1 24.4 (30.5 - 40.0) (24.9 - 35.4) (20.1 - 28.7) 31.0 26.7 23.1 (17.7 - 44.3) (13.9 - 39.4) (12.0 - 34.1) 21.3 (!) 19.2 (!) 11.1 (!) (0.0 - 42.6) (0.0 - 39.8) (0.0 - 26.8) 51.0 63.9 44.7 (30.4 - 71.6) (43.4 - 84.4) (25.8 - 63.6) 31.4 27.2 23.3 (21.8 - 41.0) (18.4 - 35.9) (15.4 - 31.1) 33.2 25.8 20.9 (26.8 - 39.7) (19.9 - 31.7) (15.9 - 25.9) 29.6 22.5 18.8 (21.1 - 38.1) (14.4 - 30.7) (11.6 - 25.9) 22 ! = Statistically Unstable Estimate Cessation Level of Comfort Receiving Cessation Services Table 9 shows that a majority (52.3%) of NHPI smokers indicated that they would be more comfortable receiving cessation services at health organizations that serve NHPI communities than health organizations serve the general public, while 20.9% indicated they would be less comfortable, and 26.8% indicated there would be no difference in their level of comfort. Percentages of smokers who reported that they would be more comfortable receiving services at NHPI serving health organizations were similar across NHPI subgroups, sex, and age. NHPI smokers who have a high school diploma (32.3%) were less likely to report that they would be more comfortable in receiving cessation services at an NHPI serving health organizations over general health organizations than NHPI smokers with some college or community college (54.2%), and NHPI smokers with a bachelor's degree (62.0%). Table 9. Percentages of NHPI smokers based on their level of comfort receiving cessation services at health organizations serving NHPI communities compared to general health organizations by NHPI subgroups, sex, age and education level More Comfortable Less Comfortable No Difference % (95% Confidence % (95% Confidence % (95% Confidence Interval) Interval) Interval) NHPI 52.3 20.9 26.8 Smokers (46.1 - 58.4) (16.2 - 25.5) (20.5 - 33.2) NHPI subgroups Native 49.9 25.4 24.6 Hawaiian (40.8 - 60.0) (17.4 - 33.7) (17.6 - 31.6) (32.2 - 60.7) (6.5 - 23.9) (23.4 - 51.7) (39.9 - 79.4) (7.6 - 45.2) (0.7 - 27.2) Fijian 47.5 25.4 (!) 27.4 (!) (24.3 - 70.7) (7.4 - 43.0) (2.7 - 52.0) Guamanian 61.0 10.1 (!) 20.9 (!) (32.9 - 89.0) (0.0 - 26.5) (0.5 - 57.5) Other PI 57.2 22.7 20.4 (!) (43.6 - 70.8) (12.4 - 32.3) (6.7 - 35.0) Sex Male 51.1 19.7 29.2 (43.9 - 58.3) (14.0 - 25.4) (21.7 - 36.8) Female 54.7 23.4 21.9 (43.7 - 65.7) (15.6 - 31.1) (12.4 - 31.4) 23 Age 18 to 24 50.6 17.7 (!) 31.7 (35.0 - 66.1) (7.2 - 28.1) (15.2 -- 48.2) 25 to 49 58.8 21.2 20.0 (51.9 - 65.8) (15.9 - 26.4) (13.8 - 26.1) 50 to 64 39.5 21.2 (!) 39.3 (20.3 - 58.6) (6.4 - 36.0) (20.4 - 58.3) (0.0 - 46.2) (0.0 - 75.9) (7.2 - 100.0) Education Less than 67.7 18.1 (!) 14.3 (!) high school (44.6 - 90.8) (0.4 - 35.7) (0.0 - 32.2) High school 32.3 31.9 35.8 graduate (19.0 - 45.6) (18.9 - 44.8) (21.4 - 50.2) Some college or community 54.2 18.1 27.7 college (46.6 - 61.8) (13.2 - 22.9) (19.8 - 35.7) Bachelor's degree or 62.0 15.7 22.2 higher (48.4 - 75.6) (5.9 - 25.4) (10.4 - 33.9) ! = Statistically Unstable Estimate Likelihood of Quitting if Cessation Services Were Tailored to NHPI Communities Table 10 shows that about two-thirds (66.1%) of NHPI smokers reported that they would more likely to quit smoking if cessation services were tailored to NHP! communities. A larger proportion of Guamanian (91.9%) and Fijian smokers (83.7%) indicated that they would be more likely to quit with NHPI specific cessation services than other NHPI smokers comparing by NHPI subgroups. Percentages indicating likelihood of smokers to quit were similar across sex and age. A larger proportion of NHPI smokers with less than high school diplomas (93.5%) reported that they were more likely to quit smoking if cessation services were NHPI specific than any other NHPI smoker when comparing by education level. Table 10. Percentages of NHPI smokers based on their likelihood of quitting smoking for good if cessation services were tailored to NHPI communities by NHPI subgroups, sex, age and education level More Likely Less Likely No Difference % (95% Confidence % (95% Confidence % (95% Confidence Interval) Interval) Interval) NHPI 66.1 21.0 12.9 Smokers (61.0 - 71.3) (16.7 - 25.2) (8.8 - 17.0) 24 NHPI subgroups Native Hawaiian Samoan Tongan Guamanian Fijian Other Pacific Islander Sex Male Female Age 18 to 24 25 to 49 50 to 64 65 and over Education Less than high school High school graduate Some college or community college Bachelor's degree or higher 51.2 27.9 20.9 (42.5 - 59.9) (19.9 - 35.9) (14.2 - 27.7) 67.2 15.7 17.1 (!) (55.4 - 79.0) (8.8 - 22.6) (6.6 - 27.5) 67.4 23.0 9.6 (!) (47.8 - 87.0) (4.1 - 41.9) (0.0 - 20.9) 91.9 8.1 (80.5 - 100.0) (0.0 - 19.4) N/A 83.7 16.3 (70.4 - 97.0) (3.0 - 29.6) N/A 67.7 24.4 5.5 (!) (53.4 - 82.1) (11.7 - 37.1) (0.0 - 17.1) 64.5 21.5 14.0 57.9-71.1 (16.1 - 27.0) (8.5 - 19.5) 68.7 19.7 10.7 (!) 59.3 - 78.1 (12.5 - 27.0) (4.4 - 17.0) 66.8 21.3 11.8 (!) 52.9 - 80.8 (9.5 - 33.1) (2.7 - 20.9) 69.9 19.3 10.3 64.1 - 75.7 (14.5 - 24.1) (6.0 - 14.7) 51.6 29.4 19.0 (!) 31.4-71.7 (12.1 - 46.7) (7.0 - 13.0) 60.0 (!) 7.6 32.4 (!) 11.5 - 100.0 (0.0 - 37.0) (0.0 - 76.8) 93.5 4.2 (!) 2.3 (!) 85.8 - 100.0 (0.0 - 10.5) (0.0 - 7.0) 51.8 25.9 22.2 38.0 - 65.6 (15.2 - 36.7) (10.2 - 34.3) 62.2 24.0 13.2 55.4 - 69.0 (18.5 - 29.5) (8.1 - 18.3) 73.0 19.0 8.0 (!) 60.1 - 86.0 (6.6 - 31.3) (2.9 - 13.1) Attempt to Quit in the Past 12 Months Table 11 shows that 16.6% of NHPI smokers did not attempt to quit smoking in the past year. A larger proportion (36.1%) of Tongan smokers did not attempt to quit smoking than any other smoker comparing by NHPI subgroups. Attempt to quit in the past 12 ! = Statistically Unstable Estimate months was similar comparing by sex. NHPI young adults (97.8%) were more likely to report having attempted to quit in the past year than any other age group. NHPI smokers with less than a high school diploma (97.7%) were also more likely to report having attempted to quit in the past year when comparing by education level. Table 11. Percentages of NHPI smokers who attempted to quit in the past 12 months by NHPI subgroups, sex, age and education level. Did Not 95% 95% Attempt to Quit Confidence Attempted to Confidence (%) Interval Quit (%) Interval NHPI Smokers 16.6 10.9 - 22.2 83.4 77.8 - 89.1 NHPI subgroups Native Hawaiian 19.0 10.0 - 28.0 81.0 72.0 - 97.1 Samoan 9.7 (!) 2.9- 16.5 90.3 83.5 - 97.1 Tongan 36.1 15.2 - 56.9 63.9 43.1 - 84.8 Guamanian 19.7 (!) 0.0 - 44.5 80.3 55.5 - 100.0 Fijian 2.8 (!) 0.0-6.7 97.2 92.3 - 100.0 Other Pacific Islander 17.2 (!) 2.8-31.5 82.8 68.5 -- 97.2 Sex Male 12.9 6.9 - 19.0 87.1 81.0 -93.1 Female 23.3 11.9-34.8 76.7 65.2 - 88.1 Age 18 to 24 2.2 (!) 0.0 - 5.3 97.8 94.7 - 100.0 25 to 49 16.5 11.0 - 22.1 83.5 77.9 - 89.0 50 to 64 30.5 (!) 5.2 - 55.7 69.5 44.2 -- 94.8 65 and over 40.2 (!) 0.0 - 100.0 59.8 (!) 0.0 - 100.0 Education Less than high school 2.2 (!) 0.0-5.3 97.7 94.7 - 100.0 High school graduate 16.5 11.0 - 22.1 88.5 77.9 - 89.0 Some college or community college 30.5 (!) 5.2 - 55.8 69.5 44,.2-94,7 Bachelor's degree or higher 40.2 (!) 0.0 - 100.0 59.8 (!) 0.0 - 100.0 ! = Statistically Unstable Estimate Ever Attempted to Quit Smoking (Lifetime) Table 12 shows that 14.0% of NHPI smokers have never tried to quit smoking cigarettes in their lifetime. Native Hawaiian smokers (32.0%) reported a higher percentage of never having tried to quit smoking in their lifetime than any other smoker comparing by NHPI subgroups, despite 77.3% of Native Hawaiian adults having reported being a current smoker. NHPI male smokers were less likely to report having attempted to quit smoking 26 in their lifetime than NHPI female smokers (78.6% vs. 93.1%), despite NHP! male adults being more likely to report being a current smoker than NHPI female adults. NHPI smokers with a bachelor's degree (92.5%) are more likely to report having attempted to quit in their lifetime than NHPI smokers with less than a high school diploma (66.5%). Table 12. Percentages of NHPI smokers who attempted to quit smoking in their lifetime by NHPI subgroups, sex, age and education level Never 95% 95% Attempted to Confidence Attempted to Confidence Quit (%) Interval Quit (%) Interval NHPI Smokers 14.0 10.9 - 17.0 86.0 83.0 - 89.1 NHPI subgroups Native Hawaiian 32.0 24.0 -- 40.0 68.0 59.7 - 76.0 Samoan 14.1 7.8 - 20.5 85.9 79.5 - 92.2 Tongan 9.1 (!) 0.0 - 18.3 90.9 81.7 - 100.0 Guamanian 0.6 (!) 0.0 - 1.7 99.3 98.3 - 100.0 Fijian 2.8 (!) 0.0-7.4 97.2 92.6 - 100.0 Other Pacific Islander 8.9 (!) 2.3-15.7 91.0 84.3 - 97.7 Sex Male 21.3 16.0 - 26.8 78.6 73.2 - 84.0 Female 6.9 3.6 - 10.2 93.1 89.7 - 96.4 Age 18 to 24 12.5 (!) 4.6 - 20.4 87.5 79.6 - 94.4 25 to 49 12.7 9.2-- 16.3 87.3 83.7 - 90.9 50 to 64 21.4 10.4 - 32.4 78.6 67.6 - 89.6 65 and over 10.4 (!) 0.0 - 25.1 89.6 74.9 - 100.0 Education Less than high school 33.5 (!) 13.6 - 54.5 66.5 46.5 - 86.4 High school graduate 11.7 6.1-17.4 88.3 82.6 - 93.9 Some college or community college 15.6 10.6 - 20.6 84.4 79.4 - 89.4 Bachelor's degree or higher 7.5 3.4- 11.7 92.5 88.3 - 96.6 ! = Statistically Unstable Estimate Top Fears if Quitting Smoking for Good Withdrawal symptoms (31.7%), relapse or unable to quit (23.6%), and decrease in social interaction with peers (15.7%) were the biggest fears that NHPI smokers had about quitting smoking for good. Percentages of the top three fears among NHPI smokers were similar across age, sex, and education level (see Appendix Table 2). 27 Barriers to Cessation Table 13 shows that around 2 in 5 (40.4%) NHPI smokers delayed or did not get nicotine replacement therapy (NRT) or prescription cessation medications due to cost. Larger proportions of Fijian (58.6%) and other Pacific Islander smokers (58.0%) reported that they delayed or did not get NRT or prescription cessation medications due to cost compared to other NHPI smokers across NHPI subgroups. Larger proportion of NHPI smokers who had less than a high school diploma (56.4%) reported that they delayed or did not get NRT or prescription cessation medications due to cost compared to any other NHPI smokers across education levels. Table 13 also shows that 37.4% of NHPI smokers delayed or did not seek cessation services because of perceived unfair treatment due to their race or ethnicity. Larger proportions of Fijian (58.6%) or other Pacific Islander (58.0%) smokers also reported having delayed or not seek cessations services due to perceived unfair treatment comparing by NHPI subgroups. Percentages of smokers who delayed or not seek cessation services because of perceived race-based discrimination were similar across sex, age, and education level. Table 13. Percentages of NHPI smokers who had delayed or did not get NRT or prescription cessation medication due to cost or delayed or did not seek smoking cessation programs because of perceived race-based unfair treatment in the past year by NHPI subgroups, sex, age and education level Delayed or Did Not Seek Delayed or Did Cessation Not Get NRT or Because of Prescription Perceived Unfair Cessation 95% Treatment Due 95% Medication Due Confidence to Race/Ethnicity © Confidence to Cost (%) Interval (%) Interval NHPI Smokers 40.4 34.2 - 46.6 37.4 31.4- 43.8 NHPI subgroups Native Hawaiian 33.2 26.9 - 40.3 34.9 26.7 - 41.5 Samoan 35.7 23.8 - 47.6 30.7 20.4 - 41.0 Tongan 33.4(!) 13.4 - 53.4 28.4 (!) 9.9 - 46.9 Guamanian 29,7 (!) 5,3 - 50.1 49,9 (!) 19.7 - 80.2 Fijian 58.6 33.9 - 83.2 56.6 32.6 - 80.7 Other Pacific Islander 58.0 43.2 -72.9 44,2 29,2 - 59.2 Sex Male 39.3 31.4 - 47.2 36.3 28.7 - 43.8 Female 42.7 32.9 - 52.6 39.7 29.8 - 49.6 Age 28 18 to 24 46.8 30.9 - 62.8 36.7 23.0 - 50.4 25 to 49 45.8 39.1 - 52.6 44.0 37.4 -- 50.5 50 to 64 15.1 (!) 0.0 - 30.7 20.8 (!) 2.1 - 39.5 65 and over 32.4 (!) 0.0 - 80.0 5.9 (!) 0.0 - 19.8 Education Less than high school 56.4 34.3 - 78.6 44.8 24.2 - 65.5 High school graduate 40.9 26.7 - 55.1 34.6 20.7 - 48.4 Some college or community college 37.5 29.8 - 45.2 33.7 26.6 - 40.8 Bachelor's degree or higher 36.3 22.4 - 50.2 44.6 31.0 - 58.1 ! = Statistically Unstable Estimate Methods of Cessation Among NHPI smokers who tried to quit in the past year, 71.2% used cessation services programs at NHPI specific organizations, while 63.5% of NHPI smokers also reported using vaping products when trying to quit, 59.8% used NRT or prescription cessation medication and 59.6% used a cessation services hotline. Comparing across NHPI subgroups, a smaller proportion of Samoan smokers (45.0%) used NRT or prescription cessation medication compared to Other Pacific Islander smokers (80.3%). Samoan smokers (30.5%) were also less likely to use a cessation services hotline than Other Pacific Islander smokers (84.6%) comparing across NHPI subgroups. A smaller proportion of Tongan smokers (41.6%) used cessation services at NHPI organizations than Fijian smokers (85.9%). A larger proportion of Fijian smokers (94.7%) used vaping products to quit than any other NHPI smoker comparing by NHPI subgroups. Percentages based on cessation methods used comparing by sex were similar, except that a larger proportion of NHPI male smokers (65.0%) reported using NRT or prescription cessation medication than NHPI female smokers (46.2%). Comparing by age groups, percentages of NHPI smokers across cessation methods used were also similar. A larger proportion of smokers (72.4%) who have less than a high school diploma reported use of NRT or prescription cessation medication than any other NHPI adult comparing by education levels, which may be due to a larger percentage of current smokers have less than a high school diploma. Smokers in the San Joaquin Valley reported higher use of vaping products when attempting to quit than any other smoker across regions in California (see Appendix Table 3). 29 Secondhand Smoke Exposure Tobacco Secondhand Smoke (SHS) or Secondhand Vape (SHV) Exposure Table 14 shows that over a third (67.0%) of NHPI adults in the survey sample indicated exposure to tobacco secondhand smoke (SHS) or secondhand vape (SHV) in the past two weeks. A larger proportion (84.8%) of Fijian adults reported exposure to tobacco SHS or SHV than any other NHPI subgroups but exposures were still similar across NHPI subgroups. About 7 in 10 (71.6%) NHPI male adults reported exposure to tobacco SHS or SHV, but exposures were still similar compared by sex. Also, over 7 in 10 (72.0%) NHPI adults aged 25 to 49 reported exposure to tobacco SHS or SHV, but exposures were still similar across age groups. NHPI adults with less than a high school diploma (92.8%) were more likely to report being exposed to tobacco SHS or SHV than any other NHPI adult when comparing across education level. Larger proportions of NHPI adults in North or Sierra counties (88.7%), Central Coast (86.7%), and Sacramento (82.3%) reported exposure to tobacco SHS or SHV than any other region in California, but exposure was still similar across regions in California. Close to 4 in 5 (79.1%) NHPI adults who are considered homeowners in a single-unit building reported exposure to tobacco SHS or SHV, but exposure was still similar across housing status. Marijuana Secondhand Smoke Exposure Table 14 also shows that 48.9% of NHPI adults reported exposure to marijuana secondhand smoke (SHS), a lower percentage of reported exposure compared to NHPI adults exposed to tobacco SHS or SHV. A majority (52.6%) of NHPI female adults reported exposure to tobacco SHS or SHV, but exposure was still similar compared by sex. Exposure to tobacco SHS or SHV was similar across age. Close to 7 in 10 (68.4%) NHPI adults with less than a high school diploma reported exposure to marijuana SHS, but exposure to marijuana SHS was still similar across education levels. Close to 2 in 5 (38.3%) NHPI adults in the larger Bay Area reported exposure to marijuana SHS, which was less than any region in California but exposure was still similar across regions in California. Table 14. Percentages of sample reporting exposure to tobacco secondhand smoke (SHS) or secondhand vape (SHV) or exposure to marijuana SHS by NHPI subgroups, sex, age, education, regions in California and housing status Exposure to 95% Exposure to 95% Tobacco SHS Confidence Marijuana Confidence or SHV (%) Interval SHS (%) Interval Overall NHPI Population 67.0 62.4 - 71.5 48.9 44.2 - 53.6 30 NHPI subgroups Native Hawaiian 70.7 65.0 - 76.4 53.4 46.0 - 60.8 Samoan 73.3 65.2 - 81.5 54.4 44.9 - 63.9 Tongan 55.7 41.5-69.8 49.8 34.9 - 64.9 Guamanian 45.0 26.3 - 63.7 39.4 21.0 - 57.7 Fijian 84.8 67.0 - 100.0 40.7 19.5 - 62.0 Other Pacific Islander 61.2 50.3 - 72.1 42.7 30.0 - 55.5 Sex Male 71.6 64.8 - 78.4 44.9 38.3 - 51.5 Female 62.6 55.8 - 69.3 52.6 45.4 - 59.7 Age 18 to 24 68.4 56.7 - 80.1 42.2 30.4 - 53.9 25 to 49 72.0 66.7 - 77.2 52.1 46.2 - 58.0 50 to 64 57.9 43.8 - 72.1 47.9 32.8 - 63.1 65 and over 45.0 17.3 --72.7 41.7 14.3 -69.1 Education Less than high school 92.8 81.7 - 100.0 68.4 47.3 -89.5 High school graduate 57.6 46.9 - 68.3 45.7 35.3 - 56.1 Some college or community college 68.1 60.7 - 75.4 46.5 38.9 - 54.0 Bachelor's degree or higher 65.8 56.0 - 75.6 49.2 39.4 - 59.1 Region North/Sierra Counties 88.7 76.4 - 100.0 34.9 (!) 11.1-58.6 Larger Bay area 55.5 45.5 - 65.6 38.3 28.4 - 48.2 Sacramento area 82.3 70.7 - 93.9 51.1 34.1 - 68.0 San Joaquin Valley 74.4 60.0 - 88.8 65.7 53.0 - 78.5 Central Coast 86.7 71.0 - 100.0 59.4 31.7 - 87.2 Los Angeles 62.6 52.7 - 72.6 50.3 41.3 - 59.2 Other Southern California 68.8 59.2 - 78.4 50.7 40.1 - 61.3 Housing Status Rent in multi-unit building 63.3 50.7 - 76.0 50.3 37.7 - 62.9 Rent in single-unit building 61.8 50.3 - 73.2 47.0 34.6 - 59.5 Homeowner in multi- unit building 79.1 68.5 - 89.6 46.0 33.2 - 58.9 Homeowner in single- unit building 67.3 60.2 - 74.4 49.3 42.2 - 56.4 Other arrangements 54.1 25.9 - 82.3 56.5 29.6 - 83.3 ! = Statistically Unstable Estimate Places of Exposure 31 Table 15 shows that larger proportions of NHPI adults reported exposure to tobacco SHS or SHV at home and on the sidewalk than in the workplace (71.2% and 72.5% vs. 58.7%, respectively). A smaller proportion of Tongans reported exposure to tobacco SHS or SHV in the workplace than any other NHPI group. Larger proportions of Native Hawaiians and Fijians reported exposure to tobacco SHS or SHV at home, on the sidewalk, and in the workplace compared across NHPI subgroups. NHPI female adults (37.6%) were less likely to reported exposure to tobacco SHS or SHV in the workplace than NHPI male adults (78.1%). NHPI female adults also reported less exposure to tobacco SHS or SHV in the workplace than at home or on the sidewalk (63.7% and 68.8%). Reported exposure to tobacco SHS or SHV at home was similar across sex, age, education level, housing status and regions in California. Likewise, reported exposure to tobacco SHS or SHV on sidewalks was similar across sex, age, education level, and regions in California. Reported exposures to tobacco SHS or SHV in the workplace was similar across age, education level, and regions in California. Table 15. Percentages of sample reporting places of exposure to tobacco SHS or SHV by NHPI subgroups, sex, age, education level, regions in California and housing status At Home In the Workplace On the Sidewalk % (95% Confidence % (95% Confidence % (95% Confidence Interval) Interval) Interval) NHPI adults exposed to 71.2 58.7 72.5 SHS or SHV (65.5 - 76.8) (52.8 - 64.7) (66.9 - 78.1) NHPI subgroups Native 84.0 82.4 86.9 Hawaiian (76.9 - 91.2) (73.5 - 91.2) (80.1 - 93.8) Samoan 66.3 45.8 65.6 (56.1 - 76.4) (34.6 - 57.1) (54.9 - 76.4) (39.4 - 88.7) (24.7 - 79.0) (43.6 - 95.8) Tongan 63.9 31.8 63.4 (46.8 - 81.1) (16.2 - 47.4) (44.1 - 82.7) Fijian 78.4 13.4 86.4 (61.1 - 95.8) (52.2 - 94.6) (72.6 - 100.0) Other Pacific 69.5 67.2 68.9 Islander (55.5 - 83.5) (53.5 - 81.0) (56.8 - 81.2) Sex Male 78.1 78.1 75.9 (71.5 -84.6) (71.4 - 84.7) (69.2 - 82.6) Female 63.7 37.6 68.8 (54.8 - 72.6) (29.4 - 45.9) (60.1 - 77.5) Age 32 18 to 24 25 to 49 50 to 64 65 and over Education Less than high school High school graduate Some college or community college Bachelor's degree or higher Region North/Sierra Counties Larger Bay area Sacramento area San Joaquin Valley Central Coast Los Angeles Other Southern California Housing Status Rent in multi- unit building Rent in single- unit building Homeowner in multi-unit building Homeowner in single- unit building 77.8 50.0 73.8 (66.6 - 89.0) (36.0 - 64.0) (68.7 - 100.0) 66.8 61.2 71.3 (60.4 - 73.2) (54.9 - 67.5) (59.4 - 83.7) 71.7 64.9 74.1 (51.4 - 92.1) (43.5 - 86.3) (53.7 -94.4) 100.0 (!) 42.6 (!) 78.6 (100.0 - 100.0) (2.6 - 82.6) (40.6 - 100.0) 64.3 (!) 62.5 86.3 (41.2 - 87.4) (39.6 - 85.5) (68.7 - 100.) 78.0 62.8 71.6 (66.6 - 89.4) (49.3 - 76.2) (59.4 - 83.7) 73.6 64.1 74.7 (66.1 - 81.1) (55.6 - 72.6) (66.5 - 82.8) 65.1 45.7 64.0 (54.7 - 75.5) (34.3 - 57.0) (51.8 - 76.1) 68.6 79.3 69.6 (37.5 - 99.6) (54.2 - 100.0) (41.7 - 97.6) 68.9 56.9 69.8 (57.5 - 80.4) (43.8 - 69.9) (57.2 - 82.3) 81.5 75.4 57.9 (69.2 - 93.9) (60.0 - 90.7) (37.8 - 78.0) 76.0 70.5 77.2 (62.5 - 89.5) (55.3 - 85.7) (63.5 - 90.9) 44.1 31.3 (!) 64.0 (10.3 - 77.8) (1.2 - 61.4) (27.1 - 100.0) 73.0 50.9 74.6 (63.3 - 82.7) (40.6 - 61.1) (66.1 - 83.2) 68.1 53.1 79.5 (55.0 - 81.3) (38.3 - 67.9) (69.0 - 89.9) 61.6 (49.3 - 73.9) N/A N/A 60.2 (45.4 - 75.0) N/A N/A 78.3 (66.4 - 90.3) N/A N/A 76.0 (68.0 - 84.0) N/A N/A 33 Other arrangements 68.7 (35.0 - 100.0) N/A N/A 34 ! = Statistically Unstable Estimate NHPI Adult Attitudes on Tobacco Use and Tobacco Control Policies Attitudes on Tobacco Use and its Impacts on the NHPI Health and Community Several attitudes-related questions regarding tobacco use and its impact on NHPI health and community were asked of NHPI adults. Betel nut with tobacco has been associated with an increased risk of certain cancers, precancerous lesions in the mouth and tooth decay. Table 16 shows that close to 4 in 5 (78.8%) NHPI adults agree or strongly agree that consuming betel nut with tobacco is dangerous to one's health with similar percentages of agreement as well as disagreement across NHPI subgroups. About 9 in 10 (90.7%) NHPI adults over the age of 65 agreed that betel nut with tobacco is dangerous to one's health with similar percentages of agreement and disagreement across age. Table 16. Percentages of agreement or disagreement on whether consuming a small quantity of betel nut with tobacco is dangerous to health by NHPI subgroups and age among NHPI adults Agree or 95% Disagree or 95% Strongly Agree Confidence Strongly Confidence (%) Interval Disagree (%) Interval Overall NHPI Population 78.8 74.5 - 83.0 21.2 17.0 - 25.4 NHPI subgroups Native Hawaiian 70.7 62.5 - 78.9 29.1 20.9 - 37.3 Samoan 77.9 69.3 - 86.6 22.1 13.4 - 30.7 Tongan 83.0 71.5-94.5 17.0 (!) 5.5 - 28.5 Guamanian 76.5 60.6 - 92.4 23.5 (!) 7.6 - 39.4 Fijian 85.9 71.7 - 100.0 14.1 (!) 0.0 - 28.3 Other Pacific Islander 85.9 77.8 - 94.0 14.1 6.0 - 22.1 Age 18 to 24 77.1 66.8 - 87.5 22.9 12.5 - 33.2 25 to 49 80.1 75.0 - 85.1 19.8 14.8 - 24.9 50 to 64 70.6 57.9 - 83.2 29.4 16.7 - 42.1 65 and over 90.7 76.2 - 100.0 9.3 (!) 0.0 - 23.8 ! = Statistically Unstable Estimate Table 17 shows that over two-thirds (67.6%) of NHPI adults agree or strongly agree that flavored vaping products and other flavored tobacco products are intentionally designed 35 to appeal to youth with similar percentages of agreement and disagreement across NHPI subgroups and age. Table 17. Percentages of agreement or disagreement on whether e-cigarettes and other flavored tobacco products are intentionally designed to appeal to youth by NHPI subgroups and age among NHPI adults Agree or 95% Disagree or 95% Strongly Agree Confidence Strongly Confidence (%) Interval Disagree (%) Interval Overall NHPI Population 67.6 62.6 - 72.7 32.2 27.1 - 37.2 NHPI subgroups Native Hawaiian 67.7 60.7 - 74.6 32.0 25.0 - 38.9 Samoan 64.1 54.7 - 73.5 35.6 26.1 - 45.0 Tongan 68.0 55.1 - 80.9 32.0 19.1 44.9 Guamanian 61.5 43.5 - 79.4 38.0 20.0 - 55.9 Fijian 71.0 49.7 - 92.3 29.0 (!) 7.7 - 50.3 Other Pacific Islander 76.6 66.0 - 87.9 23.4 12.1 - 34.8 Age 18 to 24 74.9 64.8 - 85.1 25.0 14.9 - 35.1 25 to 49 67.5 61.9 -- 73.1 32.1 26.6 - 37.7 50 to 64 57.1 42.4 -71.8 42.9 28.2 - 57.6 65 and over 74.5 50.5 - 98.6 25.5 (!) 1.4-49.5 ! = Statistically Unstable Estimate Table 18 shows that 76.2% of NHPI adults agree or strongly agree with similar percentages of agreement and disagreement across NHPI subgroups and age. Table 18. Percentages of agreement or disagreement on whether vaping, "Juuling", and using e-cigarettes are health threats to NHPI communities by NHPI subgroups and age among NHPI adults Agree or 95% Disagree or 95% Strongly Agree Confidence Strongly Confidence (%) Interval Disagree (%) Interval Overall NHPI Population 76.2 71.6 - 80.8 23.1 18.5 --27.7 NHPI subgroups Native Hawaiian 67.5 58.8 - 76.2 32.0 23.3 - 40.8 Samoan 74.3 65.9 - 82.7 25.1 16.7 - 33.6 Tongan 17.7 64.8 - 90.7 19.5 (!) 7.0 - 32.0 Guamanian 82.3 67.3 - 97.2 17.7 (!) 2.8 - 32.7 Fijian 81.6 59.7 - 100.0 18.4 (!) 0.0 - 40.3 Other Pacific Islander 82.6 72.4 - 92.7 17.1 7.0 - 27.3 Age 36 18 to 24 76.1 66.0 - 86.2 21.9 11.9 - 32.0 25 to 49 79.3 74.4 - 84.3 20.1 15.1 -- 25.1 50 to 64 69.5 56.9 - 82.1 30.0 17.5-426 65 and over 66.4 41.0 -91.8 33.6 (!) 8.2 - 59.0 ! = Statistically Unstable Estimate Table 19 shows that 66.4% of NHPI adults agree or strongly agree to this statement and with similar percentages of agreement across NHPI adults when comparing by NHPI subgroups and age. Table 19. Percentages of agreement or disagreement on whether tobacco advertising targets the NHPI community by NHPI subgroups and age among NHPI adults Agree or 95% Disagree or 95% Strongly Agree Confidence Strongly Confidence (%) Interval Disagree (%) Interval Overall NHPI Population 66.4 61.2-71.7 16.3 12.5 - 20.1 NHPI subgroups Native Hawaiian 67.9 59.9 -- 75.9 25.0 18.4 - 31.6 Samoan 59.0 49.1 - 68.9 12.2 5.8 - 18.6 Tongan 60.7 46.2 - 75.2 7.3 (!) 0.0 - 15.7 Guamanian 59.0 41.1 -77.0 29.3 12.1 - 46.6 Fijian 79.2 57.7 - 100.0 20.3 (!) 0.0- 41.8 Other Pacific Islander 83.4 75.4 - 91.3 9.2 4.4- 14.0 Age 18 to 24 66.1 55.1 -77.2 11.6 4.4- 18.8 24 to 49 70.6 65.8 - 76.4 11.5 7.9 - 15.3 50 to 64 57.6 42.0 -- 73.1 32.7 19.1 - 46.6 65 and over 54.7 27.6 - 81.7 27.6 (!) 3.6 - 51.7 ! = Statistically Unstable Estimate Table 20 shows that about 72.4% of NHPI adults agree or strongly agree that tobacco use is a bigger problem for NHPIs compared to the general public with similar percentages of agreement and disagreement when comparing by NHPI subgroups and age. Table 20. Percentages of agreement or disagreement on whether tobacco use is a bigger problem for NHPIs compared to the general public by NHPI subgroups and age among NHPI adults Agree or 95% Disagree or 95% Strongly Agree Confidence Strongly Confidence (%) Interval Disagree (%) Interval Overall NHPI Population 12.4 67.6 -77.3 27.3 22.4 - 32.2 37 NHPI subgroups Native Hawaiian 61.8 53.0 - 70.5 37.7 29.0 - 46.5 Samoan 68.7 60.0 - 77.4 30.8 22.0 - 39.5 Tongan 79.7 67.1 --92.2 20.3 (!) 7.8 - 32.9 Guamanian 79.9 65.8 - 94.0 20.1 (!) 6.0 - 34.2 Fijian 78.1 56.0 - 100.0 21.8 (!) 0.0 - 43.9 Other Pacific Islander 83.4 67.5 - 89.3 21.5 (!) 10.6 - 32.4 Age 18 to 24 67.0 54.9 -79.1 32.9 20.8 - 45.0 25 to 49 78.2 73.2 - 83.1 21.4 16.5 - 26.3 50 to 64 61.8 46.6 - 77.0 38.2 23.0 - 53.4 65 and over 64.9 37.9 -91.9 35.1 (!) 8.1 - 36.2 ! = Statistically Unstable Estimate NHPI Adult Attitudes Toward Tobacco Control Policies Two attitudes-related questions regarding tobacco control policies were asked of NHPI adults. Table 21 shows that about 76% of NHPI adults agree or strongly agree on a tobacco sales ban to anyone born after 2025. Fijian and Guamanian adults overwhelmingly support the sales ban with about 9 in 10 supporting such a policy. Larger proportions of adults between the ages of 50 to 64 and young adults disagree or strongly disagree to such a policy than adults ages 25 to 49 or older adults. Table 21. Percentages of agreement or disagreement on whether tobacco sales should be banned to anyone born after 2025 across NHPI subgroups and age among NHPI adults Agree or 95% Disagree or 95% Strongly Agree Confidence Strongly Confidence (%) Interval Disagree (%) Interval Overall NHPI Population 76.6 72.2 - 81.0 23.2 18.8 - 27.6 NHPI subgroups Native Hawaiian 62.2 54.0 - 70.4 37.6 29.4 - 45.9 Samoan 73.3 64.7 - 82.0 26.3 17.7 - 35.0 Tongan 85.5 75.5 -95.5 14.6 (!) 4.5-24.5 Guamanian 90.7 80.1 - 100.0 9.3 (!) 0.0 -- 19.9 Fijian 91.2 78.5 - 100.0 8.8 (!) 0.0-21.5 Other Pacific Islander 77.4 66.7 - 88.0 22.5 11.8 -- 33.1 Age 18 to 24 69.6 58.0 - 81.1 30.4 18.8 - 42.0 25 to 49 81.4 76.8 - 86.0 18.3 13.7 - 22.9 50 to 64 65.0 50.5 - 79.4 35.0 20.6 - 49.5 65 and over 82.6 62.0 - 100.0 17.4 (!) 0.0 - 38.0 38 ! = Statistically Unstable Estimate Table 22 shows that 83.2% of NHPI adults agree or strongly agree that apartment complexes should require all units to be smoke- and vape-free, with similar percentages of agreement across NHPI subgroups, age, and housing status. Table 22. Percentages of agreement or disagreement on whether apartment complexes should be smoke or vape- free by NHPI subgroups, age, and housing status among NHPI adults Agree or 95% Disagree or 95% Strongly Agree Confidence Strongly Confidence (%) Interval Disagree (%) Interval Overall NHPI Ponulation 83.2 79.4 - 86.9 16.1 12.5-19.8 NHPI subgroups Native Hawaiian 71.0 63.0 - 78.9 28.8 20.8 - 36.7 Samoan 85.9 79.0 - 92.9 14.1 7.1 - 21.0 Tongan 84.0 72.1 - 95.8 16.0 (!) 4.2--27.9 Guamanian 92.5 83.2 - 100.0 7.4 (1) 0.0 - 16.8 Fijian 67.3 43.5 - 91.1 21.6 (!) 0.1 - 43.2 Other Pacific Islander 90.9 85.2 - 96.6 8.9 (!) 3.2 - 14.6 Age 18 to 24 84.5 76.2 - 92.9 15.5 7.1-23.8 25 to 49 84.2 79.4 - 89.0 15.6 10.8 - 20.4 50 to 64 78.3 68.0 - 88.6 21.7 11.4 - 32.0 65 and over 82.6 61.5 - 100.0 9.3 (!) 0.0 - 23.8 Housing Status Rent in multi-unit building 79.8 69.2 - 90.4 20.2 9.6 - 30.8 Rent in single- unit building 86.3 77.0 - 95.6 13.6 4.4-22.9 Homeowner in multi-unit building 78.8 67.4 - 90.2 17.3 7.7 -27.0 Homeowner in single- unit buildina 85.1 80.3 - 89.8 14.8 10.0 - 19.5 Other arrangements 79.2 57.4 - 100.0 20.8 0.0 - 42.6 39 ! = Statistically Unstable Estimate Recommendations Future Research The California NHPI Tobacco Survey offers new insights to the ongoing health disparities that exists within NHPI communities in regards to tobacco use and other health behaviors associated with tobacco. While the California NHP| Tobacco Survey aimed to make data on NHPI communities more readily available and accessible, this survey also sought to offer avenues for researchers, policymakers and decisionmakers, and community stakeholders to advance efforts in ensuring that data collection on and within NHPI communities are more broadly exercised as well as ensuring that efforts to make the health and wellbeing of NHP! communities both a research and policy priority. While collecting data on understudied populations such as NHPI communities remain a challenge, future research should consider adopting a community stakeholder engagement model to tackle this issue. UCLA CHPR collaborated with a diverse set of community stakeholders at the onset of the California NHPI Tobacco Survey. Community stakeholders were invited to be subject matter experts of the study with the responsibility of supporting survey questionnaire development. In the process, community stakeholder engagement evolved and became vital in data collection efforts as community stakeholders became involved in survey dissemination, especially to survey respondents that UCLA CHPR would otherwise not have been able to reach. Moreover, community stakeholders were able to preview preliminary data results, provide recommendations on additional data analysis as well as interpretation of data results. In addition to community participation and engagement, UCLA CHPR also sought ways to ensure that both data and research products could be used for community outreach and advocacy around tobacco use. For example, UCLA CHPR created a standard paper- sized infographic (attached in this report) that contained key results from the study, which community members could use for public health outreach efforts. UCLA CHPR also hosted a "community report back", which was a townhall-style event that provided community members with an initial summary of the study conducted regarding NHPIs and tobacco use as well as opportunities for community members to voice out questions or future directions of the study. Ultimately, community engagement has been crucial to conducting research on NHPIs and tobacco use. Sampling Method Although the California NHPI Tobacco Survey utilized nonprobability-based sampling methods, future data collection should attempt to use probability-based sampling methods to create population-representative estimates when possible. Probability-based sampling methods not only allows for population-representative estimates, but also 40 further data disaggregation that have the potential to highlight potential drivers of health disparities and poor health outcomes among NHPI communities. COVID-19 Pandemic The COVID-19 pandemic and governmental policies that were implemented to slow the spread of the COVID-19 outbreak may have impacted data related to secondhand exposure and location of exposure. Collecting data post-pandemic would provide larger understanding of tobacco use and secondhand exposure as in-person social interactions returning to pre-pandemic levels. Modifications or Additional Questions to Consider for Future Research Income or poverty level - The latest estimates on income or level of poverty among NHPIs in the California Health Interview Survey are statistically unstable. A future follow-on study or research study in general with questions regarding household income or poverty as a percent of the federal poverty level would provide more information on whether income is a factor to tobacco use among NHPIs. In the survey results, around 90% of NHPI smokers with less than a high school diploma reported interest in smoking cessation programs, the highest when comparing NHPI smokers by education level. In this case, level of education may be a proxy for income or ability to pay. Questions regarding income or level of poverty can provide valuable insights in how to make tobacco cessation medications or treatments more affordable as well as how policy interventions such as current state taxes on tobacco products affect NHPI households. Factors to SHS or SHV exposure within a household - the study results show that tobacco SHS or SHV at home were similar across sex, age, and education level. Subject matter expert knowledge suggests that NHPI households mostly consist of intergenerational families with varying levels of tobacco use and health behaviors related to tobacco. Questions that explore these health behaviors within households may provide further insights to tobacco SHS or SHV at home and in general. Barriers to cessation - the survey asked questions regarding top fears of smokers when trying to quit for good as well as barriers to cessation such as cost of cessation treatment and perceived race-based discrimination when seeking cessation services. Subject matter experts also suggested including a greater set of questions to explore how information regarding cessation or cessation services are being received via the web and social media as well as questions that explore the social dynamics of smoking within the family and amongst peers. 41 List of Terms General Terms Young adults: adults between the ages of 18 to 24 years old. Older adults: adults who are 65 years old or older. Sex: sex assigned on original birth certificate: male or female. Tobacco Products Betel nut: Betel nut is a fruit from the tropical areca palm. In some cultures, betel nut is consumed with other ingredients such as tobacco. Big cigars: tobacco wrapped in tobacco leaf. Smokeless tobacco (chewing tobacco, snuff, or snus): loose leaf or ground tobacco leaves that come in a large pouch (bag) or in tins. Hookah: Water pipe used to smoke tobacco or something else. Heated tobacco products: tobacco in the form of heat-sticks or capsules that is heated, instead of being combusted or burned, using an electronic device. Little cigars or cigarillos (LCC): tobacco wrapped in tobacco leaf or brown paper. Nicotine pouch: is a small bag that contains nicotine and some other ingredients. Vapes: electronic devices like vape pens, vaping products, e-hookah, hookah pens, e- vaporizers, tanks, pods or mods used to inhale a vapor. Product Use Current use: use of tobacco or other products in the past 30 days. Ever used: use of tobacco or other products (lifetime). Co-use: Use of cigarettes and at least one tobacco product within the past 30 days OR use of marijuana or some other product and at least one tobacco product within the last 30 days. Poly-use: Use of two or more tobacco products within the past the past 30 days. Health Behaviors Tobacco use: use of cigarettes, vaping products or other tobacco products in the past 30 days. Other tobacco products: any tobacco product other than cigarettes or vaping products. Current smoker: respondent has had 100 or more cigarettes in their lifetime and smokes cigarettes daily or some days o Notacurrent smoker: smoked less than (<)100 cigarettes in lifetime or not smoke daily. 42 Endnote 1. U.S. Census Bureau. The Native Hawaiian and Pacific Islander Population 2010: 2010 Census Briefs. May 2012. 2. U.S. Census Bureau. A more diverse nation: Asian Americans population was the fastest growing race group from 2000 to 2019 from the 2000 to 2010 intercensal estimates (2000- 2009) and vintage 2019 estimates (2010-2019). 2019. 3. Asian Pacific Partners for Empowerment, Advocacy, and Leadership. Tobacco use among Asian American, Native Hawaiian and Pacific Islander communities in California. 2012. 4. Empowering Pacific Islander Communities and Asian Americans Advancing Justice. A community of contrasts in the United States. 2014. 5. Lew R and Tanjasiri SP. Slowing the epidemic of tobacco use among Asian Americans and Pacific Islanders. 2003. American Journal of Public Health 93(5): 764-768. 6. Palmer P, Lee C, Sablan-Santos L, and et. al. Eliminating tobacco disparities among Native Hawaiian Pacific Islanders through policy change: the role of community-based organizations. 2013. Health Promotion Practice 14(1): 36S-39S. 43