Tobacco Use Awmng U.S. Racial/Ethnic Minority G~OU/JS

Oklahoma

x    KI

Pacific
Northwest'

7%    KI

Southwest+       Other+          Total

%    KI        %    KI       %    &CI

83.4   6.2       83.0    4.6       92.3   3.7       81.1    3.6       83.3 2.1
9.7   4.6       10.8    3.8        4.5    2.3       11.5    3.1        10.4   1.7
6.9    4.3        6.2    3.0         3.2    3.1        7.4    2.2         6.4   1.3

83.3    9.1       80.2    7.1        87.3    7.3       74.7    5.9        79.3 3.4
8.2    6.7       12.0    5.4         7.2    4.2       14.1    5.0        11.6 2.7
8.5    6.5        7.8   5.0        5.6   6.4       11.1    4.0        9.1 2.3

83.5    8.4       85.3   6.2        96.4    2.7       87.5    3.9       87.1   2.4
10.9    6.2        9.8    5.3         2.3    2.3        8.8    3.6        9.2 2.1
5.6    5.9        4.9    3.6         1.2    1.4        3.6    1.8        3.7 1.3

84.0   10.0       83.5    7.2        98.1    2.1       83.5   5.6
9.2    7.1        9.2   5.5        1.8    2.1       11.9    5.2
6.8    7.7        7.4    5.2         0.1    0.2        4.6    2.6

74.6   11.9       81.1    7.1        84.8   8.7       74.0   6.6
16.0   10.9       12.8   6.2        7.0   4.4       13.3   5.0
9.3    6.7        6.1    4.1        8.2    8.2       12.7    5.0

90.2    8.4       86.0   11.1        87.8   11.4       87.1    6.1
4.9    5.5       10.9    9.9        9.9   11.2        7.6   4.6
4.8   6.8        3.1    5.6        2.3    2.7        5.3    4.3

85.9 2.9
9.3   2.5
4.8   1.8



76.8   3.9
13.7   3.3
9.4   2.6



87.2   4.1
7.5 3.1
5.3   2.8

86.0   12.5       69.7   14.5       80.3   10.9       75.1    8.6        78.6   4.9
9.2   10.8       22.0   13.3        16.4   10.6       11.3    6.7        11.2   3.6
4.8    7.3        8.3   8.2        3.3   4.0       13.6    6.6        10.2 3.8

82.2   7.0       84.7   5.1        92.0   5.4       80.3    4.5        82.1   2.7
10.5    5.6        9.5    4.1         3.6    2.5       12.9    4.0        11.9   2.4
7.3    4.7        5.8    3.3        4.5   5.0        6.7   2.7        6.0 1.5

$95% confidence interval.
SIncludes persons aged 25 years and older.
Source: Centers for Disease Control, public use data tapes, 1988-1992.

Patterm of Tobacco Use  53


Table 19.  Percentage of adult American Indian and Alaska Native smokers who reported they quit
     smoking,* overall and by region/state, gender, age, and education, Behavioral Risk Factor
     Surveillance System, 1988-1992 aggregate data

Characteristic

Alaska

%   KIS

California

%    ic1

Northern
Plains+

%    &CI

Northern
Woodlands+

%   %I

Total                  37.0 6.6        44.8   11.9       31.8    8.3       44.3 6.3

Gender
Men
Women

37.1   9.3       44.8   16.2       32.8   11.4       49.5 9.8
36.9   9.3        44.8   16.9       30.3   11.7       40.0 8.2

Age (years)
18-34
35-54
255

31.2 10.0        29.8   15.8       15.9 9.4       41.8 9.3
43.8   9.8        49.2   17.3       32.2   13.4       35.5 9.7
42.2 16.1        61.0   28.9       58.2   19.7       62.2 12.6

Education5
Less than high school
High school/any college

38.5 12.6       53.6   22.7       35.1   15.8       48.3 13.0
38.1   7.7        41.8   14.2       37.5   11.6       46.2 7.5

*The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are
persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that
they were not smoking.
+The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern
Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes
Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah;
and "other" includes all remaining states not specified above that participated in the Behavioral Risk Factor
Surveillance System during this period.

Great Falls, 63 percent of men and 62 percent of women   women (58.2 percent) with 12 or more years of educa-
reported that they smoked. In both areas, rates of   tion than among men (81.3 percent) and women (74.5
smoking were higher among persons aged 25 years   percent) with less than 12 years of education. Rates of
and older than among their younger counterparts. For   current smoking among the Oneida Indian Nation fol-
American Indians in Great Falls, those who had a high   lowed similar patterns in terms of educational status:
school education and did not go to college had lower   men (34.7 percent) and women (29.1 percent) with 12
rates of smoking than those with less than a high school   or more years of education had a lower prevalence
education or those with some college education. Gen-   of cigarette smoking than men (59.4 percent) and
der differences in smoking cessation were also ob-   women (56.9 percent) with less than 12 years of for-
served. Among American Indians in Great Falls, 16   mal education. Overall, a greater proportion of men
percent of men and 19 percent of women had quit   (44.4 percent1 than women (40.0 percent) smoked. The
smoking; among the Blackfeet American Indians, 34   prevalence of cessation, on the other hand, was fairly
percent of men and 22 percent of women had quit   similar for men (37.9 percent) and women (38.1
smoking (Goldberg et al. 1991).             percent).

  In a 1990 study of members of the Oneida Indian
Nation of New York, 71.6 percent of the men and 64.6
percent of the women reported having ever smoked
cigarettes (CDC 19901. The prevalence of ever smok-
ing cigarettes was lower among men (65.3 percent) and

  Similar findings were observed in a survey of
people on the Warm Springs Reservation (Warm
Springs Confederated Tribes 1993) and in the Western
Washington Native American Behavior Risk Factor
Survey of the Chehalis, Hoh, Quinault, and Shoalwater


Gbncco Use Anm~~ U.S. Rncial/Eflzlzic Minority Groups

Oklahoma

5%    KI

Pacific
Northwest+

R    ASI

Southwest+       Other+

5%    XI        %    ASI

Total

7c   kc1

40.7   10.2       46.8 8.0        51.2

33.1   15.1       33.8   11.8       51.8
47.1   13.8       48.5   11.1        50.3

27.8   16.1       38.7   12.3       52.7
36.9   18.0       52.7   11.7        54.1
61.0   16.7       57.4   20.6        38.0

45.0   23.5       40.4   18.1        40.9
43.5   11.7       47.8    9.5       53.2

10.3       39.8



15.0       35.4
13.8       46.1



15.9       28.5
16.7       42.2
21.2       58.7




19.5       39.7
13.6       41.4

7.0

9.4        39.2   5.5
10.5        44.4   5.6

10.0        30.6   5.4
11.9       44.0 6.6
12.2       58.2   8.3

15.3       42.6 8.3
8.1       42.7 4.8

41.5   4.0

t95% confidence interval.
SIncludes persons aged 25 years and older.
Source: Centers for Disease Control, public use data tapes, 1988-1992.

Tribes (Kimball et al. 19901. In a survey of 1,318 adult
American Indian and Alaska Native users of Indian
clinics in northern California, 40 percent of the respon-
dents reported smoking cigarettes (47 percent of
the men and 37 percent of the women) (Hedge et al.
1995).

  Aggregated data from the BRFSS indicate that
among American Indian and Alaska Native women
of reproductive age, smoking rates were highest
among women in Alaska (43.9 percent), the Northern
Plains (39.5 percent), and the Northern Woodlands
(38.8 percent) and lowest among women in the South-
west (11.5 percent) and California (15.3 percent) (Table
201 (CDC, public use data tapes, 1988-19921.

Smokeless Tobacco Use

  The use of smokeless tobacco (chewing tobacco
and snuff) among American Indians and Alaska
Natives also has varied by state and region. According

to the BRFSS data for 1988-1992, the prevalences
among men were 24.6 percent in the Northern Plains,
16.8 percent in the Northern Woodlands, 14.3 percent
in Oklahoma, 11.6 percent in Alaska, 6.5 percent in the
Southwest, and 1.8 percent in the Pacific Northwest
(CDC, public use data tapes, 1988-1992). In the Oneida
Indian Nation survey, none of the women reported
using smokeless tobacco, whereas 17.3 percent of the
men reported using it (CDC 1990).

  More recently, investigators have reported ex-
tremely high rates of smokeless tobacco use among
Lumbee women in North Carolina (CDC 1995). In
1991, the prevalence of smokeless tobacco use was
greatest among Lumbee women 65 years of age and
older (51 percent) and lowest among those 25-34 years
of age (6 percent), The prevalence was also high among
women with less than 12 years of education (42
percent).


Table 20.  Percentage of American Indian and Alaska Native women of reproductive age who reported
     being current cigarette smokers,* overall and by region/state, Behavioral Risk Factor Surveillance
     System, 1988-1992 aggregate data

                            Northern        Northern

Alaska         California        Plains+       Woodlands+

%  +CIS        Yc   +CI          %   ,CI        % +CI

43.9   9.3        15.3   9.1         39.5   12.3        38.8   7.1
                                                           Total

Oklahoma

YO   +CI

Pacific
Northwest+

%   +CI

Southwest+

%   +CI

Other+

7c   +CI

%   +CI

24.9   3.9

30.4 12.5        32.6   9.7          11.5   5.4        26.7 7.1

*Current cigarette smokers are women aged 1834 years who reported smoking at least 100 cigarettes in their
lives and who reported at the time of survey that they currently smoked.
`The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern
Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes
Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; and
"other" includes all remaining states not specified above that participated in the Behavioral Risk Factor
Surveillance System during this period.
$95% confidence interval.
Source: Centers for Disease Control, public use data tapes, 1988-1992.

Asian Americans and Pacific Islanders      Prevalence of Cigarette Smoking

  Data needed to assess long-term trends in cigarette
smoking among Asian Americans and Pacific Islanders
have been unavailable because U.S. surveys, census data,
and other national databases have not always included
detailed descriptions of race/ethnicitv. Although data
from specific Asian American and Pacific Islander groups
and state surveys have provided information about ciga-
rette smoking for certain racial/ethnic subgroups, these
data have been limited in quantity and quality The NHIS
first included information about Asian Americans and
Pacific Islanders in the 1978 sunrey. However, because
the proportion of Asian Americans and Pacific Islanders
in the United States is small, data from several years must
be aggregated to increase the precision of estimates. Be-
cause of small sample sizes and aggregation of data,
racial/ethnic subgroup differences in smoking behav-
ior are masked. These differences are important because
the category Asim Anrericml orzd Poci,fic lshrdcr is hetero-
geneous in both culture and health behaviors. For ex-
ample, this category includes about 32 different national
and racial/ethnic subgroups (Austin et al. 1989; Hawks
1989) and nearly 500 languages and dialects (Chen 19931,
and smoking patterns among these subgroups vary.

  Between 1978 and 1995, the prevalence of smok-
ing declined among Asian Americans and Pacific Is-
landers, according to NHIS data (Table 21) (NCHS,
public use data tapes, 1978-1995). However, patterns
between men and women differed. The cigarette
smoking prevalence among Asian American and Pa-
cific Islander men declined slightly, from 32.5 to 25.1
percent, whereas the prevalence of smoking among
Asian American and Pacific Islander women declined
approximately 60 percent, from 14.7 to 5.8 percent.
Throughout this period, the prevalence of smoking
among men remained more than twice that among
women; in 1994-1995, men were 4.3 times more likely
than women to report current smoking.

Number of Cigarettes Smoked Daily

  From 1978 through 1995, the percentage of Asian
American and Pacific Islander smokers who smoked
fewer than 15 cigarettes per day increased significantly,
according to the NHlS data (Table 22) (NCHS, public use
data tapes, 1978-1995). Although large declines from
1978-1980 to 1992-1993 were observed in the prevalence


Table 21.  Percentage of adult Asian Americans and Pacific Islanders who reported being current cigarette
    smokers,* overall and by gender, age, and education, National Health Interview Surveys, United
     States, 1978-1995 aggregate data

197%19so+ 1983-19s5+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic             %  fCIS %   KI 7c   IfrCI %   fC1 %   KI %   +c1

Total                  23.8 4.0   21.4 3.4   15.8 2.4   16.1 2.5   16.7 2.7   15.3 3.0

Gender
Men
Women

32.5  4.S   33.0  6.2   22.5  3.8   24.5  4.0   26.8  4.7   25.1  5.2
14.7  6.6    9.6  3.5    9.2  2.8    6.6  2.0    6.8  2.7    5.8  2.3

Age (years)
18-34
35-54
255

22.5  5.8   21.6  4.6   16.3  3.5   15.5  3.2   15.7  4.2   17.6  5.3
28.7  x.5   20.8  4.8   16.1  3.6   17.1  4.6   21.0  4.7   15.5  4.3
17.4  4.7   22.0  8.6   12.7  5.9   15.7  5.4    8.3  5.4    9.2  5.1

Educations
Less than high school
High school/any college

23.1 8.9   23.8 111.2   17.9 6.5   24.9 7.4   13.4 6.2   13.3 7.9
23.7 3.9   22.6 4.5   16.7 2.8   15.6 2.9   17.6 3.5   14.4 3.2

*Excludes Asian Americans and Pacific Islanders ~\rho indicated they were of Hispanic origin. For 1978-1991,
current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who
reported at the time of suripey that they currentlv smoked. For 1992-1995, current smokers include persons
who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they
currently smoked every day or on some days.

`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
$95% confidence interval.
3Includes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

of smoking 25 or more cigarettes per day, recent estimates
are imprecise and should be interpreted with caution.

Quitting Behavior

  Between 1978 and 1995, the percentage of Asian
Americans and Pacific Islanders who have ever smoked
100 cigarettes and have quit smoking increased some-
what, NHIS data indicate (Table 231 (NCHS, public use
data tapes, 1978-1995). The prevalence of cessation
among women increased from 1987-l 988 to 1994-l 995,
but no consistent pattern was observed among men.
During each survey period, the prevalence of cessation
was higher among Asian Americans and Pacific Island-
ers 55 years of age and older than it was among their
younger counterparts (Table 23).

   Data from the NC1 Supplement of the 1992-1993
CPS indicate that among Asian Americans and Pacific

Islanders aged 18 years and older who were daily smok-
ers one year before the survey, 57.8 percent reported that
they were still smoking daily and that they had not tried
quitting for at least one day during the previous year
(Table 4). Another 32.0 percent had tried quitting for at
least one day, 4.8 percent were occasional smokers (i.e.,
smoked only on some days), 2.5 percent had not smoked
for the past l-90 days, and 2.9 percent had not smoked
for the past 91-364 days. Among current smokers, Asian
Americans and Pacific Islanders were slightly more likely
than whites to report trying to quit for at least a day dur-
ing the previous year.

Women of Reproductive Age

  The prevalence of current smoking among Asian
American and Pacific Islander women of reproductive
age (18-44 years) has decreased substantially over


Table 22. Percentage of adult Asian American and Pacific Islander smokers* who reported smoking ~15,
    15-24, or 225 cigarettes per day, overall and by gender, age, and education, National Health
    Interview Surveys, United States, 1978-1995 aggregate data

1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic             7c  KIS %   KI %   +a %  KI %   KI %   XI

Total
<15 cigarettes
15-24 cigarettes
225 cigarettes
Gender
Men
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
Women
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
Age (years)
18-34
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
35-54
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
255
  cl5 cigarettes
  15-24 cigarettes
  225 cigarettes
Educations
Less than high school
  cl5 cigarettes
  15-24 cigarettes
  225 cigarettes
High school/any college
  <15 cigarettes
  15-24 cigarettes
  125 cigarettes

43.3 11.7   53.7 8.1   55.6 7.8   60.4 8.1   61.8 9.4   70.6 9.8
37.0 9.7   35.3 8.5   37.4 7.4   33.8 7.6   37.1 9.4   21.4 8.2
19.7 6.5   11.0 6.5    7.0 3.3    5.8 3.9    1.0 1.3    8.0 6.5

40.1 14.6   54.4 9.4   51.8 9.6   59.2 9.2   58.4 11.2   69.1 11.5
35.8 11.1   36.2 9.3   41.2 9.2   35.4 8.6   40.9 11.2   23.6 10.0
24.1 8.2    9.4 6.6    7.0 4.2    5.5 4.4    0.7 1.4    7.3 7.4

50.4 13.7   51.1 14.9   64.4 11.3   65.8 16.8   75.4 11.6   77.3 13.9
39.6 12.8   32.0 15.2   28.5 9.8   26.8 16.5   22.2 11.5   11.5 11.0
10.0 7.7   16.8 10.1    7.1 5.1    7.4 8.3    2.3 3.3   11.2 11.1

42.2 12.2   48.2 10.4   59.0 11.0   60.3 10.7   61.3 13.7   73.2 13.6
37.3 11.5   40.5 11.5   35.1 10.5   35.2 10.5   38.2 13.7   24.3 13.2
20.5 8.2   11.3 8.3    5.9 4.4    4.5 3.8    0.6 1.1    2.5 3.9

45.0 17.1   54.9 13.5   54.5 10.9   62.9 13.5   63.6 13.0   65.0 15.2
35.5 15.0   32.2 13.1   40.4 11.0   26.9 10.5   34.9 12.9   22.3 11.8
19.5 9.0   12.9 8.1    5.1 4.6   10.1 9.2    1.6 2.3   12.8 14.0

41.3 18.5   67.9 20.3   41.5 23.2   55.8 18.5   52.7 39.1   78.0 23.9
40.9 13.1   26.4 18.4   39.4 25.0   43.3 18.5   47.3 39.1    4.7 9.3
17.9 14.4    5.7 8.2   19.1 16.5    0.9 1.8    0.0 0.0   17.3 23.4

59.6 21.3   66.0 15.2   48.7 19.6   72.9 13.9   80.2 17.3   73.8 32.2
28.6 18.0   23.3 14.2   42.4 19.8   22.2 13.3   19.8 17.3    6.2 9.5
11.8 13.2   10.7 9.8    8.9 9.5    4.8 6.0    0.0 0.0   20.0 32.8

40.4 12.4   47.6 9.6   53.0 8.3   58.1 9.8   62.2 11.4   64.8 12.0
39.4 11.8   39.3 10.2   39.4 8.2   34.7 9.3   36.7 11.4   26.5 10.7
20.2 7.4   13.0 8.1    7.6 4.2    7.2 5.5    1.1 1.6    8.7 7.5

"Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978-1991,
current cigarette smokers included persons who reported smoking at least 100 cigarettes in their lives and who
reported at the time of survey that they currently smoked. For 1992-1995, current smokers included persons
who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they
currently smoked every day or on some days.

`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
$95% confidence interval.
%rcludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.


Tobncco USC AIJKWZ~ U.S. Rlzcial/Efhnic Ivkorify Groups

Table 23.  Percentage of adult Asian American and Pacific Islander ever smokers who have quit," overall
    and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995
     aggregate data
              1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic             x  +a$ %   KI 7c   fCI 4   +a 7c   ,CI %   +CI


Total                   39.9 6.5   38.4 6.5   41.2 5.7   49.0 5.3   45.5 6.5   48.3 7.2

Gender
Men                 41.2 6.1    34.2 7.8   42.7 6.9   47.2 6.4   42.2 7.4   43.3 8.7
Women                36.9 13.0   49.6 10.2   37.2 9.6   55.4 10.1   55.0 13.9   62.2 12.8

Age (years)
18-34                 34.5 9.4   25.8 7.5   31.3 7.7   34.1 7.6   30.7 9.6   28.5 10.9
35-54                 35.7 13.5   45.5 8.8   46.3 8.0   55.3 9.5   44.1 9.2   55.5 10.1
255                  59.4 10.6   48.9 16.5   58.1 14.9   60.5 11.0   76.9 13.2   70.2 14.9

Education5
Less than high school      37.0 18.7   46.1 17.1   30.1 15.3   37.7 13.3   50.4 18.1   50.3 21.9
High school/any college    45.2 7.2   39.2 7.3   46.7 6.4   54.8 6.5   48.2 7.3   53.7 8.2

*Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. The prevalence of
cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who
reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were
not smoking, and ever smokers include current and former smokers.
`1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
t95% confidence interval.
$Includes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

time, from 16.0 percent in 1978-1980 to 5.7 percent in
1994-1995, NHIS data indicate (Table 24) (NCHS, pub-
lic use data tapes, 1978-1995). Overall, the greatest
change occurred between 1978 and 1985, when the
prevalence of current smoking declined by approxi-
mately 50 percent. Since 1985, declines in smoking
prevalence have slowed.

   Recent birth certificate data from U.S. final
natality statistics indicate that 3.4 percent of Asian
American and Pacific Islander mothers smoked dur-
ing pregnancy (Table 6). Smoking rates for pregnant
Asian American and Pacific Islander women are gen-
erally low-between 0.8 and 5.2 percent for Chinese,
Japanese, Filipino, and "other" Asian Americans or
Pacific Islanders. Hawaiian mothers, however, have a
relatively high smoking rate (15.9 percent). Ventura
and colleagues (1995) reported that 3 percent of
foreign-born Asian American and Pacific Islander
mothers were reported as smokers, compared with 13
percent of their United States-born counterparts. Data

on tobacco use among these mothers (except Hawai-
ians) may be skewed because California and New York
do not report this information, and together these states
account for nearly half of births in each Asian Ameri-
can and Pacific Islander subgroup (Ventura et al. 1996).

Young People

Cigarette Smoking

  Data from MTF surveys-one of the few studies
with data on smoking prevalence among Asian Ameri-
can and Pacific Islander youths-show that these
youths have a lower prevalence of smoking than their
counterparts in all other racial/ethnic groups except
African Americans (Table 7). According to the 1990-
1994 MTF data on male high school seniors, the
prevalence of smoking was 11.6 percent among Afri-
can Americans, 20.6 percent among Asian Americans
and Pacific Islanders, 28.5 percent among Hispanics,
33.4 percent among whites, and 41.1 percent among

Pdtcrm OF Tobmcn llw  59


Table 24.  Percentage of adult Asian American and Pacific Islander women of reproductive age who reported
     being current cigarette smokers,* overall and by education, National Health Interview Surveys,
     United States, 1978-1995 aggregate data
              1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic             70  +c1$ %   KI %   fC1 %   +c1 %   KI %   fC1


Total                  16.0 6.7    8.2 3.3    8.8 2.7    6.0 2.4    6.6 2.8    5.7 3.0

Education5
Less than high school
High school/any college

15.0  26.4    7.0  7.3    9.8  8.0   14.1  9.1    3.5  4.0    2.3  4.6
15.4  6.9    8.6  3.4    9.6  3.4    6.1  3.1    5.7  3.1    5.8  3.5

*Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978-1991,
current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in
their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers
include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported
at the time of survey that they currently smoked every day or on some days.
`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
t95% confidence interval.
SIncludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

American Indians and Alaska Natives. Data on
female high school seniors show that the prevalence
of smoking was 8.6 percent among African Americans,
13.8 percent among Asian Americans and Pacific Is-
landers, 19.2 percent among Hispanics, 33.1 percent
among whites, and 39.4 percent among American In-
dians and Alaska Natives. As reported by Bachman
and colleagues (1991a1, during 1985-1989, patterns of
daily smoking were similar, with prevalence estimates
being lowest among African Americans and Asian
Americans and Pacific Islanders. Among Asian
American and Pacific Islander high school seniors, 4.4
percent of males and 4.5 percent of females reported
smoking one-half pack or more per day.

  In 1993, Wiecha (1996) surveyed public school
students from two middle schools and two high
schools in Worcester, Massachusetts. The self-
administered questionnaire used items from
CDC's YRBS; every question was written in English,
Vietnamese, and Spanish. Vietnamese males were as
likely to report cigarette smoking (27.9 percent) as were
white males (28.3 percent). The prevalence of ciga-
rette smoking among Vietnamese females (3.7 percent)
was lower than among African American (15.1 per-
cent), Hispanic (29.7 percent), and white (30.6 percent)
females. Length of time in the United States was re-

lated to smoking prevalence for males aged 17 years
and older: cigarette smoking prevalence was 7.7 per-
cent among those who had been in the United States
for at least six years and 45.2 percent for those who
had been in the United States for less than six years.

Smokeless Tobacco Use

  Wiecha (1996) also queried Worcester students
about their use of smokeless tobacco products. The
prevalence of previous-month use among males was
12.0 percent for Vietnamese, 10.3 percent for African
Americans, 10.8 percent for Hispanics, and 20.5 per-
cent for whites. Previous-month use among females
was 3.6 percent for Vietnamese, 3.2 percent for Afri-
can Americans, 1.9 percent for Hispanics, and 2.7 per-
cent for whites. Small sample sizes limit the precision
of some of these estimates.

State and Local Smoking Estimates

  Among the diverse subgroups of Asian Ameri-
cans and Pacific Islanders, wide variations in lifestyles,
health behaviors, and health practices are evident.
State and local survey data illustrate the distinct varia-
tions in cigarette smoking patterns and behaviors
among these ethnic subgroups (Klatsky and

60 Chnpter 2


Tobacco Use AmonCy U.S. Racinl/Efhnic Minority Groups

Armstrong 1991; CDC 1992~; Blaisdell 1993; McPhee
et al. 1993; McPhee et al. 1995; Wewers et al. 1995;
Jenkins et al. 1997b). Although prevalence estimates
from national surveys indicate that the smoking preva-
lence among Asian Americans and Pacific Islanders is
lower than the prevalence of smoking in all other
racial/ethnic groups and in the o\Terall U.S. popula-
tion, state and local surveys show that these estimates
vary dramatically between racial/ethnic subgroups of
Asian Americans and Pacific Islanders. Racial/ethnic
subgroup-specific information on smoking behaviors
is needed because broad groupings of these many dis-
tinct racial/ethnic groups mask important differences.

  To characterize smoking and other risk behav-
iors more fully for program planning efforts at the lo-
cal level, the California State Department of Health
Services and two California agencies-Asian Health
Services and the University of California, San Fran-
cisco, Vietnamese Health Promotion Project-adapted
versions of the CDC's Behavioral Risk Factor Surveys
for use with Chinese and Vietnamese residents. The
questionnaires were modified for cultural appropri-
ateness and translated into Chinese or Vietnamese.
The Chinese-language survey included face-to-face
interviews with 296 Chinese adults in Oakland, Cali-
fornia, between June 1989 and February 1990. In the
Vietnamese-language survey, telephone interviews
were conducted with 1,011 Vietnamese adults during
February and March 1991 (CDC 1992b). Among both
Chinese and Vietnamese respondents, men were more
likely than women to be current smokers. The high-
est smoking prevalence was among men aged 25-44
years, and the prevalence of smoking was lower among
men with higher levels of education (Table 25) (CDC
1992b). The mean number of cigarettes smoked per
day by smokers was 15.9 among Chinese men, 11.0
among Vietnamese women, and 10.1 among Vietnam-
ese men. This number declined with older age and
increasing levels of education and income. (Data on
Chinese women are unavailable because the number
of Chinese women who smoked was too small for
analysis.)

  These surveys also measured acculturation by
using several proxy variables, including the percent-
age of lifetime spent in the United States, fluency in
English, and date of immigration. Among Chinese
men, the average number of cigarettes smoked per day
increased as the percentage of their lifetime spent in
the United States increased (Table 25). Among Viet-
namese respondents, the prevalence of smoking was
higher among men who immigrated in 1981 or later
and who were not fluent in English.

  In a more recent statewide telephone survey of
32,125 California households, Burns and Pierce (1992)
found that overall, the prevalence of smoking was
lower among Asian Americans and Pacific Islanders
than among whites, African Americans, and Hispan-
ics. This trend was evident among both men and
women. Because the survey was conducted only in
English or Spanish, Asian Americans and Pacific Is-
landers with limited English fluency were unable to
participate. This exclusion of recent immigrants and
those with the lowest levels of acculturation may have
produced a biased estimate of the prevalence of ciga-
rette smoking among California's Asian Americans
and Pacific Islanders. In assessing the smoking preva-
lence for several racial/ethnic subgroups, Burns and
Pierce (1992) found that Chinese reported the lowest
prevalence of smoking (11.7 percent), whereas Kore-
ans reported the highest prevalence (23.5 percent)
(Table 26). Men in all racial/ethnic subgroups were
substantially more likely than women to smoke ciga-
rettes. For men, the prevalence of smoking was high-
est among Koreans (35.8 percent) and lowest among
Chinese (19.1 percent). The prevalence of smoking was
highest among men aged 25-44 years. Smoking preva-
lence declined substantially with increasing education
across all racial/ethnic subgroups of men except Japa-
nese men. For women, the prevalence of smoking was
highest among Japanese (14.9 percent) and Koreans
(13.6 percent) and lowest among Chinese (4.7 percent).
Smoking prevalence declined with increasing level of
education across all racial/ethnic subgroups of women
except Chinese.

  In a 1978-l 985 survey of 13,031 persons of Asian
ancestry enrolled in the Oakland, California, Kaiser
Permanente Medical Care Program, the prevalence of
cigarette smoking varied significantly by Asian sub-
group for both men and women (Klatsky and
Armstrong 1991). Among men, the prevalence of ciga-
rette smoking was highest among Filipinos (32.9 per-
cent) and lowest among Chinese (16.2 percent) (Table
27). Among women, the prevalence of smoking was
highest among Japanese (18.6 percent) and lowest
among Chinese (7.3 percent). Japanese men and
women were more likely to smoke one or more packs
of cigarettes per day than were their counterparts in
other racial/ethnic groups.

  During 1989, newly arrived Southeast Asian im-
migrants were surveyed by the Health Department in
King County, Washington, regarding health problems
and health risk behaviors (CDC 1992~). Investigators
analyzed medical interview records for 274 Vietnam-
ese, 147 Laotian, and 112 Cambodian immigrants and
found that the smoking prevalence was substantially

Patterm of Tr~bacco USC  61


Table 25.  Percentage of Chinese and Vietnamese men who reported they smoke* and the number of
    cigarettes they smoke per day, by age, education, annual household income, and level of
    acculturation, Behavioral Risk Factor Surveillance System, California, 1990 and 1991
     aggregate data

Characteristic                    9%

Chinese               Vietnamese

   Mean no.                Mean no.
XI+ cigarettes XI %   %I cigarettes &CI

Age (years)
l-24
25-44
45-64
265

t      $      t      $    12.3    8.5    10.0    6.5
38.5    15.3    12.6    9.1    42.4    5.3    10.3    1.3
28.1    15.6    22.6    12.4    27.4    7.5    9.9     1.7
24.4    12.6    15.4    7.5    23.3    15.2    7.3    3.0

Education
Eighth grade or less
Some high school
High school graduate
Some college
College or more

30.2    12.4    15.7    5.5    36.6    11.2    11.9     2.9
45.5    20.9    11.2    4.5    39.6    8.3    10.6    1.7
28.6    19.4    28.0    28.4    40.4    12.8    8.8    2.4
0.0     x     0.0     t     32.9    7.3    9.9     2.1
20.0    17.5    10.0     t    26.8     7.7    9.1    2.7

Annual household income
<$10,000
$lO,OOO-$24,999
$25,000-$50,000
> $50,000

25.5    12.0    9.5    3.9    38.7    11.1    10.3    2.1
32.1    12.6    14.7    2.7    29.9    7.2    10.1     2.0
20.0    22.4    55.0     t     36.9    7.8    10.1     1.9
t      f-      t      t     29.5    10.1     8.3    3.3

Acculturation
<25Y~ of lifetime in United States      29.8     9.8    13.0     3.7    NA    NA    NA    NA
2 25% of lifetime in United States      26.2    13.3    22.3    15.9    NA    NA    NA    NA
Fluent in English5                %      t      %      t     29.7    7.6    10.7    2.6
Not fluent in English5            31.8     8.8    13.3     3.1    36.6     4.6    10.0     1.1
Immigration before 1981          NA    NA    NA    NA    32.2     5.3    10.5     1.5
Immigration in 1981 or later        NA    NA    NA    NA    37.7    6.0    9.8    1.5

*Current cigarette smokers are men who reported smoking at least 100 cigarettes in their lives and who reported
at the time of survey that they currently smoked. Because the number of current smokers who were women
was too small for analysis, data for age, education, annual income, and acculturation are provided for men only.
`95% confidence interval.
SNumbers too small for analysis.

%elf-report of ability to speak English well or fluently.
NA = data not available.
Source: Centers for Disease Control 1992b.

higher among men (42.5 percent) than among women
(5.7 percent) (Table 27). Southeast Asian men were 1.6
times as likely to smoke as were other men in Wash-
ington, whereas Southeast Asian women were one-
fourth as likely to smoke as were other women in the
state (CDC 1992~).

  In a recent review of Hawaii's health surveillance
data for 1975-1980, Blaisdell (1993) found that the
smoking prevalence was higher among Native Hawai-
ians than among persons in other racial/ethnic groups;

61.1 percent of pure Native Hawaiian men and 56.3
percent of part Native Hawaiian men were current
smokers (Table 27). According to the 1985 BRFSS data,
42 percent of Native Hawaiian men and 34 percent of
Native Hawaiian women were current smokers. Data
from the 1989 BRFSS in Hawaii indicate that the
prevalence was 28.2 percent among Native Hawaiians
(Table 271, which was higher than that among Filipi-
nos, Japanese, and whites (Blaisdell 1993).

62 Cl7aptcr 2


7Xvcco Use Amor7g U.S. Racial/Ethnic Mirzorify Groups

Table 26. Percentage of adult Asian Americans and Pacific Islanders who reported being current smokers,*
   overall and by gender, age, and education, Screener Survey, California, 1990 and 1991 aggregate
     data+

Characteristic        Chinese (% 1  Filipinos (%)  Japanese (% 1   Koreans (% 1   All Asians (%`I

Total

Age (years)
18-24
25-44
45-64
265

Education
Less than high school
High school
Some college
College

Men
Total

Age (years)
18-24
25-44
45-64
265

Education
Less than high school
High school
Some college
College

Women
Total

Age (years)
18-24
2544
45-64
265

Education
Less than high school
High school
Some college
College

11.7         15.9         17.4         23.5         15.9



9.7          12.2         19.7          26.9         14.6
12.4         21.0         20.3         26.1         18.1
11.4         14.4         16.8         16.2         15.3
11.4          6.6          9.9         23.2          8.9

17.6         19.2         23.4         38.1         21.4
16.7         20.3         21.5         21.3         19.4
11.2         15.2         16.2         25.3         15.2
6.6          11.2         12.3          19.1         10.5



19.1         23.0         20.1          35.8         23.5



13.0         19.1         17.2         34.3         19.0
20.9         29.2         24.7          44.1         27.1
19.9         25.8         22.1          22.6         24.0
19.8         10.6          11.1         60.6         14.0



35.4         32.1          18.4         70.6         36.9
26.3         27.6         28.7         35.3         28.3
18.1         21.5         19.2         32.4         20.9
9.8         18.9         16.5         31.0         15.6



4.7          8.9         14.9         13.6          8.9



5.8          4.0         22.9         19.9          9.5
5.5         14.6         16.3         13.9         10.4
2.5          5.1         13.4          9.9          7.4
2.6          3.4          8.3          NA         3.8



1.7         11.6         28.8         20.9          9.4
9.8         12.7         17.5         14.4         12.6
4.8          8.7         13.4          19.4          9.5
3.2          4.9          7.0          5.2          4.9

*Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in
their lives and who reported at the time of survey that they currently smoked. Only English-speaking persons
were interviewed.
`The variables needed to compute confidence intervals were not available.
NA = data not available.
Source: Burns and Pierce 1992.

httfW7S (If i-OhCClJ USC  63


Table 27.  Summary of selected findings on the percentage of Asian American and Pacific Islander adults
     who smoke, overall and by gender, 1975-1995

Study Population

Sources

Location/Year

Characteristics

Total

Klatsky and
Armstrong
1991

California,
1978-1985

CDC 1992~

Blaisdell 1993

McPhee et al.
1993

McPhee et al.    Santa Clara County,
1995         California, 1990

Wewers et al.
1995

Franklin County,
Ohio, 1992

CDC 1997a

Jenkins et al.
1997b

Jenkins et al.     Houston, Texas
1997b        1990,1992

Washington State,
1989

Hawaii, 1975-1980
Hawaii, 1975-1980
Hawaii, 1985
Hawaii, 1989

San Francisco and
Alameda Counties,
California,
1987,1989

Alameda County,
California,
1994-1995

San Francisco and
Alameda Counties,
California, 1990

Adults

-

Current smokers
Chinese
Filipino
~EZeIEians

NA     16.2     7.3
NA     32.9     11.4
NA     22.7     18.6
NA     30.9     12.6

Persons who smoke 21 pack/day
Chinese                NA
Filipino                NA
Japanese               NA
Other Asians             NA

Southeast Asians, by
age (years)
18-29                  17.6
30-39                  26.3
40-59                  26.6
'60                    28.9
Total                  23.1

Pure Native Hawaiians        NA
Part Native Hawaiians        NA
Native Hawaiians           NA
Native Hawaiians           28.2

Vietnamese adults
1987                  NA
1989                   NA

4.1     1.3
7.1     1.7
8.2     4.6
6.7     1.6

29.5     3.0
53.7     5.6
54.5     8.3
55.9     7.1
42.5     5.7

61.1     NA
56.3     NA
42     34
NA     NA

56       9
45       2

Vietnamese men


Cambodians


Laotians


Vietnamese


Korean adults

NA     36

20.6*     34.0
(30.3)+    (38.8)
27.8     45.6
(32.9)    (48.2)
27.6     43.3
(29.0)    (43.3)

21      39

NA

6.6
(21.5)
4.2
(10.8)
&

6

Vietnamese men




Vietnamese men
1990
1992

NA






NA
NA

36.1     NA

39.6     NA
40.9     NA

Men

Women

*Figures not in parentheses are from self-report.
`Figures in arentheses represent cotinine-adjusted prevalences. Persons whose saliva cotinine levels were
> 14 n /m P were considered to be smokers.
NA = &ta not available.


  Data collected from several surveys (conducted
in 1987,1989,1990, and 19921 of Vietnamese men and
women living in California, Texas, and Ohio showed
that the prevalence of cigarette smoking was substan-
tially higher among Vietnamese men than among all
U.S. men (Jenkins et al. 1990; McPhee et al. 1993;
McPhee et al. 1995; Wewers et al. 1995; Jenkins et al.
1997b). Vietnamese women, however, were signifi-
cantly less likely to smoke than were Vietnamese men
or other U.S. women (Table 27).

  Several surveys have been conducted in San
Francisco and Alameda Counties, California. In the
1987 survey, which included data from 215 randomly
sampled Vietnamese, 56 percent of Vietnamese men
reported smoking cigarettes, compared with 9 percent
of Vietnamese women (Jenkins et al. 1990). Vietnam-
ese men had twice the smoking prevalence of men in
the United States. On average, however, the number
of cigarettes smoked per day was smaller among Viet-
namese men (13.4) than among men in the general U.S.
population (23.0). In the 198Y survey of 151 Vietnam-
ese adults, 45 percent of Vietnamese men and 2 per-
cent of Vietnamese women reported being cigarette
smokers (Table 27) (McPhee et al. 1993). The precision
of the estimates of smoking prevalence from the
1987 and 1989 surveys is limited by small sample sizes.
In the 1990 survey of 1,133 Vietnamese men, which
served as the baseline measure in an evaluation of a
community-based smoking cessation intervention, 36.1
percent were current smokers. These men smoked an
average of 11.1 cigarettes per day (Jenkins et al. 1997b).

  Another survey of Vietnamese men (n = 1,322),
which also served as the 1990 baseline measure in an
evaluation of a similar smoking cessation intervention,
was conducted in Santa Clara County, California. In
this population, 37.9 percent were current smokers; the
smokers consumed an average of 9.9 cigarettes per day
(McPhee et al. 1995). The comparison data for the two
evaluation studies conducted by McPhee and colleagues
were obtained from surveys of Vietnamese men living
in Houston, Texas (McPhee et al. 1995; Jenkins et al.
1997b). In the 1990 survey (n = 1,581), 39.6 percent of the
men were current smokers; in the 1992 survey (n = 1,209),
40.9 percent were current smokers. The mean number
of cigarettes smoked daily was significantly lower in 1992
(11.9) than in 1990 (13.21.

  The 1990 and 1992 survey data showed an asso-
ciation between cigarette smoking prevalence and
acculturation. In multivariate analyses that included
statistical control for education, employment, and pov-
erty status, the prevalence of cigarette smoking was
elevated among persons with limited English-lan-
guage proficiency and persons who had more recently

immigrated to the United States (McPhee et al. 1995;
Jenkins et al. 1997b). Data collected from 1,403 South-
east Asian immigrant men and women through a
household interview indicate that self-reported ciga-
rette smoking prevalence is underreported, especially
among women (Wewers et al. 1995). Cigarette smok-
ing status among Cambodian, Laotian, and Vietnam-
ese adults in Franklin County, Ohio, was verified by
saliva cotinine assay; a cutoff of 14 ng/mL was used
to indicate active smoking. Self-reported smoking
prevalence was 40.9 percent for men and 5.6 percent
for women. However, results from biochemical
verification indicated that 43.7 percent of men and
14.8 percent of women were current smokers.
Misclassification as a result of exposure to environmen-
tal tobacco smoke is unlikely, given how high the
cotinine levels were among self-reported former and
never smokers (range 17-331 ng/mL). As other stud-
ies have found, current smoking was substantially
higher among men than women for all racial/ethnic
groups in the study (Table 27) and was higher among
respondents with less education.

  From August 1994 to February 1995, a telephone
survey of 676 Korean Americans (aged 18 years and
older) was conducted in Alameda County, California
(Table 27) (CDC 1997a) , Overall, 39 percent reported
that they had smoked at least 100 cigarettes in their
lifetimes. Men (70 percent) were more likely than
women (13 percent) to have smoked at least 100 life-
time cigarettes. Current smoking prevalence was 39
percent for Korean American men in Alameda
County-an estimate that was substantially higher
than the 19 percent prevalence estimate (from the 1995
California Behavioral Risk Factor Survey) for all men
in the state. Conversely, only 6 percent of Korean
American women from Alameda County reported
current smoking-less than the statewide estimate for
women of 14 percent.

Cigarette Smoking in Asian Countries

  Because so many Asian Americans have recently
immigrated to the United States, understanding how
smoking practices in Asian countries may affect smok-
ing practices among Asian Americans here is impor-
tant. Currently, however, data are scarce on smoking
trends in the countries from which Asian Americans
and Pacific Islanders have emigrated. The informa-
tion that is available suggests that the prevalence of
smoking among men in Asia is much higher than
among Asian American men.

   Various studies from Asian countries indicate a
very high cigarette smoking prevalence among men


and a relatively low prevalence among women (Weng
et al. 1987; Li et al. 1988; Hawks 1989; Koong et al. 1990;
Gong et al. 1995; Jenkins et al. 1997a; World Health
Organization, unpublished data). In many of these
countries, the estimated prevalence of smoking among
men exceeds 50 percent. However, the prevalence of
smoking among women is generally below 20 percent.
Some of these studies indicate that the prevalence of
smoking among women increases with age (Weng et
al. 1987; Koong et al. 1990). In Pacific Island nations,
the prevalence of smoking among men is also very
high, with estimates generally exceeding 50 percent,
similar to those in Asian countries. Women in the Pa-
cific Island nations are less likely to smoke than men,
but they are more likely to smoke than women in Asian
countries, with prevalence estimates generally exceed-
ing 20 percent (World Health Organization, unpub-
lished data).

  Studies also show that smoking prevalences are
much higher among Chinese male adolescents than
among female adolescents. In a 1988 survey of 8,437
junior high school students and 3,823 senior high
school students in Beijing, the self-reported prevalence
of ever smoking was 34.4 percent among male junior
high school students and 3.9 percent among their fe-
male counterparts (Zhu et al. 1992). Among senior high
school students, the prevalence of ever smoking was
46.0 percent among males and 5.5 percent among fe-
males (Wang et al. 1994).

Hispanics

  No data are available on long-term trends in the
prevalence of cigarette smoking among Hispanics in
the United States. Before 1978, major U.S. government
databases, surveys, and publications limited their clas-
sifications of race and ethnicity to "white" and "black,"
and no information was available about persons of
Hispanic ancestry. When questions about Hispanic
ancestry were added to the NHIS in 1978, direct esti-
mates of smoking prevalence among Hispanics were
possible for the first time. Because Hispanics made
up a small proportion of the U.S. population at the
time of the initial surveys, survey data must be aggre-
gated from several years to provide meaningful
estimates. As with previous sections, data in this sec-
tion are from the NHISs, which included Hispanic
data aggregated as follows: (11 1978, 1979, and 1980;
(2) 1983 and 1985; (3) 1987 and 1988; (4) 1990 and 1991;
(5) 1992 and 1993; and (6) 1994 and 1995. Not until the
HHANES was administered from 1982 through 1984
was a large enough sample of Hispanics available to
assess long-term reconstructed trends in smoking

through retrospective analysis of smoking prevalence
among successive birth cohorts of Hispanics (Escobedo
and Remington 1989; Escobedo et al. 1989a).

Prevalence of Cigarette Smoking

  NHIS data indicate that the prevalence of smok-
ing declined among Hispanics from 1978 through
1995 (Table 28) (NCHS, public use data tapes, 1978-
1995). Birth cohort data from the HHANES also
reflect recent declines in the prevalence of smoking
among the three subgroups of Hispanics surveyed:
Cuban Americans, Mexican Americans, and Puerto
Ricans (Escobedo and Remington 1989).

  Between 1978 and 1995, the prevalence of smok-
ing among Hispanic men and women decreased, al-
though smoking prevalence was consistently greater
among men than among women, according to the
NHIS data (Table 28). Previous analysis of the
HHANES birth cohort data showed that after 1970,
the prevalence of smoking declined sharply among
Mexican American men and less dramatically among
Puerto Rican and Cuban American men (Escobedo et
al. 1989a). In contrast, the prevalence of smoking
changed little or increased among most age groups of
Cuban American, Mexican American, and Puerto
Rican women. For men participating in the 198221984
HHANES, the smoking prevalence ranged from 41.3
percent (among Puerto Ricans) to 43.6 percent (among
Mexican Americans) (Escobedo and Remington 1989),
compared with 31.6 percent of Hispanic men in the
1983-1985 NHIS. For women participating in
HHANES, the smoking prevalence ranged from 23.1
percent (among Cuban Americans) to 32.6 percent
(among Puerto Ricans) (Escobedo and Remington
19891, compared with 20.4 percent of Hispanic women
in the 1983-1985 NHIS.

  Several factors help explain why the HHANES
estimates for men are at least 10 percentage points
higher than the NHIS estimates for men for a compa-
rable period and why the HHANES estimates
for women also show a higher prevalence than the NHIS
estimates for women. Most importantly, the HHANES
was more likely to select an immigrant population than
the NHIS because HHANES offered respondents the
choice of English or Spanish questionnaires. In addi-
tion, the HHANES sampled Cuban Americans from
Dade County, Florida; Mexican Americans from Ari-
zona, California, Colorado, New Mexico, and Texas; and
Puerto Ricans from New York, New Jersey, and Con-
necticut. On the other hand, the NHIS, administered
only in English, is a national sample of the general popu-
lation, which includes a wider range of racial/ethnic


Table 28.  Percentage of adult Hispanics who reported being current cigarette smokers,* overall and
     by gender, age, and education, National Health Interview Surveys, United States, 1978-1995
     aggregate data

1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 199%1993+ 1994-1995+

Characteristic

%  +c1s 9%   +c1 %   fC1 Yc   KI %   +c1 Yo   fC1

Total                   30.1 1.9   25.6 1.6   23.6 1.4   21.5 1.4   20.5 1.6   18.9 0.7

Gender
Men
Women

Age (years)
18-34
35-54
255

Educations
Less than high school
High school
Some college
College

37.6 3.0   31.6 2.9   29.6 2.3   27.8 2.3   25.9 2.6   22.9 2.4
23.3 2.0   20.4 1.9   18.4 1.5   15.9 1.6   15.5 1.9   15.1 1.7

32.3 2.7   25.8 2.2   23.6 1.9   21.1 1.9   21.0 2.4   19.8 2.2
30.4 2.7   28.4 3.2   26.3 2.3   25.7 2.2   23.4 2.7   19.8 2.5
22.9 2.8   19.9 4.2   18.2 2.8   13.7 2.6   12.4 3.7   14.3 3.5

33.4 3.5   28.0 2.6   26.1 2.3   22.9 2.4   21.6 2.7   20.2 2.4
25.2 3.9   28.1 3.8   27.8 3.0   27.6 2.7   24.2 3.3   21.6 3.4
32.7 6.5   26.4 4.0   20.3 3.2   19.9 3.1   19.5 4.2   21.0 4.1
17.1 6.6   20.4 6.1    13.9 3.0   16.1 3.4   13.1 3.8    8.7 3.1

*For 19781991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their
lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers
include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of
survey that they currently smoked every day or on some days.
`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
$950/c confidence interval.
"Includes persons aged 25 years and older.

Source: National Center for Health Statistics, public use data tapes, 1978-1995.

groups and subgroups, including persons who identi-
fied themselves as Puerto Rican, Cuban, Mexican,
Mexicano, Mexican American, Chicano, Spanish, or of
other Latin American origin. Because Hispanics with
higher levels of education are less likely to smoke than
other groups of Hispanics (Haynes et al. 19901, the
slightly different target populations in the HHANES
and in the NH&--which probably differ in educational
attainment-may help explain differences in smoking
prevalence between the two surveys.

  Hispanics aged 55 years and older consistently
had the lowest rates of cigarette smoking in the NHIS
(Table 28), a finding similar to that from the HHANES
(Haynes et al. 1990). Rates of cigarette smoking
generally have been highest among Hispanics with a
high school education or less and lowest among those
who have graduated from college (Table 281. This pat-

tern also was observed in a smaller survey of Hispanic
adults in a semirural city near Albuquerque, New
Mexico (Samet et al. 1992).

  In the 1982-1984 HHANES, having 12 or more
years of education was associated with lower rates of
cigarette smoking among Cuban American, Mexican
American, and Puerto Rican men (Haynes et al. 1990).
Among Hispanic women, those with 7-11 years of edu-
cation had the highest rates of cigarette smoking.

  The 1982-1984 HHANES used an eight-item
scale to measure level of acculturation in Mexican
Americans (Delgado et al. 1990). The variables
used to construct the scale were language ability,
self-identification, parents' racial/ethnic identification,
and generation in the United States. Among Mexican
American women, there was a dose-response
relationship between the level of acculturation and


Table 29.  Percentage of adult Hispanic smokers* who reported smoking <15,15-24, or 225 cigarettes per
     day, overall and by gender, age, and education, National Health Interview Surveys, United States,
     1978-1995 aggregate data

1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic

%  +c1$   % +c1 %   fC1 %   fC1 %   fC1 %   fC1

Total
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
Gender
Men
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
Women
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
Age (years)
18-34
  Cl5 cigarettes
  15-24 cigarettes
  225 cigarettes
35-54
  <IS cigarettes
  15-24 cigarettes
225 cigarettes
255
  Cl.5 cigarettes
  15-24 cigarettes
~25 cigarettes

56.0 4.5   55.6 4.1   58.3 3.2   64.5 3.3   72.7 3.8   65.0 4.1
30.7 4.3   31.3 3.0   30.9 3.1   29.3 3.2   21.2 3.5   27.3 3.9
13.3 2.4   13.2 3.0   10.9 2.1    6.2 1.4    6.2 2.0    7.7 2.0

52.4 5.9   52.5 5.5   54.9 4.6   62.5 4.4   71.8 5.2   62.4 5.1
32.6 5.0   33.0 4.2   32.1 4.6   29.8 4.2   20.7 4.5   29.9 4.7
15.0 3.6   14.4 3.9   13.0 2.9    7.7 2.1    7.6 3.0    7.6 3.7

61.4 5.2   59.8 4.9   63.0 4.2   67.6 4.7   74.1 5.3   68.8 5.6
27.8 5.3   28.8 5.1   29.1 4.2   28.6 4.5   22.0 5.1   23.5 5.1
10.7 3.6   11.5 3.9    7.9 2.3    3.8 1.5    3.9 2.0    7.7 3.1

61.7 6.2   61.4 5.3   61.6 4.8   69.8 4.3   78.1 4.7   70.2 6.3
28.5 5.5   29.2 4.5   29.3 4.8   27.8 4.1   17.3 4.2   25.1 6.1
9.9 2.6    9.4 3.7    9.1 2.7    2.4 1.1    4.6 2.4    4.7 2.5

49.0 6.3   44.5 6.5   56.0 5.0   59.7 4.9   66.5 6.7   60.4 6.2
33.4 6.7   35.1 5.0   31.7 4.7   29.6 4.6   25.2 6.1   28.6 5.9
17.7 4.5   20.4 4.9   12.3 3.5   10.6 2.9    8.2 3.9   11.0 3.8

49.6 8.6   61.2 9.7   50.8 7.7   55.2 9.7   69.8 13.5   56.2 11.5
33.3 8.3   29.2 8.7   34.8 7.5   36.0 10.2   24.6 13.1   32.9 10.5
17.1 7.6    9.6 5.8   14.4 5.9    8.5 5.5    5.6 4.5   10.9 7.0

*For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their
lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers
include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of
survey that they currently smoked every day or on some days.
`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
*95% confidence interval.

age-adjusted (to the 1980 U.S. population) cigarette       Navarro (1996) used data from the 1990 Califor-
smoking prevalence; 19 percent of Mexican-oriented   nia Tobacco Survey to study level of acculturation in
women and 28 percent of U.S.-oriented women were   Hispanics (most of whom were of Mexican origin).
current cigarette smokers (Haynes et al. 1990). The    Level of acculturation was defined based on the lan-
unadjusted prevalence of cigarette smoking among U.S.   guage spoken in the home: persons from English-
women aged 18 years and older in 1983 was 29.5 per-   speaking homes were classified as having a high level
cent (CDC 1994~). No clear relationship was observed   of acculturation, and persons from Spanish-speaking
among Mexican American men (Haynes et al. 1990).    homes were classified as having a low level of

68 Chpter 2

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

Table 29. Continued




Characteristic

1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

7c  KIS %   fCI CA-   +c1 %   +c1 %   fC1 %   fC1

Educations
Less than high school
  <15 cigarettes          55.4  5.0   54.1  5.3   59.2  5.1   66.2  5.2   71.1  6.6   63.5  7.2
  15-24 cigarettes        29.9  5.6   33.7  5.9   30.3  4.7   27.6  5.1   23.1  6.1   30.0  7.2
  225 cigarettes          14.7  4.3   12.3  4.7   10.5  3.3    6.2  2.3    5.8  3.6    6.5  3.4
High school
  <15 cigarettes          53.4  9.9   53.9  7.5   53.9  6.6   60.9  6.0   70.5  7.2   61.3  7.3
  15-24 cigarettes        34.7  9.4   33.2  7.1    32.5  6.6   32.6  5.7   25.4  7.0   28.7  6.6
  225 cigarettes          11.9  5.9   12.9  4.4   13.6  4.5    6.5  2.6    4.2  3.0   10.1  4.4
Some college
  <15 cigarettes          50.6  10.3   50.5  11.8   54.1  9.2   55.1  8.6   70.8  9.7   55.5  9.9
  15-24 cigarettes        37.3  10.8   24.1  9.6   31.9  8.2   35.1  8.4   21.0  8.9   36.1  10.1
  225 cigarettes          12.2  7.5   25.5  9.9   14.0  6.4    9.8  5.3    8.2  5.1    8.4  5.1
College
  <15 cigarettes          55.6 22.1   50.0  17.1   55.3  11.7   64.4  11.3   75.8  11.7   71.6  15.7
  15-24 cigarettes        17.8  15.2   36.4  13.5   29.6  10.6   27.1  10.3   16.7  10.3   17.9  12.8
  225 cigarettes          26.7  21.7   13.6  10.1   15.0  9.3    8.5  5.9    7.5  6.3   10.5  10.7

%tcludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 19781995.

acculturation. The data were analyzed by gender and
for three levels of educational attainment (<12,12, and
>12 years). Among men, smoking prevalence varied
for those with ~12 and 12 years of education; smoking
prevalence was highest among whites, intermediate
among Hispanics of high acculturation, and lowest
among Hispanics of low acculturation. This pattern
also existed for women, but in all three of the educa-
tion categories. Additionally, in a multivariate analy-
sis that controlled for age, gender, educational
attainment, and Mexican origin, Hispanics with a low
acculturation level were significantly less likely to
smoke than those with a high acculturation level.
Navarro suggested that level of acculturation may be
related to the degree of urbanization of the person's
or family's residence in the country of origin. For ex-
ample, persons living in rural areas of Latin America
appear to be less likely to smoke than those living in
urban areas (USDHHS 1992). The relationship be-
tween cigarette smoking and level of acculturation
among Hispanics living in the United States may
be confounded by adaptation to industrial and
urban societies (Navarro 19961, especially if persons
or families from rural areas acculturate more slowly
than those from urban areas. Future research into this

topic might ideally include information on the person's
or family's residence in the country of origin.

Number of Cigarettes Smoked Daily

  Between 1978 and 1985, trends in the number of
cigarettes smoked per day by Hispanic smokers re-
mained stable (Table 29) (NCHS, public use data tapes,
19781995). More recently, however, an increasing pro-
portion of Hispanic smokers have been smoking fewer
than 15 cigarettes per day, and a declining proportion
of them have been smoking 25 or more cigarettes per
day. For example, in 1978-1980, 13.3 percent of His-
panic smokers smoked 25 or more cigarettes per day.
By 1994-1995, this proportion was 7.7 percent.

  From 1978 to 1993, Hispanic men were more
likely than Hispanic women to smoke 25 or more ciga-
rettes per day, although these differences were not sta-
tistically significant (Table 29). Consumption patterns
in 1994-1995 were similar across genders. Between
1978 and 1995, the prevalence of smoking 25 or more
cigarettes per day declined among Hispanics at all
levels of education (Table 29), although only the
decline among persons with less than a high school
education was statistically significant.

Patterns of Tobacco Use  69


Quitting Behavior

  In the NHIS, the prevalence of smoking cessa-
tion among Hispanic smokers increased moderately
between 1978 and 1995 (Table 30) (NCHS, public use
data tapes, 1978-1995). No notable differences in
smoking cessation between Hispanic men and women
were observed. The prevalence of cessation was higher
among persons in the older age groups and among
college graduates (Table 30).

  Data from a recent multivariate analysis of the
1991 NHIS (CDC 1993) indicate that after the analysis
controlled for gender, age, education, and poverty sta-
tus, Hispanics were more likely than whites to stop
smoking for at least one day during the previous year.
Hispanics who had stopped smoking for at least one
day were about as likely as whites to have stopped for

at least one month. Overall, Hispanic smokers were
slightly more likely than whites to have quit smoking
for at least one month.

  Data from the NC1 Supplement of the 1992-1993
CPS indicate that among Hispanics aged 18 years and
older who were daily smokers one year before the sur-
vey, 59.8 percent reported that they were still smoking
daily and that they had not tried quitting for at least
one day during the previous year (Table 4). Another
28.5 percent had tried quitting for at least one day, 5.6
percent were occasional smokers (i.e., smoked only on
some days), 2.5 percent had not smoked for the past
l-90 days, and 3.6 percent had not smoked for the past
91-364 days. This distribution was similar to that
among whites, with the exception that slightly more
Hispanics had become occasional smokers.

Table 30.  Percentage of adult Hispanic ever smokers who have quit,* overall and by gender, age, and
     education, National Health Interview Surveys, United States, 1978-1995 aggregate data

197%1980+ 1983-1985+ 1987-1988+

1990-1991+

Characteristic             5%  +c1* R   +c1 %   +c1    %   +c1

Total                  35.0 2.8

Gender
Men
Women

Age (years)
18-34
35-54
255

Education_
Less than high school
High school
Some college
College

35.5 3.4   40.5 4.1   43.0 3.3   43.0 3.6   45.8 4.1   48.2 4.3
34.2 4.3   37.6 4.3   42.5 3.4   45.6 3.5   41.6 4.5   43.1 4.5

27.9 4.2   32.6 3.2   33.7 3.6   34.3 3.5   31.4 4.3   32.5 4.9
37.2 3.9   39.2 5.2   44.9 3.7   45.3 3.6   46.4 4.7   49.6 4.9
51.0 5.5   57.2 7.6   60.4 5.0   67.1 5.6   70.3 6.9   68.1 6.4

30.5 3.6   37.7 4.0   43.3 3.6   45.5 4.4   42.8 5.0   47.6 5.1
45.7 7.1   40.0 6.0   41.2 4.6   41.9 4.4   44.2 6.0   44.5 6.2
38.5 9.8   47.8 6.9   55.0 6.3   52.6 6.1   52.8 8.8   49.1 7.6
59.4 14.2   52.2 10.3   59.2 7.2   56.6 7.3   64.0 8.9   71.1 9.1

-

-

39.3 2.8   32.8 2.4   44.1 2.6   44.2 3.1   46.2 3.2

199%1993+

1994-1995+

%   +c1

YO   fC1

*The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are
persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that
thev were not smoking, and ever smokers include current and former smokers.
`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
t95% confidence interval.
%cludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.


Tobacco Use Anzmig U.S. Racinl/Et/mic Minorify Group

Women of Reproductive Age

  From 1978 to 1995, a large proportion of Hispanic
women of reproductive age (18-44 years) have smoked
cigarettes, although this proportion has been declining
over time (Table 31) (NCHS, public use data tapes,
1978-1995). Some evidence suggests that the prevalence
of smoking among women of reproductive age v7aries
according to the country of origin, with Cuban Ameri-
can women (22.6 percent) and Mexican American
women (23.2 percent) reporting cigarette smoking in
lower proportions than Puerto Rican women (33.5 per-
cent) (Pletsch 1991). In a comparison of data from the
HHANES and the National Health and Nutrition Ex-
amination Survey (NHANES), Guendelman and
Abrams (1994) found that Mexican American iTomen
of reproductive age were less likely than their lz'hite
counterparts to smoke cigarettes at each of the repro-
ductive stages (interconception, pregnancy, lactation,
and postpartum).

  The National Survey of Family Growth collected
data in 1982 and 1988 on the smoking behavior of
females 1544 years of age during their most recent
pregnancy. In 1982,17.2 percent of Hispanic women
reported smoking during their most recent pregnancy,
compared with 13.7 percent in 1988 Wamuk and
Masher 1992; Chandra 1995). More recent data from
U.S. final natality statistics indicate that smoking rates
for Hispanics during pregnancy declined from 8 per-
cent in 1989 to 4.3 percent in 1995 (Table 6). Hispanic
adolescent mothers were about as likely as older
Hispanic mothers to have smoked (USDHHS 1994).

  Hispanic mothers report generally low rates of
tobacco use, ranging from 1.8 to 4.1 percent for Mexi-
can, Cuban, Central American, and South American
mothers to 8.2 to 10.4 percent for Puerto Rican and
"other" Hispanic mothers and those of unknown
Hispanic origin (Table 6). Ventura and colleagues
(1995) reported that 3 percent of foreign-born or Puerto

Table 31.  Percentage of Hispanic women of reproductive age who reported being current cigarette
    smokers,* overall and by education, National Health Interview Surveys, United States,
     1978-1995 aggregate data

1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic              7c  KIS 7%   KI 5%   +c1 %   KI Y0   XI %   KI


Total                  25.5 2.7   22.2 2.2   19.8 1.7   16.7 1.8   17.3 2.3   16.4 2.0

Educations
Less than high school      29.2 4.3   24.4 4.4   23.5 4.0   17.6 3.7   17.0 4.4   17.0 3.7
High school            21.3 5.6   27.6 5.3   24.1 3.7   21.4 3.6   25.1 5.3   21.4 4.7
Some college            12.9 7.5   21.5 6.7   15.9 4.6   19.5 4.2   17.0 6.1   16.5 5.3
College               17.3 12.0   16.7 8.3   12.7 4.7   15.2 5.0   12.9 5.8    5.1 4.1
*For 1978-1991, current cigarette smokers include women aged 1844 years who reported smoking at least 100
cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995,
current smokers include women aged 1844 years who reported smoking at least 100 cigarettes in their lives
and who reported at the time of survey that they currently smoked every day or on some days.
`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
$95% confidence interval.
gIncludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

Prrf term of Tuhncco Use  71


Rican-born Hispanic mothers smoked, compared with
9 percent of their United States-born counterparts
(Ventura et al. 1995). Data on tobacco use among these
mothers may be skewed because California and New
York do not report this information, and together these
states account for almost half of all Hispanic births
(Ventura et al. 1996).

  The National Pregnancy and Health Survey, con-
ducted between October 1992 and August 1993 and
sponsored by NIDA, provides nationally representa-
tive data on the prevalence of prenatal drug use among
Hispanic females of reproductive age (15-44 years).
According to National Pregnancy and Health Survey
data, 5.8 percent of Hispanic women reported using
cigarettes during their pregnancies (NIDA 1994). In
the 1985 and 1990 NHISs, questions related to smok-
ing were asked of women aged 1844 years who had
given birth within the past five years. In 1985, 16.8
percent of Hispanic women smoked during the 12
months before the birth and 10.3 percent smoked after
learning of their pregnancy; in 1990, 12.1 percent
smoked during the year before birth and 8 percent af-
ter learning of their pregnancy (Floyd et al. 1993).

Young People

Cigarette Smoking

  Despite the dearth of information on tobacco use
among Hispanic youths, several studies have been able
to identify trends in smoking initiation and patterns
of tobacco use by analyzing data from the HHANES,
the MTF surveys of high school seniors (Figure 3), and
small local surveys (for example, Smith et al. 1991;
Dusenbury et al. 1992; Vega et al. 1993).

  HHANES data have shown that smoking initia-
tion increased rapidly among Cuban Americans, Mexi-
can Americans, and Puerto Ricans between ages 11 and
15 years, peaked between ages 15 and 19 years, and
declined after the age of 20 years (Escobedo et al. 1990).
In all age groups, smoking initiation rates were higher
among males than among females.

  Slight variations in smoking initiation by level
of education were found when the HHANES data were
combined for all three Hispanic subgroups (although
these were three separate surveys, it was necessary
to combine three groups to estimate trends for all
three groups). Hispanics with less than a high school
education had the highest rates of smoking initiation,
with an earlier age of onset and a more accelerated
rate of smoking initiation during young adolescence,
than Hispanics with more years of schooling. Hispan-
ics with a high school education had intermediate rates

of smoking initiation, whereas those with more than
a high school education had slightly lower smoking
initiation rates. Because educational attainment is a
reliable (Liberatos et al. 19881 although limited (Mont-
gomery and Carter-Pokras 19931 indicator of socioeco-
nomic status, these data suggest that an association
between smoking initiation and socioeconomic status
may exist among Hispanics, as it does for the general
U.S. population. However, these differences in smok-
ing initiation by educational attainment were not as
large as those found among whites.

  In addition, data from the 1994-1995 (combined)
NHSDAs indicate that among persons aged 30-39
years, Hispanic men and women were less likely to
become daily smokers than whites (Table 11)
WSDHHS, Substance Abuse and Mental Health Ser-
vices Administration, public use data tapes, 1994-
1995). Among persons in this age group who had ever
smoked daily, the initiation patterns among Hispan-
ics were more like those of African Americans than
those of whites. The average ages for first trying a
cigarette and for becoming a daily smoker were about
one year higher for Hispanic men than for white men
and about two years higher for Hispanic women than
for white women (Table 11).

  Among high school seniors who participated in
the MTF in 1985-1989,23.8 percent of Mexican Ameri-
can males, 22.0 percent of Puerto Rican and Latin0
males, 18.7 percent of Mexican American females, and
24.7 percent of Puerto Rican and Latina females
smoked cigarettes in the previous month (Bachman et
al. 1991 b). In addition, 11.6 percent of Mexican Ameri-
can males, 13.3 percent of Puerto Rican and Latin0
males, 8.1 percent of Mexican American females, and
13.3 percent of Puerto Rican and Latina females
smoked cigarettes daily in the previous month. The
prevalence of smoking one-half pack of cigarettes or
more per day was somewhat higher among males
(5 to 6 percent) than among females (2 to 4 percent).

  Between 1976 and 1989, the prevalence of daily
smoking declined among Mexican American high
school seniors of both genders and among Puerto
Rican and Latina females, according to the MTF
data (Bachman et al. 199lb). Decreases occurred be-
tween 1976 and 1984 among Mexican American males
and between 1980 and 1989 among Puerto Rican and
Latina females. Among Mexican American females,
decreases in the prevalence of daily smoking occurred
between 1976 and 1984, and no decline was observed
in more recent years. In contrast, little change in the
prevalence of daily smoking was observed among
Puerto Rican and Latin0 males over the entire survey
period (Bachman et al. 1991b).


Tt~/mco Use Arnmg U.S. Racinl/Efhnic Minority Gro14ps

  Recent data indicate that rates of smoking are
generally lower among Hispanic youths than among
white youths. The 1989 TAPS showed that 11.8 per-
cent of Hispanics reported some level of cigarette
smoking, compared with 17.7 percent of whites and
6.2 percent of African Americans (Moss et al. 1992).
However, patterns may differ for migrant and resident
youths. In a recent study of 214 migrant Hispanic ado-
lescents enrolled in school in San Diego, the prevalence
of cigarette smoking within the 30 days preceding the
survey increased by school grade, from a low of
10 percent of 9th graders to 14 percent of 10th graders,
21 percent of 11th graders, and 18 percent of 12th
graders (Lovato et al. 19941. Also, acculturation may
influence smoking behavrior. In a study of sixth and
seventh graders in Dade County, Florida, Vega and col-
leagues (1993) found that cigarette smoking \vas more
frequent among United States-born Cuban American
children (23.8 percent) than among foreign-born
Cuban Americans (15.1 percent).

  According to the 1995 YRBS, 34.0 percent of His-
panic high school students and 38.3 percent of white
high school students smoked on one or more days
during the previous month (CDC 1996). Hispanic stu-
dents were significantly more likely than African
American students (19.2 percent) to have smoked dur-
ing the previous month. Regarding more frequent
smoking, Hispanic youths (10.0 percent) and African
American youths (4.5 percent) were less likely than
white youths (19.5 percent) to have smoked on at least
20 days during the previous month.

  Lowry and colleagues (1996) analyzed cross-
sectional data on 6,321 adolescents (aged 12-17 years)
from the YRBS supplement to the 1992 NHIS. His-
panics were significantly less likely than whites to have
smoked in the previous 30 days. This analysis con-
trolled statistically for the educational level of the re-
sponsible adult, for family income, for the age and
gender of the adolescent, and for whether the adoles-
cent was in or out of school. In an analysis comparing
measured carbon monoxide from expired air with self-
reported smoking among a sample of seventh- through
tenth-grade New York State public school students,
Wills and Cleary (1997) found that the self-report sen-
sitivity was slightly lower for Hispanics than for whites
but that the magnitude of the effect was small. When
self-reported smoking rates were adjusted for carbon
monoxide values, ninth- and tenth-grade Hispanic
students had significantly lower smoking prevalences
than whites.

  Recent findings from focus groups conducted at
several U.S. sites suggest that Hispanic parents may
be more likely than white parents to express clear anti-

smoking messages and that smoking by Hispanic ado-
lescents may be a sign of disrespect toward parents
(Mermelstein et al. 1996).

  According to the 1996 MTF surveys, the preva-
lence of previous-month smoking (estimated by com-
bining 1995 and 1996 data) among Hispanic high school
seniors (25.4 percent) was intermediate to that among
African American seniors (14.2 percent) and white se-
niors (38.1 percent) (Institute for Social Research, Uni-
versity of Michigan, unpublished data from the 1996
MTF surveys). A similar pattern was observed for tenth-
grade students: previous-month smoking prevalences
were 23.7 percent for Hispanics, 32.9 percent for whites,
and 12.2 percent for African Americans. However,
among eighth-grade students, the Hispanic-white
difference was attenuated: 19.6 percent of Hispanics,
22.7 percent of whites, and 9.6 percent of African Ameri-
cans were previous-month smokers. Trends in daily
smoking among high school seniors show that rates for
Hispanics have been consistently lower than for whites
since 1977 and higher than for African Americans since
the early 1980s (Figure 3).

  The MTF surveys suggest that rates of smoking
among Hispanics have increased in the 1990s. The
prevalence of previous-month smoking (based on two-
vear rolling averages) among eighth-grade students
was 16.7 percent in 1992 and 19.6 percent in 1996;
among tenth-grade students, the prevalence was 18.3
percent in 1992 and 23.7 percent in 1996; and among
high school seniors, the prevalence was 21.7 percent
in 1990 and 25.4 percent in 1996 (Johnston et al. 1996;
Institute for Social Research, University of Michigan,
unpublished data from the 1996 MTF surveys). Simi-
larly, YRBS data indicate that the prevalence of previ-
ous-month smoking among Hispanic high school
students was 25.3 percent in 1991 (USDHHS 1994) and
34.0 percent in 1995 (CDC 1996).

Other Risk Behaviors

  Using data from the YRBS supplement to the 1992
NHIS, Escobedo and colleagues (1997) observed asso-
ciations (USDHHS 1994) between cigarette smoking
among Hispanic adolescents and specific behaviors com-
promising to health. Marijuana use, binge drinking, and
weapon carrying were significantly associated with ciga-
rette smoking among Hispanic adolescent males; mari-
juana use, binge drinking, multiple sexual partners, and
physical fighting were associated with cigarette use
among Hispanic adolescent females. The analysis
controlled statistically for age, ethnic@, gender, paren-
tal educational level, region of the country, and other risk
behaviors.

Patferfzs of T@t7acco use  73


Smokeless Tobacco Use

  Recent trends in smokeless tobacco use among
Hispanic adolescents have changed little. According
to the MTF surveys, previous-month smokeless
tobacco use (based on two-year rolling averages)
was reported by 4.2 percent of eighth-grade Hispanic
students in 1992 and 5.2 percent in 1996; among
tenth-grade students, the prevalence was 6.2 per-
cent in 1992 and 4.0 percent in 1996; and among high
school seniors, the prevalence was 4.4 percent in 1987
and 8.1 percent in 1996 (Johnston et al. 1996;
Institute for Social Research, University of Michigan,

unpublished data from the 1996 MTF surveys). YRBS
data indicate that the prevalence of previous-month
use among Hispanic high school students was 5.5 per-
cent in 1991 (USDHHS 1994) and 4.4 percent in 1995
(CDC 1996).

  Hispanic adolescent males are much less likely
than white adolescent males to use smokeless tobacco.
Among male high school students participating in the
1995 YRBS, for example, 5.8 percent of Hispanics and
25.1 percent of whites had used smokeless tobacco
during the previous month (CDC 1996). Prevalence
among females was 3.1 percent for Hispanics and 2.5
percent for whites.

Retrospective Analyses of Smoking Prevalence Among
African Americans and Hispanics

  Because of the lack of long-term national survey
data on smoking behavior among racial/ethnic groups,
retrospective analysis is the only way to reconstruct
smoking prevalences for African Americans before
1965 and for Hispanics before 1978. The retrospective
method of constructing smoking prevalences for suc-
cessive birth cohorts of men and women in the U.S.
population was first reported by Harris (USDHEW
1979; Harris 1983). Harris's methodology later served
as the basis for a report in which smoking prevalences
were presented for Cuban American, Mexican Ameri-
can, and Puerto Rican men and women (Escobedo
and Remington 1989). Most recently, the NC1 (1991)
published some results of an analysis of birth cohorts
of whites and African Americans. Another type of ret-
rospective analysis has also been used to estimate long-
term trends in cigarette smoking. This approach has
been the basis of two published reports, one that pre-
sented smoking trends among Hispanics in various age
groups (Escobedo et al. 1989a) and another that pre-
sented smoking trends among Hispanic young adults
(Escobedo et al. 1989b). For this section of the report,
both types of retrospective analysis were used to gen-
erate information not previously available.

Prevalence of Cigarette Smoking Among
Successive Birth Cohorts

  The following detailed analysis of smoking
trends over time-according to gender and educational

attainment ot defined birth cohorts (based on the year
of birth)-uses data from the 1987 NHIS (for African
Americans) and the 1982-1984 HHANES (for Hispan-
ics). The smoking histories of respondents were con-
structed according to the ages they reported cigarette
smoking initiation and cessation. Information about these
two smoking-related events was then used to classify
each respondent as a nonsmoker, current smoker, or
former smoker from birth to interview and to calculate
the proportion of people smoking each year in each birth
cohort. (See Appendix 5 for a discussion of the valida-
tion of this methodology.) The resulting birth cohort
curves (Figures 7-10) represent smoking prevalences of
each cohort for each year from birth to interview
(throughout childhood, adolescence, and adulthood)
(NCHS, public use data tapes, 1978, 1979, 1980, 1982-
1984, and 1987 and 1988 combined). By comparing the
curves among successive birth cohorts, one can examine
smoking trends-over time for those cohorts.

African Americans

  The prevalence of smoking among successive
birth cohorts of African American men with at least a
high school education has declined gradually, with the
peak and age-specific smoking prevalences for the
most recent cohort (1958-1967) being lower than the
prevalences for previous cohorts' curves (Figure 4).
  In contrast, little progress has been made in re-
ducing the prevalence of cigarette smoking among

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

successive birth cohorts of African American men with
less than a high school education (Figure 7). Although
smoking prevalences declined slightly for successive
cohorts, the peak prevalence for the most recent co-
hort continues to be nearly as high as that for previ-
ous cohorts. In addition, smoking prevalences during
adolescence among African Americans with less than
a high school education did not decrease between suc-
cessive birth cohorts.

  Despite initial increases in smoking prevalence
among successive birth cohorts of African American
women with at least a high school education,
prevalences have declined in recent years (Figure 8).
The declines in prevalence among African American
women with at least a high school education are not
as marked as the declines observed among successive
birth cohorts of African American men of a similar
educational background. Smoking prevalences among
African American women with less than a high school
education have increased markedly, with the most
recent cohort (195881967) showing the highest peak
(Figure 8).

Hispanics

  Among six successive birth cohorts of Hispanic
men with at least a high school education covering the
years 1908-1967, the peak prevalence of smoking in-
creased gradually for the first three cohorts but declined
beginning with the 1938-1947 cohort (Figure 9). In ad-
dition, the rate of increase in smoking prevalence dur-
ing adolescence slowed markedly for the most recent
cohort compared with rates for previous cohorts.

  The smoking prevalence pattern among succes-
sive birth cohorts of Hispanic men with less than a
high school education (Figure 9) is similar to the pat-
tern among African American men with a similar edu-
cational background. Smoking prevalences have
declined slightly since the early 195Os, when the high-
est prevalence was observed for the 1918-1927 cohort.

  The slight decline in smoking prevalence among
successive birth cohorts of Hispanic women with at
least a high school education is similar to the decline
among African American women with a similar edu-
cational background (Figure 10). However, the decline

Figure 7.  Cigarette smoking prevalence among successive birth cohorts of African American men, by
     education, National Health Interview Surveys, United States, 1978-1980,1987, and 1988*

8o- High school                         80-  Less than a high
  70 - education                           70 - school educatio

  60-                                   60-
2 50-                                    50-
E 40-          `i $ 40-
2 30-                           2
                  ?  30-

  20-                                    20-

  IO-                                    10-

   0       I     I     I     I     I     I     I          O-
   1910 1920 1930 1940 1950 1960 1970 1980        1910 1920 1930 1940 1950 1960 1970 1980

                Year                                   Year

Birth cohorts:

- 1908-1917 -.-`. 1918-1927       1928-1937  ----  1938-1947 - 1948-1957   -  1958-1967

*Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth
to interview, they provide information about the smoking prevalence of each cohort during childhood,
adolescence, and adulthood.
Sources: National Center for Health Statistics, public use data tapes, 1978-1980,1987 (Cancer Control
Supplement and Epidemiology Supplement), and 1988; Escobedo and Peddicord 1996.

Patterm of Tobacco Use  75


Surgeon Geneyal's Report

among Hispanic women began more recently, with the
1938-1947 cohort. The peak prevalence for the most
recent cohort of Hispanic females with at least a high
school education was similar to the peak prevalence
for African American women of the same educational
level (25 percent).

  The smoking prevalences among successive birth
cohorts of Hispanic women with less than a high school
education increased slightly over time and then lev-
eled off (Figure 10). In addition, the prevalence of
smoking during adolescence increased much more
rapidly in the most recent birth cohort than in previ-
ous cohorts. However, the overall pattern of smoking
prevalence in this subgroup of Hispanic women does
not show the dramatic increases observed in succes-
sive birth cohorts of African American women with a
similar educational background. The peak prevalence
for the most recent birth cohort of Hispanic women
with less than a high school education (34 percent) was
substantially lower than the peak prevalence for the
corresponding cohort of African American women (54
percent).

  The slight changes in smoking prevalences
among successive birth cohorts of Hispanic women,

regardless of educational background, may be the re-
sult of the larger proportion of Mexican American
women who compose these subgroups. Although
few changes have been observed in the prevalence
of smoking among successive birth cohorts of Mexi-
can American women, in recent birth cohorts of
Cuban American and Puerto Rican women, more
women have smoked cigarettes than those in previ-
ous cohorts (Escobedo and Remington 1989). Had
more Cuban American and Puerto Rican women been
included in the HHANES, the pattern may well have
been different.

  The results of these birth cohort analyses show
that educational attainment is the most powerful pre-
dictor of temporal trends in smoking prevalence. In
both racial/ethnic groups, men, and to a lesser extent
women, with at least a high school education have
made progress in reducing cigarette smoking. How-
ever, men with less than a high school education, re-
gardless of race/ethnicity, are as likely to smoke now
as they were in previous decades. Recent cohorts of
African American women with less than a high school
education are now substantially more likely to smoke
than their counterparts in previous decades.

Figure 8.  Cigarette smoking prevalence among successive birth cohorts of African American women, by
     education, National Health Interview Surveys, United States, 1978-1980,1987, and 1988,

80

70

60

High school
education

5  50-
-z
i 40- 30-

  20-

  lo-

   0,      I     I     I     I     I     I     I

80

70

60

Less than a high
school education

   1910 1920 1930 1940 1950 1960 1970 1980         1910 1920 1930 1940 1950 1960 1970 1980

                Year                                  Year

Birth cohorts:

-  1908-1917   -.-..  1918-1927       1928-1937  ----  1938-1947 -  1948-1957   -  1958-1967

*Because these birth cohort curves are the result of calculations of smoking prevalence for each year from
birth to interview, they provide information about the smoking prevalence of each cohort during childhood,
adolescence, and adulthood.
Sources: National Center for Health Statistics, public use data tapes, 1978-1980,1987 (Cancer Control
Supplement and Epidemiology Supplement), and 1988; Escobedo and Peddicord 1996.

76 Clzaptey 2


Tobnczo Use Among U.S. RncinIIEfh,ric Minority Groups

Figure 9. Cigarette smoking prevalence among successive birth cohorts of Hispanic men, by education,
     Hispanic Health and Nutrition Examination Survey, 1982-1984,

80 I  High school
70   education
                     d'-.- .,
60        h,\ -

                                                                     I
$  50-
`;                  &b                    ,
                                        50-                I

p:  40-             E  40-               ,
                                                                   ,
2  30-                2  30-              ,
                                                                  I
  20-                                    20-            .'
  10-              .'                 10-

   0                ,*
           I                   I     I     I          0      I     I     I

1910 1920  1930  1940 1950  1960  1970 1980       1910 1920  1930  1940 1950  1960  1970 1980

            Year                                  Year

Birth cohorts:

-  1908-1917   -.-`.  1918-1927       1928-1937  - - - -  1938-1947   -  1948-1957   -  1958-1967

*Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth
to interview, they provide information about the smoking prevalence of each cohort during childhood,
adolescence, and adulthood.
Sources: National Center for Health Statistics, public use data tapes, 1982-1984; Escobedo and Peddicord 1996.

Figure 10.  Cigarette smoking prevalence among successive birth cohorts of Hispanic women, by education,
     Hispanic Health and Nutrition Examination Survey, 1982-1984*

8o- High school                          80-  Less than a high
  70 - education                      70 - school education

   60-                                     60-
5 50-
E 40-          2 $  50-

                                        40-
2 30-          2 8  30-

   20-                                   20-

   10-                                   10-

   0       I                                O-
   1910 1920 1930  1940 1950  1960  1970 1980        1910 1920 1930 1940 1950  1960  1970 1980

                Year                                   Year

Birth cohorts:

- 1908-1917 -`-"  1918-1927       1928-1937  ----  1938-1947 - 1948-1957   -  1958-1967

*Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth
to interview, they provide information about the smoking prevalence of each cohort during childhood,
adolescence, and adulthood.
Sources: National Center for Health Statistics, public use data tapes, 1982-1984; Escobedo and Peddicord 1996.

Pnfterns of Tobncco Use  77