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204 Chapter 3


Chapter 4
Factors That Influence Tobacco Use
Among Four Racial/Ethnic Minority Groups

Introduction 207

Historical Context of Tobacco  208

African Americans 208
American Indians and Alaska Natives  209
Asian Americans and Pacific Islanders  211
Hispanics 222

Economic Influences 213

Tobacco Industry Support for Racial/Ethnic Minority Communities  213
Employment Opportunities 213
Advertising Revenues 214
Funding of Community Agencies and Organizations  215
Support for Education 217
Support for Political, Civic, and Community Campaigns  217
Support for Cultural Activities  218
Support for Sports Events  219

Advertising and Promotion 220
Magazine Advertisements 221
Outdoor Advertisements 221
In-Store Promotions 222
Racial/Ethnic Symbols, Names, and Events  222
Targeted Products 223

Psychosocial Determinants 225
Initiation and Early Use of Tobacco  225
African Americans 226
American Indians and Alaska Natives  227
Asian Americans and Pacific Islanders  227
Hispanics 228

Multiple Group Studies 229
Prevalence of Risk Factors for Cigarette Use  229
Factors Associated with Initiation of Cigarette Use  231
Factors Associated with Initiation of Smokeless Tobacco Use  232
Summary, Initiation and Early Use of Tobacco  233
Tobacco Use Among Adults  233
African Americans 233

American Indians and Alaska Natives  233
Asian Americans and Pacific Islanders  234
Hispanics 234
Summary, Tobacco Use Among Adults  235


Smoking Cessation 235
African Americans 235
American Indians and Alaska Natives  237
Asian Americans and Pacific Islanders  237
Hispanics 23 7
Summary, Smoking Cessation 237
Methodological Limitations of the Literature  238

Chapter Summary 239

Conclusions 240

Appendix. A Brief History of Tobacco Advertising Targeting African Americans  240
Early Assumptions 240

Early Targeted Advertising Efforts (194Os-1960s)  242
Recent Targeted Advertising Efforts (Late 196Os-1980s)  243

References 245


Tobacco Use Among U.S. Racial/Ethnic Mitzorify Groups

Introduction

  Tobacco use is determined and influenced by
several kinds of factors: (1) individual factors (per-
ceptions, self-image, peers); (2) social factors (societal
norms); (3) environmental factors, such as advertising
and economics; and (4) cultural factors, such as
traditional uses of tobacco, acculturation, and the
historical context of the tobacco industry in various
communities. Behavior and patterns of tobacco use
result from each of these factors and from their com-
plex interplay, which is difficult to study and measure.
Although available evidence has demonstrated that
these factors contribute to behavior, research has been
unable to quantify the distinct effect of each one and
the effects of their interaction. The lack of definitive
literature points to the need for further research to bet-
ter quantify the ways in which a person's exposure to
various social, environmental, and cultural influences
affects tobacco use behavior. Most likely, it is not a
single factor but rather the convergence or interaction
of some or all of these factors that significantly influ-
ences both a person's decision to use tobacco and pat-
terns of tobacco use (U.S. Department of Health and
Human Services [USDHHS] 1989; Lynch and Bonnie
1994; USDHHS 1994). This chapter examines the com-
plex factors that influence tobacco use among the four
major racial/ethnic minority groups.

  Tobacco has a role in all communities through
social, economic, and cultural connections. These con-
nections include (1) social customs, such as the shar-
ing and giving of tobacco in Asian communities; (2)
employment opportunities and economic growth
provided to racial/ethnic groups through tobacco
agriculture and manufacturing; (3) tobacco industry
support of community leaders and organizations; (4)
tobacco industry sponsorship of cultural events; and
(5) ceremonial and medicinal uses of tobacco. Indeed,
tobacco's history has led to some positive social
perceptions of tobacco, perceptions that may also
influence use.

  Cigarette advertising and promotion may stimu-
late cigarette consumption by (1) encouraging children
and adolescents to experiment with and initiate regu-
lar tobacco use, (2) deterring current tobacco users from
quitting, (3) prompting former users to begin using
again, and (4) increasing daily consumption by serv-
ing as an external cue to smoke (Centers for Disease
Control [CDC] 1990a). Whether or not they are
intended to do so, advertising and promotional activi-
ties appear to influence risk factors for adolescent

tobacco use (USDHHS 1994). Cigarette advertising
appears to affect young people's perceptions of the per-
vasiveness, image, and function of smoking. Because
misperceptions in these areas constitute psychosocial
risk factors for the initiation of smoking, cigarette ad-
vertising appears to increase young people's risk of
smoking. The Food and Drug Administration (FDA)
recently concluded that although advertising may not
be the most important factor in a child's decision to
smoke, studies establish that it is a substantial con-
tributing factor (Federal Register 1996).
  A different kind of influence is found in psycho-
social variables, which help explain why people start
using tobacco, why some continue using it, and why
some stop using it. Published research findings are
scant about individual and interpersonal factors that
influence tobacco use among African Americans,
American Indians, Alaska Natives, Asian Americans,
Pacific Islanders, and Hispanics. This paucity of data,
in fact, both inspired and hampered the development
of this report. Although research findings based on
samples of the majority white population may be
applicable to racial/ethnic populations, such
generalizability has not been sufficiently studied.
Furthermore, cultural differences exist among commu-
nities and members of various racial/ethnic groups in
values, norms, expectancies, attitudes, and the histori-
cal context of tobacco and the tobacco industry. Such
differences, in turn, may influence both the prevalence
of cigarette smoking in a particular racial/ethnic mi-
nority group and the effect of certain associated risk
factors (Marin et al. 1990a; Vander Martin et al. 1990;
Robinson et al. 1992a).

  Another important factor that may influence to-
bacco use behavior is the actual infrastructure within
a community for conducting tobacco control activities
that support a non-tobacco-use norm. This capacity
of the community for tobacco control activities is also
discussed in Chapter 5 of this report because it directly
affects such programs, in addition to the influence it
may have on the environmental context of tobacco use.

  The first part of this chapter summarizes the his-
tory of tobacco use among members of the four major
racial/ethnic groups in the United States-African
Americans, American Indians and Alaska Natives,
Asian Americans and Pacific Islanders, and Hispan-
ics. The association between the tobacco industry and
these communities, including economic influences and
the role of targeted advertising and promotion, is also

Factors That Inflllelrce Tobacco Use  207


Surgeon General's Repot9

described. The second part of the chapter discusses   tory of tobacco advertising targeting African Ameri-
psychosocial influences associated with initiation of   cans. Because so little information is available on the
tobacco use, maintenance, and cessation among the   history of cigarette advertising aimed at American In-
four groups. Unfortunately, the limited information   dians, Alaska Natives, Asian Americans, Pacific Island-
available affects the length and comprehensiveness of   ers, and Hispanics, these groups are not discussed in
the presentation. The appendix presents a short his-   the appendix.

Historical Context of Tobacco

African Americans

  The first recorded landing of Africans in the
United States was in 1619, when a group of indentured
servants was brought to Jamestown, Virginia (Foner
1981), and Jamestown quickly became the center for
profitable tobacco trade with England and other Eu-
ropean nations (USDHHS 1992). Indeed, a significant
portion of the early colonies' wealth derived from the
exportation of tobacco (Northrup and Ash 1970). Cot-
ton did not become preeminent until the invention of
the cotton gin in 1793 (Foner 1981). Tobacco farming
was widespread throughout the south, and although
tobacco was later supplanted by other crops (includ-
ing cotton) in many areas, it remains a major crop in
six states-Georgia, Kentucky, North Carolina, South
Carolina, Tennessee, and Virginia (Gale 1993).

  Whites initially were employed in tobacco culti-
vation, but as tobacco prices fell in Europe, tobacco
companies began using less expensive labor (Kulikoff
1986). Among other factors, the need for a larger and
less expensive labor force to grow tobacco led the colo-
nies to gradually transform the status of Africans from
indentured servants, who earned their freedom after
a period of involuntary servitude, to slaves, who were
the property of their masters for life. In addition to
slaves, many free African Americans worked in to-
bacco farming during the 18th and 19th centuries. In-
deed, more free African Americans were employed in
tobacco production than in any other occupational
category in the south during that time (Northrup and
Ash 1970). Slaves also hired themselves out as tobacco
laborers, and some earned enough funds to purchase
their freedom.

  After emancipation, freed African Americans
who had obtained some acreage began farming to-
bacco because it was a cash crop that did not require
much land to be profitable. In particular, freed
African Americans farmed tobacco in Georgia, North
Carolina, South Carolina, and Virginia. Nevertheless,

the number of tobacco farms owned by African Ameri-
cans has declined dramatically in the 20th century, pos-
sibly because so many African Americans, including
tobacco farm owners and laborers, were migrating to
the north (U.S. Commission on Civil Rights 1982; Gale
1993).

  In the colonial period and early years of the
United States, African Americans and whites worked
side by side in cigarette-manufacturing factories,
which tended to be primarily small cottage industries.
However, the introduction of the cigarette-making
machine in the mid-1880s changed this pattern. Be-
cause white women were viewed as the only group
that had the manual dexterity needed to operate the
machines, and it was socially unacceptable for Afri-
can American men and women to work alongside
white women, African Americans were replaced as
factory workers and relegated to less skilled, menial,
field jobs (Northrup and Ash 1970; Meyer 1992). Dur-
ing the early 19OOs, the dirtiest, unhealthiest, and low-
est paying jobs in tobacco factories were carried out
by African American women (Jones 1984). Because
the jobs held by African Americans in stemming and
processing the tobacco leaf were low paying, the to-
bacco industry made little effort to mechanize such jobs
before the early 1930s. Thus, many African Americans
remained employed in the tobacco industry, even as
tobacco factories began replacing people with labor-
saving machines (Northrup and Ash 19701.

  The high concentration of African Americans in
certain occupations helped them gain a foothold in one
of the few areas in which organized labor had achieved
success in the south. Initial unionizing efforts by the
Tobacco Workers International Union began in the
early 20th century (Kaufman 1986). The efforts of the
United Tobacco Workers Local 22 to encourage Afri-
can American members to register for and vote in
municipal elections are credited with the election of
an African American to the city council of Winston-
Salem, North Carolina, in 1947. At the same time, a

208 Cl1f7ptcr 4


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

rival-the Food, Tobacco, Agriculture, and Allied
Workers Union-sought to involve African Americans
in its unionizing efforts as equals. United Tobacco
Workers Local 22, which represented workers at the
R.J. Reynolds Tobacco Company in Winston-Salem,
remained one of the strongest unions in the south. The
union represented equal numbers of African Ameri-
can and white workers. In addition, African Ameri-
can women held significant leadership roles in the
union (Lerner 1973; Foner 1981). This early unioniza-
tion among African Americans in tobacco-producing
states was of such historic importance that it is con-
sidered one of the first civil rights movements (Korstad
and Lichtenstein 1988). Probably as a result of the ra-
cial divisions within the union movement and the re-
sidual power held by African American workers, R.J.
Reynolds was the first company to have African Ameri-
cans operate cigarette-making machines after World
War II and, in 1961, to open a factory with integrated
production lines and desegregated facilities (Northrup
and Ash 1970).

  Nevertheless, tobacco cultivation has not contrib-
uted significantly to the economic well-being of Afri-
can Americans in the southern states. In each of
the decennial censuses conducted between 1960 and
1990, about one-third of all counties in the south where
tobacco is a major agricultural product have been iden-
tified as areas of persistent poverty. These poverty-
stricken counties-concentrated in Georgia, North
Carolina, and South Carolina-tend to have more
farms owned and operated by African Americans than
the south in general (Gale 1993). In addition, econo-
mies of scale and the increasing mechanization of to-
bacco growing have accelerated the decrease in tobacco
farming, particularly by African Americans (U.S. Com-
mission on Civil Rights 1982; Gale 1993). For example,
by 1987, more than 50 percent of the farms operated
by African Americans specialized in livestock produc-
tion, and only 11 percent specialized in tobacco grow-
ing (Gale 1993).

  In summary, tobacco has been a part of the expe-
rience of African Americans since the early 16OOs, when
Africans were first brought to the Americas. The rela-
tionship between African Americans and tobacco
growers and manufacturers has changed in the
postslavery era but remains strong and complex, par-
ticularly since the mid-1940s. The strength derives
from the important economic role of tobacco among
African Americans, and the complexity comes from
the contradictory social and economic forces that
affected the African American worker. In addition,
changing market forces helped make African Ameri-
cans significant users of tobacco. As a result, the rela-

tionship of African Americans to the tobacco industry
was no longer primarily dependent on their role as
workers in the tobacco labor force but was now influ-
enced as well by their status as consumers. For ex-
ample, until the mid-1940s, many African Americans
held low-paying jobs in tobacco-related agriculture
and industry; around the time of World War II, how-
ever, some tobacco companies began to advertise to
African Americans. Advertising efforts increased in
the 195Os, a decade that saw African American men
surpass white men in smoking prevalence. During this
same time, the tobacco industry was hiring and pro-
moting African American workers. Other influences
affecting African Americans' ties to tobacco were the
tobacco industry's increased attention to and positive
steps toward civil rights in the 1950s and 196Os, the
broadcast ban on tobacco advertising that led the to-
bacco industry to seek more targeted market segments
in the 197Os, and the expansion of African American
political power in the 1980s and 199Os, which served
to give the tobacco industry additional access to the
African American community (Robinson et al. 1992bl.
The historical patterns underpinning the African
American community's relationship to tobacco may
affect African Americans' attitudes and behaviors to-
wards tobacco.

American Indians and Alaska Natives

  Tobacco has long played an important role in
the cultural and spiritual life of North and South
American Indians and Alaska Natives. When the Eu-
ropeans colonized the Americas, tobacco already was
being cultivated and used in many parts of the conti-
nent. Early European explorers documented the
cultivation and farming of tobacco and its extensive
use among tribes throughout most of North and South
America (Hedge 1910; Linton 1924) and in Alaska's
interior (Sherman 1972)---findings that have been sup-
ported by archaeological discoveries at a variety of sites
(Haberman 1984).

  When Europeans first arrived in the Americas,
tobacco served various purposes among American
Indians and Alaska Natives, including ceremonial, re-
ligious, and medicinal functions (McCullen 1967; Seig
1971; Ethridge 1978). In ceremonial and religious rites,
tobacco was a significant part of sacramental offerings.
For example, tobacco was used to ensure good luck in
hunting and to seal peace and friendship agreements.
When used for medicinal purposes, tobacco often was
mixed with other substances in topical ointments and
ingested for internal healing. For example, in the

Factors That I~zflueme Tobacco Use  209


Surgeon General's Report

northwest region of North America, tobacco was com-
bined with shell lime powder and then formed into
small marble-sized balls that were dissolved in the
mouth (Linton 1924). Tobacco smoke often was used
during prayers to aid in healing and was prescribed
to cleanse people, places, and objects of unwanted spir-
its. Tobacco smoke also was used at the beginning of
meetings as a ritual to cleanse the room and secure the
truth from the spoken word.

  Early inhabitants of the American continent also
inhaled tobacco smoke (Linton 1924). They often
placed burning or smoldering tobacco on the bare
ground or on a mound and then waved the smoke to-
ward their faces using the palms of their hands. Early
inhabitants also smoked rolled sheets of dried tobacco
leaves (cigars) and wrappings of cut tobacco, and they
smoked tobacco through a flaxen reed. The most com-
mon way to smoke tobacco was to place cut tobacco
within the bowl of a calumet-either a stone or a
hollowed-out bone pipe (Linton 1924).

  Tobacco smoking was part of many solemn oc-
casions among American Indians, such as when lead-
ers met (Paper 19881. In some tribes, the pipe became
such a powerful object that it was considered sacred.
Only certain individuals could use the pipe, and only
sacredly gathered tobacco could be burned in a pipe's
bowl (Linton 1924). The Hopi Tribe used tobacco reli-
giously, blowing smoke in the four sacred directions
to invoke good planting and to encourage rainfall.
Other tribes, such as the Delaware, Iroquois, and Sioux,
smoked tobacco during prayers, at the opening of the
sacred bundle-a collection of religious artifacts (Paper
1988). Tobacco also was used between enemies in
battle to signify a truce. If one party offered the pipe
and the other party accepted it, this signified the end
of the battle, and both parties would then put down
their weapons. As a result, the smoking of tobacco
leaves, often with the peace pipe, became associated
with the American Indian as a common symbol
that had significant positive social and cultural
connotations.

  During the 17OOs, tobacco became one of the most
important commodities traded among American In-
dians and Alaska Natives. For example, Alaska Na-
tives in the Arctic and sub-Arctic regions depended
on trade with tribes from the east and south of the
North American continent to obtain tobacco products
(Fortuine 1989). Among the items traded were special
smoking vessels, such as pipes made of stone quar-
ried in what is now Wisconsin and Minnesota (Linton
1924; Paper 1988).

  With the European colonization of the American
continent, tobacco became known in Europe, where it

was at times expressly forbidden, primarily because
of health concerns about the dangers of tobacco spit-
ting. Following tobacco practices in the Americas,
early European explorers smoked tobacco the way it
was smoked by American Indians (Linton 1924). In-
deed, many of the pipes these explorers used were
fashioned after tribal pipes. Europeans also adopted
many of the tribes' medicinal uses of tobacco. How-
ever, the use of tobacco for recreational purposes was
widely accepted and soon became primary. Euro-
peans also began to chew tobacco raw rather than in a
mixture of powdered shells or roots, as was the cus-
tom of North American tribes.

  Most early American Indian tobacco harvesting
was done with farming technologies that originated
in the Southern part of North America (Paper 1988).
For example, nonfarming nomadic tribes and light
farming tribes scattered tobacco seeds on holy grounds
near waterways or marshes and let the plants grow
without much cultivation. In fact, the Iroquois pro-
hibited their people from cultivating tobacco plants
or coming in contact with them while the plants were
growing to maturity. Other tribes, such as the
Blackfeet, Crow, and some Northern Plains Indian
people, grew tobacco plants instead of food crops in
small sacred patches for medicinal and ceremonial uses
(Linton 1924).

   Over the centuries as American Indians and
Alaska Natives experienced vast cultural and political
upheaval, their attitudes about tobacco changed sig-
nificantly. Today, among some contemporary Ameri-
can Indian and Alaska Native groups, tobacco use has
lost some of its traditional attributes and no longer is
endowed with the same special meaning. However,
some American Indians have maintained the traditional
practices associated with tobacco. For example, tobacco
is given as a gift to traditional healers and dancers at
powwows and many other social gatherings, and it is
presented to honor persons celebrating important
events, such as marriages. Many American Indians
consider tobacco to be a medicine that can improve their
health and assist in spiritual growth when used in a
sacred and respectful manner.  It is important to rec-
ognize the positive social context in which tobacco is
viewed in American Indian communities and to recog-
nize the difficulties these connotations may cause in
preventing tobacco use among youth and helping
adults to quit. It is possible that tobacco control efforts
could be enhanced by emphasizing the distinction be-
tween sacred uses of tobacco on ceremonial occasions
and addictive tobacco use by individuals. An additional
complicating factor for tobacco control efforts among
this population is that American Indians have become

210 Clznpter 4


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

increasingly reliant on tobacco sales and on the
revenues these sales bring to the reservations (see
Tobacco Industry Support for Racial/Ethnic Minority
Communities later in this chapter).

Asian Americans and Pacific Islanders

  Because about 63 percent of the Asian Americans
and Pacific Islanders in the United States are immi-
grants (U.S. Bureau of the Census 19931, their lives have
been influenced by the history of tobacco use in Asia
and the Asian Pacific. Asia's many countries and cul-
tures have different traditions regarding the use of to-
bacco. These differences are also reflected in Asian
Americans and Pacific Islanders themselves. Tobacco
was introduced in Asia in the early 17th century by
Europeans (Goodman 1992). Like the introduction of
opium in China, the exportation of tobacco to Asia has
led to an addiction that has dramatically changed the
health behaviors of Asians (Chen and Winder 1990).
The Dutch brought tobacco to China, where it was
mixed with opium. The Chinese subsequently intro-
duced tobacco in Mongolia, Tibet, and Eastern Siberia
(Goodman 1992). Early Portuguese explorers then
carried tobacco to India, Japan, and Java in 1605, and
the Japanese in turn introduced tobacco in Korea
(Laufer 1924). Asians later used tobacco in ways more
similar to its medicinal uses in other parts of the world.
In China, for example, tobacco was used as a remedy
against colds, malaria, and cholera. The beliefs about
the usefulness of tobacco as a medicine were so in-
grained in China during the 17th century that two
imperial edicts (1638 and 1641) prohibiting its use
failed to curtail tobacco use.

  Currently, tobacco is a crop of great significance
in Asia. In 1990, Asian countries produced approxi-
mately 60 percent of the world's tobacco crop
(Goodman 1992). By 1995, United Nations statistics
showed that Asian countries were producing 63.2 per-
cent of tobacco leaves in the world (Food and Agricul-
ture Organization of the United Nations [FAOI 1996).
Both China (34.1 percent) and India (9.0 percent)
ranked above the United States (6.3 percent) in the
percentage of total tobacco leaf production (FAO 1996).
In China, the manufacture and sale of tobacco prod-
ucts are part of the economic role that tobacco plays.
After foreign investment was legalized in China in
1979, the China National Tobacco Corporation entered
into joint ventures with Philip Morris, R.J. Reynolds,
and other foreign tobacco companies. The China Na-
tional Tobacco Corporation has dramatically increased
production after implementing western technology,
and its 183 cigarette factories, 150 tobacco drying

plants, 30 research institutes, and 520,000 workers
make up a strong part of the local economy (Frankel
and Mufson 1996).

  Whereas cigars, pipes, snuff, chewing tobacco,
cheroots (cigars), bidis (cigarettes of India), and kreteks
(clove cigarettes) initially were more commonly used
than regular tobacco cigarettes in Asia, cigarettes now
are an integral part of contemporary Asian and Asian
Pacific life. As expected, Asians and Pacific Islanders
who migrate to the United States bring with them the
attitudes and expectancies that have characterized the
use of tobacco in their countries of origin. Sharing ciga-
rettes, particularly among adult male guests, is a ges-
ture of hospitality in a number of Asian cultures (Tamir
and Cachola 1994). For example, distributing ciga-
rettes, particularly U.S. cigarettes, at Cambodian wed-
dings is a customary way of honoring the bride and
groom. In China, foreign visitors are expected to give
cartons of cigarettes to their hosts. In this regard, the
importance of using tobacco as a form of social ex-
change is very similar to the reinforcement given to
tobacco use among Hispanics.

  Cigarette smoking also has acquired utilitarian
uses in some Asian countries. In Southeast Asia, for
example, cigarette smoking is perceived as a way to
keep warm at night and to keep mosquitoes away
(Mackay and Bounxouie 1994). In some provinces in
China, anecdotal information indicates that babies and
toddlers are given puffs of lighted cigarettes to stop
them from crying (Mackay et al. 1993).

  Cigarette smoking in Asian society has been
popularly associated with affluence and sophistication
(Frankel and Mufson 1996). Accordingly, the promo-
tion of cigarette smoking in Asian countries follows
patterns fairly similar to those found in the United
States, where cigarette smoking is glamorized and of-
ten associated with affluence. In a recent article, Sesser
(1993) recounted how in one week of traveling in Asia
he "attended a Virginia Slims fashion show at a Tai-
wanese disco, watched the finals of the Salem Open
tennis tournament in Hong Kong, and followed the
progress of the Marlboro Tour `93, a bicycle race in the
Philippines" (p.78). Cigarettes made in the United
States are not only promoted in those Asian countries
where the importation of foreign cigarettes is allowed,
but also in China, where U.S. cigarettes are not freely
sold (Stebbins 1990). In these cases, brand recognition
is an important outcome of promotional campaigns
once the market is opened to imported cigarettes.

  Before market access trade actions by the United
States in the 198Os, advertising was unnecessary in
most Asian countries because tobacco production was
operated through state-owned tobacco monopolies.

Factors That Influence Tobacco Use  211


Surgeon General's Report

As a result, few brands were available for purchase.
The expansion of large transnational corporations
(e.g., British American Tobacco Company, Ltd., and
Philip Morris Companies Inc.) into Asian markets
brought about more brand competition and, thus, more
advertising. Advertising techniques have included
sponsorship of rock concerts and teen dances and ex-
tensive radio and outdoor advertising (Frankel and
Mufson 1996). According to a study reported by the
National Bureau of Economic Research using data from
Japan, Taiwan, South Korea, and Thailand, ". . . in 1991,
average per capita cigarette consumption was nearly
ten percent higher than it would have been had the
markets remained closed to U.S. cigarettes"
(Chaloupka and Laixuthai 1996, p. 13).

  The paucity of information about tobacco use
among Asian Americans and Pacific Islanders ham-
pers the formation of substantive conclusions about
the relationship between community attitudes and
behaviors and the historical relationship with tobacco
and the tobacco industry. Existing information, how-
ever, is sufficient to show that factors associated both
with the respective native cultures and with accultura-
tion are important. Tobacco prevention and control
programs must take these cultural factors into account
to positively influence the norms, attitudes, and be-
haviors of these racial/ethnic communities.

Hispanics

  The cultivation and processing of tobacco have
played a significant role in the economies of most Latin
American countries, including Brazil (Nardi 19851,
Colombia (De Montana 1978), Cuba (River0 Muniz
1964), and Mexico (Ros Torres 1984). In 1995, the level
of production of tobacco leaf in South America alone
reached 9.1 percent of the world total (FAO 1996).
In the United States, Hispanics, primarily those of
Cuban ancestry, have played a key role in the manu-
facture of cigars in Florida factories. As is true of all
immigrants, Hispanics who migrate from Latin
America are influenced by historical conditions in their
native countries regarding tobacco and the tobacco
industry and bring with them the attitudes and ex-

pectancies that characterize tobacco use in their coun-
tries of origin. These attitudes and expectancies are
often modified as the process of acculturation takes
place (Marin et al. 1989a).

  The history of tobacco use in Central and South
America as well as in the Caribbean predates the ar-
rival of the European explorers and therefore has ac-
quired a rich lore. Tobacco played a prominent role in
religious and healing practices of native inhabitants
of those regions. It was used by shamans or spiritual
leaders to induce trancelike states, ensure fertility, and
facilitate spiritual consultations. Many cultural and
social norms surrounded tobacco, all of which have
contributed to defining the role of tobacco in these
societies. Tobacco became a staple crop of the Ameri-
cas when the predominant means of obtaining food
shifted from hunting to agriculture. Tobacco manu-
facture and trade played a significant role in the econo-
mies of the Caribbean, Latin America, and North
America. A detailed account of the history of tobacco
in the Americas can be found in the Surgeon General's
report Smoking and Health in the Americas (USDHHS
1992).

  Recent surveys also indicate that Hispanic ciga-
rette smokers have group-specific expectancies and
attitudes that differentiate them from smokers of other
racial/ethnic groups. These expectancies and attitudes
are the product of social conditions and norms that
have dictated the use of tobacco in Latin American
countries for the last few centuries and are also the
effects of certain relevant cultural values, such as
simpath (a social mandate for positive social relations),
personalismo (the value placed on personal relation-
ships), and fmnilialism (the normative and behavioral
influence of relatives) (Marin and Marin 1991). Among
many Hispanics in the United States, cigarette smok-
ing is a social activity (Marin et al. 1989a; 1990a,b).
Although tobacco use remains a social activity among
all communities, given the cultural values of simpatiu
and personalismo, sharing cigarettes often serves as a
particularly strong form of social affiliation and friend-
ship. This norm must often be considered when to-
bacco prevention and control programs are initiated
within Hispanic communities.

212 Chapter 4


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

Economic Influences

Tobacco Industry Support for Racial/Ethnic
Minority Communities

  The tobacco industry's longtime economic
support for U.S. racial/ethnic communities may have
contributed to the survival of many of these commu-
nities' institutions (Robinson et al; 1992b). For
example, the tobacco industry supports African Ameri-
can communities in five main ways: (1) direct employ-
ment of African Americans, (2) support for social
services and civil rights organizations, (3) contributions
to politicians and political organizations, (4) support
for educational and ctiltural programs, and (5) con-
tracts with small businesses (Blum 1989; Robinson et
al. 1992a,b). More recently, the tobacco industry also
has provided economic support to American Indian,
Alaska Native, Asian American, Pacific Islander, and
Hispanic communities.

  As detailed below, the tobacco industry has em-
ployed members of racial/ethnic communities prima-
rily in farming and manufacturing, although some
have been employed in sales and marketing positions.
The industry's support for social services and civil
rights organizations and its involvement in educational
and cultural activities have been wide-ranging: This
support has included contributions to endowments,
scholarship funds, and literacy campaigns as well as
support for artistic groups, exhibits, and performances.
Contributions from tobacco companies and tobacco-
related political action committees have underwritten
the growth of racial/ethnic political power at the
local, state, and national levels. In addition, many to-
bacco companies use the services of minority-owned
businesses either through their own internal programs
or through formal alliances with such groups as Op-
eration PUSH (People United to Save Humanity) and
the National Association for the Advancement of Col-
ored People (NAACP). In addition, tobacco product
sales and promotions have contributed to the econo-
mies of racial/ethnic communities. For example, the
sale of cigarettes and smokeless tobacco contributes
to the economies of small corner convenience stores
catering to racial/ethnic minority communities in ur-
ban areas. Tobacco is an important income-generating
resource also on some Indian reservations. Because
reservations are exempt from paying excise and sales
taxes on tobacco products, tobacco shops are operated
to produce additional income for the community. Al-
though these shops are legally restricted to selling

tax-free cigarettes to American Indians, this restriction
is rarely monitored.  A number of reservations are
located a short distance from major cities whose resi-
dents often drive to the reservations to purchase tax-
free or low-tax cigarettes and other tobacco products.

  The interrelationships between the tobacco in-
dustry and racial/ethnic group leaders, industries, and
community agencies may have served to strengthen
bonds between the industry and the four racial/eth-
nit groups that are the subject of this report. These
relationships are based on several factors, one being
that the tobacco industry has often been the only source
of funds for community initiatives. In addition, the
tobacco industry has built personal alliances with
members of racial/ethnic groups through employment
and personal relationships (Robinson et al. 1992b).
Indeed, Philip Morris's record in making financial com-
mitments to community programs a$ a result of
racial/ethnic-related networking has been noted
(Stanley 1996). Efforts in African American commu-
nities to put tobacco control strategies in place have
had to overcome some leaders and organizations who
were reticent about such action because the commu-
nity had a positive relationship with the tobacco in-
dustry, partly based on the industry's strong support
for local economic, social, and cultural activities
(Robinson et al. 1992b). Many leaders and members
of these communities have a positive predisposition
toward both the industry and cigarette smoking.

Employment Opportunities

  Although the tobacco industry initially discrimi-
nated against African Americans, excluding them from
many types of factory jobs, it eventually began hiring
many African Americans in manufacturing positions
(Northrup and Ash 1970). By the 193Os, African Ameri-
cans made up about half of all persons employed in
the process of taking tobacco from its leafy state to a
finished product (Northrup and Ash 1970; Foner 1981).

  African Americans have been concentrated in the
tobacco industry for three main reasons: (1) factories
were located in the Southern states, where the African
American population was largest; (2) more laborers
were needed as the demand for cigarettes grew after
World War I; and (3) other opportunities opened for
whites in an expanding economy, leaving African
Americans with few job alternatives because of racial

Factors That Influence Tobacco Use  213


Surgeon General's Report

discrimination and other factors (Northrup and Ash
1970).

  In the last few decades, the involvement of Afri-
can Americans in the production and marketing of
tobacco has changed significantly. By 1960, African
Americans represented less than 25 percent of tobacco
workers-a decline from more than 50 percent 30 years
earlier. Possible reasons for this dramatic decrease
include (1) the migration of African Americans from
southern to northern states; (2) the imposition of the
minimum wage, which eliminated many of the low-
paying jobs in which African Americans were concen-
trated; (3) the mechanization of tobacco factories,
which required fewer people to produce the same
number of cigarettes; and (4) the inability of unions to
change the poor working conditions of African Ameri-
can workers, leading to their exodus from those com-
panies (Northrup and Ash 1970).

  Today, the tobacco industry employs African
Americans as well as members of other racial/ethnic
minority groups in a variety of factory, marketing, and
promotional positions. In the latter two types of posi-
tions, members of racial/ethnic groups conduct pro-
motional and marketing activities with owners of local
shops and convenience stores serving racial/ethnic
neighborhoods in urban areas and racial/ethnic en-
claves in metropolitan areas.

  The tobacco industry was one of the early lead-
ers among corporations in providing opportunities in
management to qualified African Americans. Two
African American executives of tobacco companies
were honored in 1997 by the Business Policy Review
Council at its annual Corporate Pioneers Gala Tribute
for their long-term contributions as corporate pioneers
in breaking down color barriers in the business world
(US Newswire, Inc. 1997).

  Members of various racial/ethnic communities
also have been employed as models or spokespersons
in the advertising and promotion of tobacco products.
Advertising and public relations agencies select racial/
ethnic minority models and celebrities to promote and
advertise tobacco products to targeted racial/ethnic
groups in print and outdoor advertisements. These
easily recognizable racial/ethnic models and celebri-
ties are essential to targeted advertising, and advertis-
ing agencies have relied heavily on members of racial/
ethnic communities to fill these modeling jobs. For
example, the tobacco industry used African American
athletes extensively to advertise tobacco products dur-
ing the 1950s and 196Os, when racial integration was
taking place in sports (see the appendix). In a study
of advertising in Ebony magazine during the 1950s and
196Os, investigators found that African American ath-
letes were used in cigarette advertisements far more

frequently than other African American celebrities and
entertainers (Pollay et al. 1992). The use of well-known
athletes, entertainers, and public figures in tobacco in-
dustry marketing and public relations campaigns has
continued into the 1990s.

Advertising Revenues

  By placing advertisements in racial/ethnic pub-
lications, primarily those with limited circulations,
tobacco companies have become important contribu-
tors of advertising revenues for these publications
(Blum 1986). As a result, many racial/ethnic minority
publications-including community-oriented newspa-
pers and national magazines-rely on revenues from
tobacco advertising (Cooper and Simmons 1985;
Milligan 1987; Blum 1989; Tuckson 1989; Robinson et
al. 1992b). Some racial/ethnic publications indepen-
dently sought closer economic ties with the tobacco
industry For example, after the ban on the broadcast
advertising of tobacco products took effect in 1971, a
group of African American newspaper publishers ap-
proached the tobacco companies and asked them to in-
crease their business with African American media
(Williams 1986).

  Corporate media leaders are aware of the reli-
ance of African American publications on tobacco
advertising (Robinson 1992). The publisher of Target
Market News, an African American consumer-
marketing publication, has suggested that "reducing
cigarette ads could deprive the inner city of much-
needed revenues" (Johnson 1992b, p. 27). Similarly,
the president of an African American advertising
agency has predicted that "if they kill off cigarette and
alcohol advertising, black papers may as well stop
printing" (Johnson 1992b, p. 27). In 1988, the National
Black Monitor, a monthly insert in about 80 African
American newspapers, published a three-part tribute
to the tobacco industry. The National BlackMonitor has
defended its relationship with the tobacco industry and
has stated that "black newspapers . . . could not have
survived without the past and continuing support
from the tobacco industry" (1990, p. 4).

  National and local publications directed at other
racial/ethnic groups also frequently carry tobacco
product advertisements and promotions. These include
full-page, four-color advertisements in magazines and
full-page advertising spreads in community newspa-
pers. In 1989, for example, Hispanic magazine ran a short
story contest, sponsored by Philip Morris, which offered
a $1,000 honorarium and publication of the winning
story. The contest was promoted in a special issue cel-
ebrating Hispanic Heritage Month, and announcements

214 Chapter 4


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

appeared in a message from the editor on the magazine's
first page and in a one-page display.

  The relatively high level of tobacco product ad-
vertisements in racial/ethnic and general publications
is problematic because the editors and publishers may
limit stories dealing with the damaging effects of to-
bacco or limit the level of antitobacco information in
their publications for fear of retribution from tobacco
companies (Evans 1990; Robinson et al. 1992a; Warner
et al. 1992). Their concerns may be valid. For example,
when New: week published an article on the nonsmok-
ers' rights movement, tobacco advertisers removed all
tobacco advertisements from that issue and ran them
later (Warner 1985). In addition, a study of cancer cov-
erage and tobacco advertising over a six-year period
in three African American popular magazines (Ebony,
Essence, and jet) found that these magazines published
only nine articles that focused on cancers caused by
cigarette smoking (six on lung or bronchus cancer, one
on bladder cancer, and two on throat cancer).  In the
articles on lung cancer, smoking was rarely discussed
as a major contributing cause; smoking was not men-
tioned as a cause of throat cancer (Hoffman-Goetz et
al. 1997).

  Although magazines and newspapers with large
circulations can sustain the sporadic loss of advertis-
ing revenues, the livelihood of racial/ethnic publica-
tions can be effectively threatened by such losses,
Tobacco companies typically place less than 10 per-
cent of their advertising budgets with small African
American weeklies (Russ 1993); however, these adver-
tisements may often mean the difference between sur-
vival and failure for small publications (Tuckson 1989;
Robinson et al. 1992b). Magazine advertisements of
tobacco products have decreased recently in all types
of publications (Federal Trade Commission [FTC]
1997), indicating that magazines distributed nation-
ally, including those serving racial/ethnic minority
communities, may rely somewhat less on tobacco
companies for advertising revenues. For example, 6.5
percent of Ebony's full-page advertisements were for
tobacco products in 1993, compared with 9.4 percent
in 1988,13.5 percent in 1983, and 11.6 percent in 1978
(Gerard0 Marin and Raymond Gamba, unpublished
data). Additionally, a comparison of revenues gener-
ated from advertising for the first 11 months of 1989
showed that major African American publications such
as Iet, Ebony, and Essence received proportionately
higher revenues from tobacco companies than did
major mainstream publications (Ramirez 1990).

  Industries associated with the tobacco industry
may also provide public relations support to racial/
ethnic publications. In 1992, for instance, an adver-

tisement in Ebony paid for by the Nabisco Foods Group
(RJR Nabisco, Inc., of which R.J. Reynolds Tobacco
Company is a subsidiary) saluted the magazine's
publisher and seven other African American entre-
preneurs as "role models to our nation's youth and as
inspiration to all of us" (Nabisco Foods Group 1992,
p. 2).

  Eight-sheet billboards are also frequently used
to advertise tobacco products in racial/ethnic commu-
nities. These billboards are small (5 x 11 feet) and are
often placed close to eye level on the sides of build-
ings and stores. In 1985 alone, tobacco companies
spent $5.8 million on eight-sheet billboards in African
American communities; this amount accounted for 37
percent of total expenditures for this medium. Tobacco
companies spent $1.4 million on such billboards in
Hispanic neighborhoods (Davis 1987).

Funding of Community Agencies and
Organizations

  The tobacco product and alcoholic beverage in-
dustries have made significant financial and in-kind
contributions to various racial/ethnic community or-
ganizations at the local, regional, and national levels.
These contributions have at times been described as
marriages of convenience in which community orga-
nizations and agencies receive much-needed income
and tobacco companies gain, at a minimum, name rec-
ognition and goodwill (Maxwell and Jacobson 1989).
Trade publications suggest that such community rela-
tions efforts are "effective . . . devices to augment mi-
nority advertising efforts and throw some water on
any hot spots" (DiGiacomo 1990, p. 32). Recipients of
tobacco industry support include most of the larger
national organizations as well as a plethora of smaller
local community agencies. In fiscal year 1989, for ex-
ample, organizations receiving support from tobacco
companies included the Congressional Hispanic Cau-
cus, the National Black Caucus of State Legislators, the
National Urban League, and the United Negro Col-
lege Fund (UNCF) (Johnson 1992a,b). Internal tobacco
industry documents released by Doctors Ought to Care
(DO0 show that Philip Morris gave more than $17
million to racial/ethnic, educational, and arts groups
in 1991 (Solberg and Blum 1992).

  One large racial/ethnic minority organization
that has refused the support of the tobacco industry is
the National Coalition of Hispanic Health and Human
Services Organizations (COSSMHO), which has
adopted a formal policy not to accept money from to-
bacco companies or their subsidiaries. The diversity

Factors That I@uence Tobacco Use  215


Surgeon General's Report

of contributions to racial/ethnic community agencies
can be illustrated through a review of contributions
made to African American organizations. For example,
Philip Morris has contributed to such organizations
as the Leadership Conference on Civil Rights, the Na-
tional Association of Black Social Workers, the National
Association of Negro Business and Professional
Women's Clubs, the National Black Police Association,
100 Black Men of America, Inc., the National Coali-
tion of 100 Black Women, the National Conference of
Black Lawyers, the National Minority AIDS Council,
and Operation PUSH (Jackson 1992; Rosenblatt 1994).
R.J. Reynolds has contributed to the NAACP; UNCF;
and Opportunities Industrialization Centers of
America, a national network of job training centers
(Russ 1993). Other tobacco companies and the Tobacco
Institute itself have made similar contributions to
African American and Hispanic organizations
(Robinson et al. 1992a).

  In communities where tobacco companies have
offices and factories, additional programs and activi-
ties have been funded to the benefit of whites as well
as members of racial/ethnic communities. This sup-
port has ranged from funding for local sites of the
Young Men's Christian Association to sponsorship of
Christmas tree-lighting ceremonies (Jackson 1992). The
tobacco industry also has participated in special cel-
ebrations and has sponsored awards and recognition
events for various civic organizations. For example,
at each year's conference of the National Urban
League, Philip Morris presents the Herbert H. Wright
Awards to African American executives of major cor-
porations who have excelled in working on behalf of
humanitarian causes. The awards are named in
memory of one of the first African American execu-
tives at Philip Morris.

   Promotional materials further document the to-
bacco industry's involvement with racial/ethnic com-
munities. Current information is difficult to obtain,
but in 1986, RJR Nabisco published the booklet called
A Growing Presence in the Mainstream, which summa-
rized the company's involvement with racial/ethnic
communities amid quotations from Martin Luther
King, Jr., John F. Kennedy, Booker T. Washington, Maya
Angelou, and the New Testament, along with photo-
graphs of an African American member of the
company's board of directors (RJR Nabisco, Inc. 1986).
The booklet reported a number of the company's ac-
complishments, including RJR Nabisco's record for
employing members of racial/ethnic minority groups,
the provision of more than 25 percent of RJR Nabisco's
total company-paid employee group life insurance
by African American-owned insurance firms, the

advertising of RJR Nabisco's products in more than
200 racial/ethnic magazines and newspapers each
year, and recognition by the UNCF as the largest con-
tributor to the fund's schools since 1983. The booklet
also listed 122 different organizations to which the
company provided funding, including the National
Urban League; the NAACP; the League of United Latin
American Citizens; Howard University; Alpha Kappa
Alpha Sorority; the Portland Life Center; the Harlem
Dowling-West Side Center for Children and Family
Services; New Jersey's Special Supplemental Food Pro-
gram for Women, Infants and Children; the National
Council of Negro Women; the National Puerto Rican
Coalition; and ASPIRA, Inc., of New Jersey (RJR
Nabisco, Inc. 1986).

  At the community level, tobacco companies rely
on athletic, cultural, and social events to promote their
products' images, often in association with small com-
munity agencies. In African American and Hispanic
communities, tobacco companies frequently sponsor
street fairs, jazz festivals, Little League baseball teams,
soccer teams, symphony orchestras, auto races, and
art exhibits, just as they do in white communities (Blum
1986; Robinson et al. 1992b; Sanchez 1993). These con-
tributions place community agencies in a particular
dilemma, because many of the agencies' programs
depend directly or indirectly on contributions received
from the tobacco industry. At the same time, accep-
tance of money and services from the tobacco indus-
try may be perceived as an indirect endorsement of
tobacco use. Community leaders generally are split
in their opinions about the propriety of accepting sup-
port from tobacco companies and alcoholic beverage
companies (Robinson et al. 1992al. Opponents argue
that the costs of compromised integrity, implicit en-
dorsement of tobacco and alcoholic beverages, and
current and future increases in disease and death in
these communities are far greater than the benefits
these funds provide. Proponents argue that these
funds-when made available for such purposes as
scholarships, conferences, business development,
health fairs, and the organizations' survival-benefit
the various racial/ethnic communities, particularly
when other sources of financial support have been in
short supply or unavailable. Strategies and policies
that promote funding sources other than tobacco com-
panies are needed to alleviate communities' reliance
on tobacco-related support (Satcher and Robinson
1994).

  The tobacco industry also supports the opera-
tions and activities of racial/ethnic organizations by
providing special services, such as the publication of
resource guides and other materials (Blum 1986). For

216 Chapter 4


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

example, Philip Morris has biennially published the
Guide to Black Organizations since 1981 (Philip Morris
Companies Inc. 1992). The guide lists national,
regional, and local African American nonprofit orga-
nizations throughout the United States, as well as Af-
rican American state and regional caucuses of elected
and appointed officials. Philip Morris also publishes
and widely distributes two similar publications, the
hJdiona1 Directory of Hispanic Organizations (Congres-
sional Hispanic Caucus Institute, Inc. 1993) and the Na-
tional Directoq of Asian Pacific American Organizafions
1997-1998 (Organization of Chinese Americans 1997).

Support for Education

colleges and universities were located (Blum 1985). In
addition to supporting the UNCF, tobacco companies
have supported African American higher education
in a variety of other ways, such as through other
scholarships and internship programs (Robinson et al.
1992b).

  In recent years, the tobacco industry has begun
supporting adult literacy efforts. In 1990, Philip Mor-
ris joined with the Pew Charitable Trusts and the Phila-
delphia Mayor's Commission on Literacy to launch
the Gateway Program, an adult literacy campaign de-
signed to serve as a national model. Philip Morris con-
tributed $1.5 million to the program and an additional
$1.5 million for media support (Robinson et al. 1992b).
In yet another outreach effort, Philip Morris subsidized
the Milwaukee County Youth Initiative, a program
designed to help low-income and minority families
become more involved in the education of their chil-
dren (Haile 1991).

  For years, the tobacco industry has contributed
to programs that aim to enhance the primary and sec-
ondary education of children, has funded universities
and colleges, and has supported scholarship programs
targeting-African Americans (the UNCF) and Hispan-
ics<the National Hispanic Scholarship Fund).   -

  Philip Morris has contributed to Teach For
America, a not-for-profit group that trains teachers, pri-
marily those in racial/ethnic urban school systems, such
as those in Baltimore City and the District of Columbia
(Marriott 1992). In addition, both Philip Morris and R.J.
Reynolds donate money to public school systems in
racial/ethnic minority communities (Milloy 1990).

Support for Political, Civic, and
Community Campaigns

  The emergence of racial/ethnic minority politi-
cal power, mostly at the local level, has provided yet
another avenue for the tobacco industry to bolster its
support of racial/ethnic communities. Although most
of the contributions at the national level have gone
to white legislators, two African American legislators
were 14th and 16th on a list of tobacco industry-related
campaign contributions received from January 1985
through September 1995 (Fisher 1995).

  For more than a century, the tobacco industry has
provided financial support to historically and pre-
dominantly African American colleges and universi-
ties in the United States. This funding tradition can
be traced to Richard Joshua Reynolds, who founded
R.J. Reynolds about the time that African Americans
were emerging from slavery. In 1891, Reynolds gave
money to a school that eventually became Winston-
Salem State University, a school that educated freed
slaves (Russ 1993).

  The tobacco companies also have been strong
supporters of the UNCF, which was founded in the
mid-1940s to provide a central fund-raising arm for a
number of small, struggling, predominantly African
American private colleges and universities. When
questioned in the mid-1980s about the appropriateness
of accepting contributions from tobacco companies, a
former head of the UNCF gave three reasons for ac-
cepting the contributions: (1) the companies had been
longtime supporters of higher education for African
Americans, even when the cause was not popular;
(2) the contributions from the tobacco companies were
too large to reject because the colleges needed the
money to survive; and (3) the tobacco companies had
factories in communities where the African American

  At the state and local levels the tobacco industry
has been generous to all, including racial/ethnic
legislators, particularly those in a position to vote on
increases in tobacco excise taxes and smoking restric-
tions on the job and in public places. Since Califor-
nians passed Proposition 99, which raised the cigarette
sales tax by 25 cents per pack, political contributions
from tobacco companies in California rose from less
than $800,000 in the 1985-1986 elections to more than
$7.6 million in the 1991-1992 elections (Begay et al.
1993). These politicians, some of whom are of racial/
ethnic origins, once elected, control how the excise tax
revenues are spent and what proportion of the
revenues is spent on tobacco control and tobacco-
education projects.

  Other contributions have been made by the to-
bacco industry to civic leaders through such mecha-
nisms as Brown & Williamson Tobacco Corporation's
Kool Achiever Awards, which are designed to recog-
nize a dozen or so urban achievers "working to create
long-term benefits for urban communities" (Brown &

Factors That Irzflr~e~zce Tobacco Use  217


Surgeolz General's Report

Williamson Tobacco Corporation 1993, back cover).
Each recipient chooses a nonprofit organization
to which Brown & Williamson donates $5,000. In
1993, R.J. Reynolds began a similar campaign entitled
Salem FreshsideTM Salute, which recognizes African
Americans working to improve the conditions usually
found in center cities by giving these individuals do-
nations of $5,000. In addition, promotional campaigns
directed at the nation as a whole can affect racial/
ethnic minority communities. For example, in 1989,
Philip Morris sponsored a touring exhibition of the Bill
of Rights. Philip Morris placed advertisements cel-
ebrating the freedoms guaranteed by the Bill of Rights
in dozens of magazines and newspapers, including a
large number of African American and Hispanic pub-
lications. Photographs of admired celebrity members
of racial/ethnic groups appeared in the tobacco
company's advertisements. Such efforts engender
good will and name recognition among various racial/
ethnic groups. Just as some organizations, such as
COSSMHO and, more recently, the Tet Festival in San
Jose, California, and the Dia De Fiesta Latina Day of
the Del Mar Fair in California, have refused to accept
tobacco industry dollars (Fernandez 1996; Levin and
Perry 1996; San Diego Union-Tribune 1996), individu-
als are also refusing to accept similar tributes. For ex-
ample, a community activist was awarded but declined
to accept the Kool Achiever Award because of the ethi-
cal dilemma he perceived related to the high number
of African Americans whose diseases or deaths are
caused by tobacco use (Rosenberg 1993).

Support for Cultural Activities

  Tobacco companies have been creative in their
efforts to reach all members of society via cultural
events (Johnson 1992b). Tobacco companies sponsor
large museum exhibitions, concerts, and performances
for the full spectrum of society. Advertisements for
cigarettes and, in some cases, for smokeless tobacco
are often placed conspicuously at these events, al-
though sometimes the tobacco industry's sponsorship
is noted more subtly in catalogs and program notes.
Some of the activities, however, are directed at racial/
ethnic communities and are designed to support or
enhance racial/ethnic pride and culture-such as
Mexican rodeos; American Indian powwows; racial/
ethnic minority dance companies; racial/ethnic pa-
rades and festivals; Tet festivals; Chinese New Year
festivities; Cinco de Mayo festivities; and activities re-
lated to Black History Month, Asian/Pacific Ameri-
can Heritage Month, and Hispanic Heritage Month
(Warner 1986; Maxwell and Jacobson 1989).

  In some instances, tobacco products are associ-
ated with popular community events through spon-
sorships and store promotions. In 1989, for example,
Skoal Bandit smokeless tobacco was tied to the
promotion of Miami's Calle Ocho festival through live
radio remotes from several 7-Eleven stores in the Mi-
ami area (Gross 1989). During that same year, the pro-
motion of Skoal Bandit was associated with a Hispanic
festival in Corpus Christi, Texas, and with the 10th
anniversary car and truck show of Lowrider magazine
(Gross 1989). Recently, the 1994 Little Saigon Tet Fes-
tival in Orange County, California, was sponsored by
Marlboro and 555 State Express of London brands of
cigarettes. Booths at the festival were used to promote
the two brands of cigarettes through displays and the
distribution of promotional items.

  The sponsorship of artistic events has been one
of the fastest growing segments of special events
marketing, and tobacco companies have taken full ad-
vantage of this trend to expand and strengthen their
linkages with various racial/ethnic communities
(Bergin 1990). The tobacco industry's link with racial/
ethnic music and art is not new; for example, in the
195Os, tobacco companies featured African American
jazz artists in cigarette advertisements in Ebony maga-
zine. However, these links are more complex today
(Pollay et al. 1992; Robinson et al. 1992b). For example,
in 1994, New York City art institutions that received
funds from Philip Morris were placed in a difficult situ-
ation when the tobacco company asked them to in-
form city council members about the role that Philip
Morris had played in sponsoring artistic events in New
York City. At that time, the city council was consider-
ing a ban on cigarette smoking in most restaurants and
public places, and Philip Morris was threatening to
move the company headquarters away from New York
City if such a ban was approved (Goldberger 1994).
The headquarters did not move despite the city's pas-
sage of a 1995 law that banned smoking in workplaces
(except for physically separated, separately ventilated
smoking rooms and private offices), restaurants seat-
ing more than 35 patrons, day care centers, and play-
grounds (Smith 1995).

  Musical events have long been a primary outlet
for targeting support among racial/ethnic groups. For
example, jazz, rap, blues, rhythm and blues, salsa,
gospel, and world music concerts are often heavily
sponsored by tobacco companies and are identified
with specific cigarette brands targeted toward African
Americans, Hispanics, and Asian Americans and Pa-
cific Islanders. Tobacco companies heavily promote
these concerts on racial/ethnic minority radio stations,
in the press, and through magazines that have large
circulations (Robinson et al. 1992a,b). At these

218 Chapter 4


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

concerts, companies often promote their cigarette
brands by naming events after the brands, by placing
promotional signs on and around stages, and by dis-
tributing free cigarettes and other promotional items
featuring cigarette brand logos. These musical events
have included the Parliament World Beat Concert Se-
ries, Brown &Williamson's Kool Jazz Festival, Benson
& Hedges's blues and jazz concerts, and Philip Morris's
Superband Series. The Superband Series was launched
in 1985 by Philip Morris to support and publicize jazz
as "America's unique contribution to the field of mu-
sic" (let 1990, p. 36). The Superband, which featured
African American musicians, performed throughout
the world and the United States.

  Racial/ethnic dance troupes and the visual arts
have been strongly supported by tobacco companies.
Philip Morris has contributed significantly to African
American troupes, including the Alvin Ailey Ameri-
can Dance Theater and the Dance Theatre of Harlem
(Blum 1989; Rothstein 1990; Jackson 1992; Johnson
199213). Philip Morris also has provided substantial
funding to the Studio Museum in Harlem, one of the
main repositories of African American paintings,
sculptures, and crafts. In addition, tobacco companies
have underwritten traveling art shows featuring Afri-
can American and African artists and have displayed
the artists' work in corporate settings (Jackson 1992;
Robinson et al. 3992131. Traveling exhibits of Hispanic
and Asian American artists have received significant
support from tobacco companies as well.

  One of the longest running cultural events in
African American communities is the annual eight-
month tour of the Ebony Fashion Fair. Founded in 1958
by the publisher of the leading African American
magazine, this event is attended by more than 300,000
women in 190 cities. From the late 1970s to the early
199Os, R.J. Reynolds's More cigarettes supported the
fair (Assael 1990). Proceeds from the tour have ben-
efited African American churches, sororities, and other
charitable and civic organizations whose antidrug
campaigns, health fairs, and other projects are cited in
the program. When the show was supported by More
cigarettes, fashion models lit cigarettes during walks
down the runway. In addition to reciting the names
of clothing designers, the announcer noted that the

models smoked More cigarettes. Free samples of More
cigarettes were distributed to members of the audi-
ence as they left the performance. At the Chicago per-
formance of the 1984 Ebony Fashion Fair, R.J. Reynolds
marked the UNCF's 40th anniversary by donating a
$250,000 ruby necklace to the fund as part of the tradi-
tion of giving rubies on 40th anniversaries (Joyner 1984;
Blum 1985,1986).

  Estimating how much money is actually spent
by the tobacco industry on the sponsorship of racial/
ethnic cultural and social activities is difficult. Detailed
financial records of tobacco manufacturers are not
public record, and the financial information that is
published in annual reports and similar company pub-
lications does not separate the amount of money spent
on the promotion of cultural and artistic events among
racial/ethnic groups from the amount spent on adver-
tising and other forms of product promotion.

Support for Sports Events

  Although the negative effect of tobacco on health
has made direct links between tobacco companies and
sports less tenable today than they were in the 1950s
and 196Os, tobacco companies have increased their
involvement in sports by sponsoring community-
based softball, golf, soccer, and baseball (Blum 1989;
Robinson et al. 1992b). One such example is U.S.
Tobacco's Skoal Brand sponsorship of the Hispanic
championship soccer tournament, Copa National
(Brandweek 1995). Tobacco companies have maintained
a link to sports and racial/ethnic communities through
such means as sponsoring the Jackie Robinson Foun-
dation Awards Dinner. In 1995 alone, the six major
cigarette-manufacturing companies in the United States
spent $83 million to sponsor, advertise, or promote
sporting events; to support individual athletes or group
teams; to advertise in sports venues; and to promote
items connected with sporting events (FTC 1997). To-
bacco industry support for sports is consequential, in
part, because of the perception among some youth, par-
ticularly African Americans, that athletic ability pro-
vides an avenue of personal advancement.

Factors That Influence Tobacco Use  219


Surgeon General's Report

Advertising and Promotion

  Advertising is an important influence on tobacco
use initiation and maintenance, as documented in
Preventing Tobacco Use Among Young People (USDHHS
1994). Cigarette advertising and promotion may
stimulate cigarette consumption by (1) encouraging
children and adolescents to experiment with and ini-
tiate regular use of cigarettes, (2) deterring current
smokers from quitting, (3) prompting former smokers
to begin smoking again, and (4) increasing smokers'
daily cigarette consumption by serving as an external
cue to smoke (CDC 1990a). In addition, cigarette ad-
vertising appears to influence the perceptions of
youths and adults about the pervasiveness of cigarette
smoking and the images they hold of smokers
(USDHHS 1989,1994). Cigarette advertising also may
contribute to the perception that smoking is a socially
acceptable, safe behavior and may produce new
perceptions about the functions of cigarette smoking
in social situations. All of these perceptions have been
shown to be risk factors for the initiation of cigarette
smoking (Lynch and Bonnie 1994; USDHHS 1994;
Federal Register 1996).

  Unfortunately, the specific effect of advertising on
youth in racial/ethnic minority communities is not well
understood, to some extent because research is scarce
on youth in racial/ethnic communities. Available data
indicate that young people smoke the brands that are
most heavily advertised. In 1993, the three most heavily
advertised brands of cigarettes, Marlboro, Camel, and
Newport, were the three most commonly purchased
brands among adolescent smokers. More than 45
percent of Hispanic and 63 percent of white teenagers
reported purchasing Marlboro. African American
teenagers most often chose Newport, one of the men-
tholated cigarettes heavily marketed to the African
American community (Cummings et al. 1987; CDC
1994a). Although combined sales of these three brands
represented only 35 percent of the adult market share,
they represented 86 percent of the adolescent market
share. These data suggest that tobacco advertising in-
fluences brand preference among youths and that there
are differences in preference among racial/ethnic
groups (CDC 1994a).

   Another reason that research to date has been
unable to quantify the specific effect of tobacco adver-
tising on racial/ethnic groups is that advertising for
tobacco products is ubiquitous and uses images, such
as glamour, independence, and attractiveness, that
appeal to all segments of society. Overall, tobacco

220 Chapter 4

products are among the most heavily advertised
products in the United States. However, studies have
documented that some tobacco products are advertised
disproportionately to members of racial/ethnic
groups, such as mentholated products to African
Americans and brands named "Rio" and the earlier
"Dorado" to Hispanics (Gloede 1985; Leviten 1985;
Walters 1985).

  In a study of adolescents who had never tried
smoking, Evans and colleagues (1995) reported an
association between a measure they constructed on
receptivity to tobacco marketing and a measure of sus-
ceptibility to begin smoking. Higher scores on the
receptivity index were associated with increasing like-
lihood of being susceptible to start smoking. The
association persisted, even after statistical control for
exposure to other smokers, race/ethnicity, and other
socioeconomic status variables. Racial/ethnic minor-
ity-group specific analyses were not conducted. The
findings in this study, though suggestive, require
further validation.

  Market segmentation is a well-developed strategy
for crafting advertising campaigns that present particu-
larly persuasive appeals to targeted audiences (Murphy
1984). It has been suggested that the tobacco industry
strategically targets new consumer groups (e.g., women,
racial/ethnic groups, and youths) by developing ad-
vertisements that exploit the psychological interests and
needs of those targeted populations (e.g., Basil et al.
1991). A large and increasing portion of advertising and
marketing is targeted to racial/ethnic groups, especially
youth (Moore et al. 1996; Zbar 1996). The challenge for
the audience is to distinguish the advertising that rep-
resents consumer goods with benefit or satisfaction from
advertising that represents products that may harm the
target community (Moore et al. 1996). Targeted tobacco
advertising presents images of success, wealth, happi-
ness, and sophistication, all of which are attractive to
racial/ethnic groups, perhaps particularly in contrast
with other, less flattering images of those communities
presented by the news media. A recent article on the
health of African American women discussed the at-
tractive images used to target the African American
community. "We have grown almost numb to negative
images of ourselves in the media-Black teen girls sur-
rounded by screaming babies or men in handcuffs.
Except in cigarette or liquor advertisements. In these
we are beautiful, confident, well-dressed, happy,
wealthy, in love. . . " (Villarosa 1994, p. 13).


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

  Concern about targeted tobacco advertising has
been the subject of various congressional hearings (e.g.,
U.S. Congress 1987,199O). Efforts have been made by
communities to counteract such advertising. Indeed,
tobacco companies' targeting of racial/ethnic commu-
nities appears in some cases to have created a reverse
marketing effect, such as that seen with the African
American community's negative and forceful response
to Uptown and X brand cigarettes (see Targeted
Products later in this chapter). Recent data show that
African Americans' spending on tobacco decreased
5 percent between 1994 and 1995 (Schmeltzer 19961,
perhaps due in part to an adverse reaction to the tar-
geted marketing of a harmful product (McIntosh 1995).
Counteradvertising has also been used; one poster dis-
tributed by Harlem Hospital in 1991 depicted the
Marlboro man lighting a cigarette for an African
American child. The caption read, "They used to make
us pick it. Now they want us to smoke it." A televi-
sion spot, "Rappers/Pick It," produced by the
California Department of Health Services, conveys a
similar theme (Kizer et al. 1990, p. 76).

  Although many companies are sensitive about
disclosing targeted marketing strategies, particularly
efforts focused on racial/ethnic minority markets, re-
cent analyses of marketing trends document tobacco
companies' efforts to sell their products to racial/eth-
nic groups and to youths (Davis 1987; Altman et al.
1991; Johnson 1992a; Moore et al. 1996; Stoddard et al.
1997). At least one major tobacco company, Philip
Morris, has argued that it does not exclusively target
any particular group (Nelson and Lukas 1990). Ques-
tions also have been raised about the appropriateness
of using targeted advertising and promotional tech-
niques when the quantity and intensity of these efforts
are well beyond the proportional purchasing power
of the targeted group or when particular promotional
techniques such as billboard placements are used in
quantities that are out of proportion to the population
size of the targeted groups. Examples of targeted ad-
vertising and promotion that may be inappropriate in-
clude the overly frequent placement of billboards that
advertise tobacco products in racial/ethnic enclaves,
the use of cultural values and symbols valued by mem-
bers of racial/ethnic groups to promote tobacco prod-
ucts, and the use of certain promotional practices (e.g.,
coupons, discounts, tie-ins, and free gifts).

Magazine Advertisements

  Certain tobacco products are advertised dispro-
portionately to members of racial/ethnic groups. For
example, menthol cigarettes are more frequently

advertised in magazines targeting African Americans
than in magazines directed at the general public
(Cummings et al. 1987). An analysis of one year of
issues (June 1984 through May 1985) of three maga-
zines primarily directed at African Americans-Jet,
Ebolzy, and Essence-and of four magazines directed
at the general population-Newsweek, Time, People,
and Mademoiselle-found that 12 percent more adver-
tisements for cigarettes appeared in the African Ameri-
can magazines. In addition, 65.9 percent of the
cigarette advertisements in the African American
magazines were for menthol cigarettes, compared with
15.4 percent of those in the general population maga-
zines (Cummings et al. 1987). Indeed, Newport, a
menthol brand, is the number one preferred cigarette
among African American adults and youth (CDC
1990b, 1994a).

Outdoor Advertisements

  Early research showed that marketing ap-
proaches such as billboards and point-of-sale displays
have been particularly effective in reaching African
Americans. In one early study, Bullock (1961) sampled
1,106 African Americans and 537 whites from Atlanta,
Birmingham, Houston, Memphis, and New Orleans
to assess a variety of consumer behaviors. Bullock
found that billboards and point-of-sale materials were
particularly effective in reaching a high proportion
of African American consumers and that African
American consumers were more likely than whites to
trust advertising. In addition, a disproportionately
high number of billboards and other outdoor adver-
tisements promoting cigarettes and other tobacco prod-
ucts have been placed in racial/ethnic minority
communities. A recent study in Los Angeles found
that the density of cigarette advertisements on bill-
boards was 4.6 times greater in the city proper than in
the suburbs (Ewert and Alleyne 1992). In a study con-
ducted in San Diego, Elder and colleagues (1993) found
that the highest proportion of billboards featuring to-
bacco products was in Asian American (13.0 percent)
neighborhoods, followed by African American (9.6 per-
cent), Hispanic (4.7 percent), and white (1.1 percent)
neighborhoods. The volume of outdoor advertising
in Asian American neighborhoods was relatively low,
although the proportion of that space devoted to to-
bacco products was high (Elder et al. 1993). In an ear-
lier study, Mitchell and Greenberg (1991) found that
most billboards in racial/ethnic communities in four
New Jersey cities were predominantly dedicated to
advertised alcoholic beverages and tobacco products.
In several urban centers, the proportion of billboard

Factors That Inflllence Tobacco Use  221


tobacco advertising has been found to be higher in Af-
rican American neighborhoods than in white areas
(Tuckson 1989; Mitchell and Greenberg 1991; Mayberry
and Price 1993). Stoddard and colleagues (1997) docu-
mented tobacco billboard advertising in four neigh-
borhoods (African American, Asian American and
Pacific Islander, Hispanic, and white) in Los Angeles
during 1993 and 1994. Tobacco billboard density (the
number of billboards per mile) was highest in African
American communities, intermediate in Hispanic and
Asian communities, and lowest in white communities.
The models in billboards in African American neigh-
borhoods were more likely to appear younger than in
the other neighborhoods. In addition, 91 percent of
the billboards in African American neighborhoods fea-
tured an African American as the central character; in
the other three neighborhoods, whites portrayed the
central characters.

In-Store Promotions

  In-store and over-the-counter promotions for to-
bacco products also seem to disproportionately target
racial/ethnic communities. For example, in racial/
ethnic neighborhoods in San Diego, Asian American
retail outlets had the highest average number of to-
bacco promotion displays (6.41, compared with His-
panic (4.6) and African American (3.7) stores (Elder et
al. 1993). In addition, low-cost or generic cigarettes
that have begun to capture increasing market shares
may be particularly effective as part of a targeted cam-
paign directed at members of racial/ethnic groups
with low-socioeconomic status and for whom price
may be an important consideration in the purchase of
cigarettes (Assael1990).

  Convenience store owners often are eager to
promote tobacco products, which account for about
26.5 percent of their total sales (National Association
of Convenience Stores 1993). In such stores, tobacco
companies frequently promote their products through
special displays and point-of-sale promotions that pro-
vide monetary or product allowances for the store
owners (Cummings et al. 1991; Wildey et al. 1992;
Davis 1993; USDHHS 1994). In a study of 23 super-
markets and convenience stores in San Diego, Wildey
and colleagues (1992) found that 52 percent of store
owners reported receiving payments from tobacco
companies for displaying advertisements in their
stores and that 69 percent of the stores displayed to-
bacco advertisements on the outside walls, windows,
or parking lot signs. The researchers also found that
stores in Asian American neighborhoods were more
likely than stores in white communities to have

outside advertisements for tobacco products. A San
Francisco study found that a large number of small
stores in racial/ethnic minority neighborhoods display
outside placards and small billboards for tobacco prod-
ucts (Gerard0 Marin and colleagues, unpublished
data). About 57.6 percent of small stores in predomi-
nantly African American neighborhoods displayed at
least one advertisement for tobacco products, com-
pared with 37.7 percent in predominantly Hispanic
neighborhoods and 28.6 percent in predominantly
Asian American and Pacific Islander neighborhoods.

Racial/Ethnic Symbols, Names, and Events

  Another area of concern about targeted adver-
tising and promotion is the use of clearly identifiable
racial/ ethnic models; group-specific messages, such
as salutes to Latin0 community organizations during
Hispanic Heritage Month, and group-relevant place-
ments. Examples of group-relevant placements are
cigarette advertisements appearing during Black His-
tory Month and featuring pictures or quotations of
African American leaders and Philip Morris's salute
to its Bill of Rights campaign during news coverage of
Nelson Mandela's release from prison. These adver-
tisements target racial/ethnic communities by mak-
ing use of symbols and events that are held in high
esteem by community members.

  Individuals' psychosocial characteristics are com-
monly used in the design of targeted advertising and
marketing campaigns (Basil et al. 1991). Consumers,
particularly those who identify with an racial/ethnic
group's culture, tend to prefer buying goods that are
specifically advertised to their cultural group.
Deshpande and colleagues (1986) found that Hispan-
ics who strongly identified with their racial/ethnic
culture preferred Spanish language advertising, were
more likely than those with less cultural identification
to maintain brand loyalty, and were more likely than
those with less cultural identification to buy prestige
brand goods and those advertised specifically to their
racial/ethnic minority group. In addition, Lee and
Barnes (1989-1990) found that advertisements target-
ing African Americans differ from those directed at the
general population in that they feature certain bright
colors.

  Tobacco product promotions also feature sym-
bols and names that have special meaning for racial/
ethnic groups. Certain names have special significance
for particular groups (Uptown among African Ameri-
cans), the use of non-English names may appeal to
certain linguistic groups (Rio and Dorado among
Hispanics), and the use of certain words can conjure

222 Chapter 4


Tobacco Use AVIOH~ U.S. Racial/Ethnic Minority Groups

symbols that are meaningful to a particular group
(American Spirit among American Indians). The use
of racial/ethnic events and symbols to market tobacco
can present a complex issue that is difficult for
communities to resolve. For instance, the American
Spirit cigarette package portrays an American Indian
smoking a pipe, and the product's literature features
American Indian cultural themes, stating that the
American Indian custom was to smoke tobacco leaves
the "natural way" and that American Spirit cigarettes
are "natural" cigarettes. In early 1997, the American
Indian Tobacco Education Network criticized the Sante
Fe Tobacco Company for exploiting sacred Indian tra-
ditions and imagery to sell its tobacco products. The
Sante Fe Tobacco Company countered that it honors
Indian traditions in its use of community symbols and
even donates tobacco to tribes for ceremonial purposes
(Guthrie 1997). The fact remains that American Spirit
cigarettes contain tobacco with amounts of tar and
nicotine similar to those of commercial brands and are
thus dangerous to health, despite their lack of addi-
tives. Although targeted marketing of products may
bring economic benefits to racial/ethnic communities,
when such marketing is for a harmful product such as
cigarettes, the target community is challenged to
choose between potential economic gain and social
recognition versus the inevitable long-term adverse
health outcomes from use of the product (Moore et al.
1996).

  Cigarette advertisements also have been accused
of trivializing social causes and cultural values. For ex-
ample, a Virginia Slims advertisement that appeared in
the July 1994 issue of Life uses the concept of racial/eth-
nic equality to promote use of the product. In addition,
certain tobacco product advertisements have used visual
images, such as American Indians as warriors, that de-
mean the culture and insult some individuals (Green
1993).

  Another significant concern is the effect that
targeted tobacco advertising may have on recent im-
migrants. For many immigrants, the advertising of
cigarettes in their country of origin has helped mold
their attitudes and perceptions of tobacco use. These
perceptions in turn create expectations about the
social effects of cigarette smoking as portrayed in ad-
vertisements, as well as brand recognition and brand
loyalties toward the most frequently advertised
brands. Targeted promotional and marketing practices
also can affect the decisions of consumers who have
recently migrated to the United States and who, in
general, have not been exposed to marketing tech-
niques and promotional approaches common in the
United States. Immigrants not exposed to lifelong

learning from the commercial practices of a market
economy may be less critical and overly trusting of
the messages and implied promises presented in ad-
vertisements. Webster (1990-1991) found that highly
acculturated Hispanics rated certain consumer prod-
ucts as defective and overpriced and claimed that ad-
vertising was problematic, whereas less acculturated
Hispanics were more accepting of such defective prod-
ucts and saw advertising not only as informative but
also as enjoyable. Immigrants also respond differently
to promotional techniques with which they are unfa-
miliar. For example, Hispanics who have a low level
of acculturation may not respond to certain novel pro-
motional techniques such as the use of coupons
(Donthu and Cherian 1992) but are more influenced
by radio and billboard advertisements and point-of-
sale displays (Webster 1992). Other studies have also
found that promotional techniques have differential
effects on various sectors of the Hispanic population.
The more acculturated Hispanics report being prima-
rily influenced by magazine advertisements, bro-
chures, product labels, and consumer guides, such as
Consumer Reports and the Yellow Pages (Webster 1992).

Targeted Products

  Although a few cigarette brands have names that
imply specific racial/ethnic minority targeting (e.g., Rio
and Dorado for Hispanics), their promotion has been
limited to a few states. The recent introduction of
American Spirit seems to be directed at American
Indians as well as youths and individuals preferring
natural products. In addition, Japan Tobacco Inc. has
begun to market its top-selling brand, Mild Seven, in
the United States (Stebbins 1990; Sesser 1993). The
brand is being promoted as a cigarette manufactured
by Asians for Asians, and full-page advertisements ap-
pear in magazines primarily targeting Asian Americans
(Koeppel1990b). Mild Seven billboards also have ap-
peared in Koreatown and Little Tokyo in Los Angeles
as well as in other U.S. cities with large Asian Ameri-
can populations.

  One of the best examples of product targeting
was the cigarette Uptown, designed by R.J. Reynolds
in the 1980s to reach African American smokers
(Dagnoli 1989; Simmons 1989; Koeppel 1990a;
Robinson and Sutton, in press). The attempted
introduction of this cigarette is a case study in racial/
ethnic product targeting. The characteristics, packag-
ing, and planned promotion of Uptown cigarettes
allegedly were designed specifically for African Ameri-
cans. The menthol formulation of this new brand was
designed to compete directly with Lorillard's Newport

Frzctors That Influence Tobacco Use  223


Surgeon General's Report

cigarette, which was one of only three full-price ciga-
rettes to gain market shares in 1989 along with Philip
Morris's Marlboro and Virginia Slims cigarettes
(Dagnoli 1989). In 1986, Newport was the leading
brand of cigarettes among African American smokers,
ahead of Brown & Williamson's Kool cigarettes and
R.J. Reynolds's Salem cigarettes (Simmons 1989; CDC
1990b). The mentholated Uptown cigarettes were to
be packed with their filters down in the belief that
African American blue-collar workers often open their
cigarettes from the bottom to avoid crushing the fil-
ters or having to put unwashed hands on the part of
the cigarette that goes into their mouth (Ramirez 1990).
Furthermore, in its statement announcing Uptown
cigarettes, the company defined African Americans as
the primary market for the new brand. Unlike New-
port cigarettes, which were purported to be aimed at
all smokers rather than just African Americans, R.J.
Reynolds was specific (Dagnoli 1989). "We expect
Uptown to appeal most strongly to black smokers,"
said Lynn Beasley, vice president of strategic market-
ing for the company. "Our research led us to believe
that Uptown's blend . . . will be an appealing alterna-
tive to smokers currently choosing a competitive
brand. We have developed a product based on re-
search that shows that a significant percentage of black
smokers are currently choosing a brand that offers a
lighter menthol flavor than our major menthol brand,
Salem" (Philadelphia News Observer 1990, p. 7).

  Uptown cigarettes were to yield 19 milligrams
of tar per cigarette, which was the highest level of tar
in all of R.J. Reynolds's cigarette brands, with the ex-
ception of unfiltered Camel cigarettes. The planned
advertisements were to depict African American
couples enjoying cigarettes in a sophisticated urban
environment with the slogan "Uptown. The Place.
The Taste" (Koeppel 1990a). The marketing plan for
Uptown cigarettes was designed to take advantage of
media that were particularly effective in reaching
African Americans, including billboards, transit adver-
tising, bus shelters, point-of-purchase signs,
and advertisements in racial/ethnic newspapers and
magazines.

  The introduction of Uptown cigarettes was
planned for the first week in February 1990 to coin-
cide with Black History Month activities, including
receptions, exhibits, festivals, award ceremonies, and
other events highlighting the African American expe-
rience. Promoting Uptown cigarettes during this high
level of activity-through the distribution of free

samples and the underwriting of events-would
afford R.J. Reynolds a prime opportunity to promote
the new brand (Simmons 1989).

  R.J. Reynolds selected Philadelphia as the test
market site because of its demographics. In 1990, the
city's population was approximately 40 percent Afri-
can American and was served by several African
American newspapers. In addition, African Ameri-
cans tended to live in distinct neighborhoods that could
be reached effectively through billboards and transit
advertising. Furthermore, unlike some communities
that had mobilized against excessive billboard adver-
tising of alcoholic beverages and tobacco products,
Philadelphia's African American community had been
quiet in this respect.

  In the wake of a firestorm of negative national
publicity (see Chapter 5), R.J. Reynolds withdrew its
plans to test-market Uptown cigarettes in Philadelphia.
The protest against this targeted product involved
community members, civic and religious leaders,
health professionals, and then-Secretary of Health and
Human Services Dr. Louis W. Sullivan. Ultimately, R.J.
Reynolds decided to withdraw Uptown cigarettes from
the market permanently.

  The same leadership and strategy were used again
in Boston in early 1995 and similarly resulted in the
withdrawal of a new brand of cigarettes called "X,"
thought to be targeted to African Americans because of
its red, green, and black packaging and the suggestion
of the name of noted leader Malcolm X. In this instance,
however, both the manufacturer and the distributor
denied that the brand was targeted to African Ameri-
cans or any other racial/ethnic market (Jackson 1995)
(see Efforts to Control Tobacco Advertising and Pro-
motion in Chapter 5).

  In January 1997, R.J. Reynolds released a men-
tholated version of Camel cigarettes. R.J. Reynolds had
last marketed a mentholated brand of Camels in 1966
(Tobacco Merchants Association of the United States
1978). Approximately three-fourths of African Ameri-
can smokers smoke mentholated cigarettes (USDHHS
1990) and Camel cigarettes are popular, so the African
American community has been concerned that a new
menthol brand may escalate smoking among African
Americans. In an event similar to that precipitating
the withdrawal of Uptown cigarettes, key religious
leaders, led by the National Association of African
Americans for Positive Imagery, launched a national
crusade against the new brand extension of Camel
Menthols (Rotzoll 1997).

224 Chapter 4


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

Psychosocial Determinants

  Psychosocial variables help explain why people
start using tobacco (initiation), why some continue
using it (maintenance), and why some stop using
tobacco products (cessation). This section of the chap-
ter provides a summary of research to date on the
factors associated with initiation, maintenance, and
cessation of tobacco use among ethnic groups. Unfor-
tunately, the literature is sparse on individual and in-
terpersonal factors that influence tobacco use among
African Americans, American Indians, Alaska Natives,
Asian Americans, Pacific Islanders, and Hispanics.

  Research and etiologic theory on smoking and
smokeless tobacco use have largely excluded members
of racial/ethnic groups. In fact, few researchers have
included persons other than whites as part of their stud-
ies. Although research findings based on samples of
the majority white population may be applicable to
racial/ethnic minority populations, such general-
izability has not been sufficiently studied. Racial/
ethnic groups may have different exposure levels and
different reactions to risk factors or protective condi-
tions than do whites. Furthermore, cultural differences
in values, norms, expectancies, and attitudes may dif-
fer among members of various racial/ethnic groups.
These differences, in turn, may influence the prevalence
of cigarette smoking in a particular racial/ethnic group
and the relationship between smoking behavior and as-
sociated risk factors (Marin et al. 1990a; Vander Martin
et al. 1990). Certain experiences and values associated
with tobacco use thus may be unique to some racial/
ethnic groups and may not be relevant to others.
Understanding group-specific and community-based
factors is necessary to help shape the development of
culturally appropriate interventions. (Interventions are
detailed in Chapter 5. For a detailed discussion of the
range of variables that prompt youths to start smoking
and to use smokeless tobacco, see Preventing Tobacco Use
Among Young People, USDHHS 1994.)

Initiation and Early Use of Tobacco

  Much of the research on tobacco use among
racial/ethnic minority groups has focused primarily
on a constellation of risk factors that affect people's
behaviors (Bry et al. 1982; Newcomb et al. 1986,1987;
Moncher et al. 1990; Scheier and Newcomb 1991; Felix-
Ortiz and Newcomb 1992; Newcomb and Felix-Ortiz
1992; Vega et al. 1993). These studies have assessed
environmental, behavioral, psychological, and societal

attributes proposed by the various theories of tobacco
use initiation (Ajzen and Fishbein 1970; Jessor and
Jessor 1977; Kandell980; Yamaguchi and Kandel1985;
Elder and Stern 1986; Newcomb and gentler 1988;
Chassin et al. 1990,1992), considering these attributes
as individual risk factors or as a set of variables that
affect an individual's behavior (Hawkins et al. 1992).
Some studies have proposed that the particular fac-
tors that increase an individual's vulnerability are not
as important as the accumulation of such factors in a
person's life and that tobacco use is but one of many
responses people use to cope. Investigators have fo-
cused on some environmental and behavioral factors
(such as parental and peer smoking or the availability
of cigarettes) that may be useful in developing preven-
tion strategies, but they have paid less attention to other
equally important environmental conditions (such as
price, access, exposure to advertising, economic history,
customs and practices associated with tobacco in the
native country, and tobacco industry influence on
community organizations and leaders) that are differ-
entially related to tobacco use and initiation.

  Some investigators have studied the onset of
adolescent smoking as a phenomenon of gradual pas-
sage through various cognitive and behavioral stages
of change-for example, from abstaining to using to-
bacco regularly (Conrad et al. 1992). Following
Prochaska and DiClemente's (1983) paradigm for
studying smoking cessation, Stern and colleagues
(1987) found that a predominantly white sixth-grade
population progressed through stages, such as
precontemplation (when the youth would not even
consider smoking), to decision making (thinking about
taking up the behavior and experimenting with
cigarettes), to maintenance (regular smoking). Similar
results were found in a study of California high school
students, about one-third of whom were Hispanic
(Elder et al. 19901, but potential differences between
white and Hispanic students were not fully explained.

  More recently, Pierce and colleagues (1996) found
that baseline susceptibility to smoking (defined as the
absence of a firm decision not to smoke) was a stron-
ger independent predictor of experimentation than the
presence of smokers among either family or best
friends. In this study, African American, Asian Ameri-
can, and Pacific Islander adolescents were significantly
less likely to experiment than whites or Hispanics.
However, exposure to smokers was more important
than susceptibility to smoking in distinguishing

Factors That Influence Tobacco Use  225


Surgeon General's Report

adolescents who progressed to established smoking
from those who remained experimenters. African
American, Asian American, and Hispanic adolescents
appeared less likely than whites to become established
smokers (Pierce et al. 1996).

African Americans

  A few studies have tried to identify variables that
predict cigarette smoking among African Americans.
Brunswick and Messeri (1983) examined five domains
of variables to assess their effects on the onset and con-
tinuation of cigarette smoking among 379 African
Americans aged 18-23 years who resided in the
Harlem area of New York City. In this eight-year
prospective study, multiple regression analyses
showed that variables in each of five domains-
personal background, school achievement, family and
peer orientations, emotional conflict, and health atti-
tudes and behaviors-were significant predictors of
smoking initiation, although the patterns of influence
differed by gender. In further analyses, Brunswick and
Messeri (1984) found that poor school achievement
predicted the onset of cigarette smoking among
the young men and women. In addition, young
women who reported higher cigarette use had low self-
efficacy and were worried more about school.

  Among white youths, the presence of a best
friend who smokes is a significant predictor of smok-
ing, but the data on African American youths are
contradictory. Some studies have shown that having
peers who smoke is a poor predictor of cigarette smok-
ing among African American youths (Headen et al.
19911, whereas others have found the opposite (Botvin
et al. 1992,1993). Botvin and colleagues (1993) found
that the most powerful predictor of cigarette smoking
among those students initially sampled was having
friends who smoke, together with personal factors such
as lack of assertiveness in refusing cigarettes. A study
of 757 African American and Hispanic seventh grad-
ers in six New York City public schools yielded simi-
lar results (Botvin et al. 1994).

  A few studies have analyzed retrospectively the
predictive power of various sets of variables. Benson
and Donahue (19891, for example, studied cigarette
use among African Americans and whites by analyz-
ing data from the 1976, 1979, 1982, and 1985 Nation-
al High School Senior Surveys that were part of the
University of Michigan's Monitoring the Future (MTF)
Project. The researchers analyzed 10 predictors of ciga-
rette use: personal importance of religion, region of
the country where respondents resided, gender, school
type, community size, college plans, hours worked, a

father present, level of parental education, and mater-
nal employment.  For each year examined, the
researchers found that the association between these
10 variables and cigarette use was substantially lower
for African American high school seniors than for
white high school seniors. Among both African Ameri-
cans and whites, cigarette smoking was associated with
the frequency with which the respondents went out at
night, low levels of religiousness, and lack of concrete
plans for college. In another study, Wallace and
Bachman (1991) analyzed data from the MTF surveys
for the years 1985-1989. They found that among Afri-
can American high school seniors, four variables were
significantly associated with cigarette smoking in the
30 days preceding the survey: living in a nonurban
area, being truant, frequently attending rock concerts,
and having peers who used cigarettes. Among white
high school seniors, 10 variables were significantly
associated with cigarette use: being female, living in
a single-parent family, having low attachment to
school, being truant, going to parties, going to rock
concerts, doing poorly in school, not being committed
to future education, spending evenings out for fun and
recreation, and having peers who used cigarettes (these
last 4 variables were also associated with cigarette use
among African Americans, but the association was
stronger among whites).

  Weinrich and colleagues (1996) examined
the relationship among three factors-adolescent
smoking under stress, psychological distress, and
social support-among 1,168 sophomore and junior
high school students. They found that race was
strongly associated with smoking to cope with stress,
as measured by indices of anger/anger control, depres-
sion, somatization (expression of anxiety in physical
symptoms), anxiety, obsessive/compulsive behavior,
and social support. In each case, white students were
more likely than African American students to engage
in stress-related smoking.

  Also using a risk factor approach, Farrell and
colleagues (1992) found that among 1,352 African
American adolescents from the Southeastern United
States, the following risk factors were associated with
cigarette use: being home alone after school, having
friends who approved of and used drugs, knowing
adults who used drugs, feeling pressured to use drugs,
expecting to use drugs in the future, being highly in-
volved in delinquent behavior, having a history of
trouble with the police, and having used cigarettes and
alcohol previously. As noted, comparison of these
studies is hampered by the noncomparability of the
variables assessed.

226 Chapter 4


Tobacco Use Among U.S. Racial/Ethnic Minority Groups

American Indians and Alaska Natives

  Among American Indians and Alaska Natives,
tobacco use has a long and unique history that includes
its use in rituals and spiritual ceremonies (Weibel-
Orlando 1985; Siegel 1989). Despite this important his-
tory, little is known about current predictors of the
initiation of cigarette smoking and smokeless tobacco
use among young American Indians and Alaska
Natives. Schinke and colleagues (1989) have reviewed
the scant literature and theories regarding tobacco use
and believe that because of the historical association
of tobacco with spiritual rites (Weibel-Orlando 1985),
its contemporary daily use is also imbued with posi-
tive cultural attributes. But more behavioral explana-
tions for tobacco use among American Indian and
Alaska Native youths include peer pressure and
expected pharmacologic effects (Schinke et al. 1990).

  In a study of cigarette smoking initiation among
North American Indians, Pickering and colleagues
(1989) surveyed a sample of 689 Cree schoolchildren
aged 9-18 years in Canada's James Bay Region. Fac-
tors associated with being a smoker included being
older, being female, having a mother who smoked, and
having a best friend who smoked. In a larger study,
conducted in the northwestern United States, Moncher
and colleagues (1990) examined tobacco use in a cross-
sectional sample of 1,147 fourth and fifth graders of
American Indian and Alaska Native descent. The re-
searchers assessed 16 possible risk factors related to
peer and family use of various drugs, school adjust-
ment, intentions to use various drugs, quality of fam-
ily relationships, nondrug-related deviant behavior,
cultural identity, and religiousness. All of the 16 risk
factors correlated with the prevalence of any current
or ever use of cigarettes or smokeless tobacco by these
children.

  In an earlier study, also in the northwestern
United States, Hall and Dexter (1988) studied smoke-
less tobacco use in a sample of 1,180 adolescents that
included 257 American Indians. Multiple regression
analyses revealed that among male adolescents,
smokeless tobacco use was significantly associated
with having friends who used smokeless tobacco; with
cigarette smoking; and with tobacco use by the youths'
siblings, father, and other relatives. Among female
adolescents, a similar pattern was observed, except
that age also was positively associated with more
smokeless tobacco use. Other explanations of tobacco
use may include the relatively weak tobacco control
infrastructure within American Indian communities
and the presence of other environmental factors, such
as advertising, that promote the use of tobacco prod-
ucts (Hedge 1995; Robinson et al. 1995).

Asian Americans and Pacific Islanders

  Research on the factors that influence initiation
of tobacco use among Asian Americans is sparse, and
there is no such information about Pacific Islanders.
Zane and Sasao (1992) reviewed the literature to iden-
tify possible explanations for the use of substances (in-
cluding tobacco) among Asian Americans and Pacific
Islanders. They mention several influences observed
in other populations that may be relevant for Asian
Americans and Pacific Islanders: (1) multiple
stressful life events related to cultural adjustment;
(2) culture-specific social skills needed in the United
States, particularly direct self-expression, asser-
tiveness, and individualism, which are often the op-
posite of traditional Asian and Pacific Island values
and role expectations; and (3) family cohesion, which
may reduce the role of peer influences that are central
among members of other racial/ethnic groups.

  Wiecha (1996) studied 226 Vietnamese adoles-
cents in two public middle schools and two public high
schools in Worcester, Massachusetts, to examine the
correlates and patterns of tobacco use. Four factors
were independently and significantly associated
with smoking among Vietnamese adolescents: male
gender, older age, smoking by friends, and reporting
carrying a weapon in the last month. Other factors
that suggested associations but did not reach statisti-
cal significance included performing poorly in school,
ever using marijuana, and fighting. Acculturation was
inversely associated with current cigarette smoking,
i.e., study participants who were more acculturated,
as indicated by longer time in the United States, better
spoken English, or no use of Vietnamese translation
on the survey, were less likely to be current smokers.
Findings also suggest that the adolescents in this study
knew less about the health consequences of cigarette
smoking and might share a lower-than-average
perceived susceptibility to cancer (Wiecha 1996).

  Data from adults may be of use in identifying
factors related to initiation among youths. Chen (1993),
for example, found that the influence of friends or
peers was the most frequent reason for smoking ini-
tiation reported by 13 adult Cambodian immigrant
men. Data collected in 1991 indicate that among 296
adult Chinese Americans in Oakland, California,
40 percent of those who smoked reported that they
began smoking "to be sociable" (Rod Lew and Art
Chen, unpublished data). Other factors mentioned
frequently were peer pressure (25 percent) and
boredom 06 percent).

Factors That Influence Tobacco Use  227