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256 Chapter 4


Chapter 5

Tobacco Control and Education Efforts Among
Members of Four Racial/Ethnic Minority Groups

Introduction 259
Principles for Developing Culturally Appropriate Tobacco Control Strategies  259
Information Needs 262
Research and Development Limitations  263

Primary Prevention Efforts 266
Efforts to Restrict Youth Access to Tobacco  266
School-Based Health Education Approaches  269
Project SMART (Self-Management and Resistance Training)  271
Life Skills Training Program  272
Project SHOUT (Students Helping Others Understand Tobacco)  272
Southwestern Cardiovascular Curriculum Project and Pathways to Health  272
Other Primary Prevention and Intervention Efforts  272
Mass Media Efforts to Prevent Tobacco Use  273

Smoking Cessation Programs 274

Self-Help Approaches 275
Rompa Con el Vicio: Unu Guiu Para Dejur de Fumur (Break the Habit:
A Guide to Stop Smoking)  275
Pathways to Freedom 276

Urn The^' Ndo& Bd Hlit ThuG'c? (How to Quit Smoking)  276
It's Your Life-Zt's Our Future  276
Victo y Over Smoking-A Guide to Smoking Cessation for You and Your Family
Smoking: Facts and Quitting Tips Series  277
Hot Lines 277
Group Approaches 277

277

Community Approaches 278
Stanford Five-City Multifactor Risk Reduction Project  279
Programa Latin0 Para Dejar de Fumar (Hispanic Program to Quit Smoking)  279
Si Puedo (Yes, I Can)  280
Pathways to Freedom Community Demonstration Project  280
Quit Today! 280
Chicago Lung Association's Multifaceted Smoking Cessation Intervention  282
Chicago Community-Based Interventions for Low-Income African Americans  282
Freedom from Smoking@ for You and Your Family on TV/Par Su Salud y

Su Familia 281

A Su Salud (To Your Health)  282
University of North Carolina/North Carolina Mutual Quit for Life Guide  282
Legends 282

Great American Smokeout 283
Sue Khoe La Vang! (Health is Gold!)  283


Involvement of Health Care Providers  283
For You and Your Family  284
American Indian Cancer Control Project  286
Involvement of Employers 286
Involvement of Nontraditional Providers  286

Environmental Tobacco Smoke and Clean Indoor Air Policies  287

Economic Efforts to Reduce Tobacco Use  292

Efforts to Control Tobacco Advertising and Promotion  293

Tobacco Product Regulations 298

Conclusions 299

References 302

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

Introduction

  Various approaches have been used to prevent
and control tobacco use among racial/ethnic minority
groups in the United States. This chapter addresses
six major approaches to tobacco control: (1) primary
prevention efforts, (2) smoking cessation programs,
(3) environmental tobacco smoke (ETS) and clean in-
door air policies, (4) economic efforts to reduce tobacco
use, (5) efforts to control tobacco advertising, and (6)
tobacco product regulations (Satcher and Eriksen 1994).
Each section presents a selection of interventions and
focuses on activities that reflect the specific character-
istics of given racial/ethnic groups.

  Because most of these efforts are relatively new
among racial/ethnic group members and many have
been developed or applied in predominantly white
communities, little information is available about the
ease and feasibility of their implementation or repli-
cation in racial/ethnic contexts. Although data exist
on the overall effectiveness of programs that do not
differentiate racial/ethnic minority groups from
whites, data are limited on the effectiveness of racial/
ethnic-specific tobacco control efforts, because results
of their evaluations are just beginning to appear in the
literature. Although an increasing number of tobacco
control programs are being implemented among vari-
ous racial/ethnic groups, many of these programs lack
evaluation components. To remedy the lack of infor-
mation, culturally appropriate research and evalua-
tions need to be conducted in the future, and more
professionals need to be trained in culturally appro-
priate research and evaluation methodologies. More-
over, the types of tobacco control efforts that are most
effective, easiest to implement, and most cost-effective
among racial/ethnic groups must be identified (Fiore
et al. 1996). In some instances, smoking cessation treat-
ments that have been shown to be effective with non-
Hispanic whites also have produced positive effects
with racial/ethnic populations (Fiore et al. 1996). It is
already well known that preventing tobacco use is of
paramount importance because cessation is difficult.

   Tobacco control infrastructures in white and
racial/ethnic minority communities have developed
differently, although the reasons are not well under-
stood. This development has been influenced by many
factors: immigration; the historical and current role of
the tobacco industry in the economic, political, social,
and cultural life of the community; and the resources
invested in communities for research and the estab-
lishment of tobacco control programs (Robinson et al.

1995; Shelton et al. 1995). Robinson and colleagues
developed an index to measure the capacity of racial/
ethnic communities to engage in, develop, and imple-
ment tobacco control initiatives. The researchers then
applied the index to racial/ethnic communities on a
national level. They defined capacity in the index as
being made up of four broad components, each of
which is composed of numerous elements: (1) research,
(2) infrastructure, (3) diffusion of programs, and
(4) internalization of policy initiatives. The index as-
sumes that a logical order exists among these compo-
nents, that is, that a community's ability to gather data
and assess its needs precedes program development
and dissemination. During this process, it is likely that
a community's capacity grows through the evolution
of new leaders, establishment of more communication
networks, and emergence of a deeper understanding
and acceptance of community needs and interventions
to meet those needs. Robinson and colleagues (1995)
concluded that racial/ethnic communities have fewer
resources and less infrastructure to develop and imple-
ment tobacco control initiatives than the white com-
munity. In addition, racial/ethnic communities were
compared with one another, and findings demon-
strated variability among communities. The index can
be considered a preliminary but important step in
providing a useful framework for evaluating the rela-
tive tobacco control capacity of racial/ethnic minority
communities. Mature tobacco control infrastructures
provide leadership, advocacy for a smoke-free
environment, communication systems, established re-
search initiatives, effective tobacco control programs,
and environmental norms; these elements enable
communities and their residents to counter tobacco
industry marketing strategies and the appeal of an
addictive substance.

Principles for Developing Culturally
Appropriate Tobacco Control Strategies

  To be culturally appropriate, interventions must
properly reflect the characteristics of the group mem-
bers; that is, programs must recognize that cultural
groups-whether they are based on race/ethnicity, na-
tional origin, or other characteristics-are not mono-
lithic entities. Behavior can be affected by not only
demographic characteristics, such as gender, employ-
ment status, educational level, literacy, income, and

Tobacco Control and Education Efforts  259


Sllrgeon General's Report

age but also such variables as national background (i.e.,
the place of birth of individuals, their parents, or
grandparents); acculturation (with its correlates of
generational history, time of migration, and language
preference); and large social circumstances such as rac-
ism, discrimination, and poverty. In particular, and as
discussed in Chapter 4, tobacco prevention and con-
trol strategies must respond to the historical context
of racial/ethnic communities as well as to their
current needs (Ellis et al. 1995). Those attitudes and
behaviors that have been shaped by the historical re-
lationship between the community on one hand and
tobacco and the tobacco industry on the other need to
be considered when tobacco control strategies are
developed.

  Although few tobacco control programs target-
ing racial/ethnic groups have been culturally appro-
priate, they are increasing, and their evaluation will
further guide the development of culturally appropri-
ate tobacco control strategies. Such programs would
address these racial/ethnic groups' differing psycho-
social and large social factors related to tobacco use.

  Development of culturally appropriate interven-
tions also must go beyond language translations and
adaptations of materials (e.g., Rogler et al. 1987; Marin
1993; Bayer 1994) and should do more than simply
include contemporary, group-specific traditions or
ancestral symbols and traditions. In addition, plan-
ners should not assume that the involvement of com-
munity leaders and organizations will automatically
guarantee a program's success. Marin (1993, p. 149)
has argued that to be culturally appropriate, an inter-
vention must meet these requirements: "(1) it is based
on the cultural values of the group, (2) the strategies
that make up the intervention reflect the subjective
culture (attitudes, expectancies, norms) of the group,
and (3) the components that make up these strategies
reflect the behavioral preferences and expectations of
the group's members."

   Recent studies have identified numerous inter-
group differences in beliefs, attitudes, expectancies,
and norms that are useful in designing effective to-
bacco control programs by identifying optimal mes-
sages or techniques that are culturally appropriate.
Racial/ethnic cultural values are often an asset in to-
bacco control efforts. For example, Marin and col-
leagues (1990a) found that Hispanic smokers were
more likely than white smokers to think that an effec-
tive motivator to quit smoking was the knowledge that
adults who smoke set a bad example for children and
endanger children's health. According to Robinson
and colleagues (1992), African Americans responded
to the use of prayer during smoking cessation

programs, and Hodge and colleagues showed that
American Indians were unresponsive to confronta-
tional approaches for curtailing tobacco use (Ameri-
can Indian Cancer Control Project 1991). Materials
developed for Chinese Americans have offered the use
of martial arts as a behavioral alternative to cigarette
smoking (Chinese Community Smoke-Free Project
1992). Another example of a culturally appropriate
message is a billboard used by the California Depart-
ment of Health Services to target Hispanics (Figure 1).
The billboard makes use of a basic Hispanic value
(@niliaIism) within the context of a message that is an
important motivator to Hispanics to quit smoking-
quitting to protect the health of the family (Marin et
al. 1989,199Oa). More recently, in an analysis of a popu-
lation-based survey of Californians 18 years of age and
older, researchers found that African Americans and
Hispanics were more likely than whites to plan to quit
smoking in the near future and to have tried to quit at
least one time (Kaplan et al. 1993). In a comparison of
smoking cessation intentions and behaviors among
white and African American smokers, white smokers
were more likely to set quitting smoking as a goal,
whereas African Americans were more likely to focus
on a goal of reducing the number of cigarettes they
smoked per day or making other changes in smoking
behavior (Hahn et al. 1990). Another study found that
intentions to breast-feed predicted smoking cessation
among African American pregnant women (O'Campo
et al. 1992).

  Other recent studies of smoking cessation pro-
grams indicate that members of most racial/ethnic
groups tend to be very interested in quitting smoking.
In the 1993 National Health Interview Survey (NHIS),
current smokers in all racial/ethnic groups said they
were willing to quit smoking (Table 1) (National Cen-
ter for Health Statistics [NCHSI, public use data tape,
1993). African Americans (71.4 percent) reported the
desire to quit in greater proportions than members of
the other racial/ethnic groups, whereas Asian Ameri-
cans and Pacific Islanders (60.2 percent) showed the
least interest in quitting. In all four racial/ethnic
groups, women were more likely than men to want to
stop smoking. Moreover, data from the Community
Intervention Trial for Smoking Cessation's (COMMIT)
initial survey in 10 U.S. communities showed that
more African Americans than whites, both men and
women, said they wanted "a lot" to quit (Royce et al.
1993). In a San Francisco study, Hispanics considered
a high interest in quitting smoking to be more desir-
able than did whites (Marin et al. 1989).

  Despite their interest in smoking cessation, mem-
bers of these racial/ethnic minority groups have been

260 Chapter 5

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

Figure 1.  Billboard used by the California Department of Health Services in targeting Hispanics to quit
     smoking*

"Translation: If you smoke, she smokes.
Source: California Department of Health Services, Tobacco Control Media Education Campaign, Sacramento, 1993.

Table 1.  Percentage of adult smokers who would like to stop smoking,* by race/ethnicity and gender,
     National Health Interview Survey, United States, 1993

Characteristic

African     American Indians/
Americans     Alaska Natives

%   x1+     %      %I

Asian Americans/
Pacific Islanders

%      KI

Hispanics

%   kc1

Whites

%   KI

Total           71.4   4.8     65.0     14.6      60.2     12.2     68.7   5.8    70.4   1.8


Men           68.6   7.3     57.3     23.4       58.3     14.6     63.8   7.8    67.8   2.6


Women         74.9   5.4     70.3     16.1       65.3     22.6     79.3   8.1    72.4   2.1

*In response to the question,
+95% confidence interval.  "Would you like to completely stop smoking cigarettes?"

Source: National Center for Health Statistics, public use data tape, 1993.

less likely than whites to actually quit. In a study of
786 adult smokers in the Minneapolis-St. Paul area,
Hahn and colleagues (1990) found that 52 percent of
African American men had tried to quit smoking in
the previous year, compared with 63 percent of white
men. They also found that 56 percent of African Ameri-
can women had tried to quit, compared with 58 per-
cent of white women. In a recent survey conducted in
California, African Americans, Asian Americans, and
Hispanics were more likely than whites to report that
they tried to quit smoking in the previous year; how-
ever, relapses were more common among African

Americans (49.5 percent), Asian Americans (39.8 per-
cent), and Hispanics (37.8 percent) than among whites
(35.0 percent) (Burns and Pierce 1992). NHIS data from
1991 that were statistically adjusted for gender, age,
education, and poverty status indicate that African
Americans and Hispanics were more likely than whites
to quit for a day during the previous year but that Af-
rican Americans who tried to quit were more likely
than whites to relapse (Centers for Disease Control and
Prevention [CDCI 199313). In another study-
conducted in Milwaukee, Wisconsin; Minneapolis,
Minnesota; and Seattle and Spokane, Washington-

Tobacco Control and Education Efforts  261


Surgeon General's Report

American Indians who were patients at Indian Health
Service (IHS) clinics reported a moderate desire to quit
smoking (mean of 5.97 on a scale of 0 to 10) but a high
rate of relapse (70 percent) (Land0 et al. 1992). These
data suggest the need for culturally appropriate pro-
grams that not only help smokers stop smoking but
also support them in their efforts to maintain a smoke-
free lifestyle and to avoid relapses.
  In addition to considering intergroup differences,
tobacco control programs targeting members of racial/
ethnic groups must involve culturally competent
staff-persons with the academic and interpersonal
skills needed to understand and appreciate racial/
ethnic groups' cultural differences and similarities and
to respect these groups' beliefs, attitudes, norms, and
behaviors (Cross et al. 1989; Roberts 1990; Orlandi
1992). Such staff must have the skills to understand
their own cultural beliefs and values, to understand
the dynamics of cultural differences, and to translate
that understanding into culturally appropriate behav-
iors. Cross and colleagues (1989) and Davis and
Voegtle (1994) propose that culturally competent health
care systems-and by implication culturally compe-
tent staff-should (1) be aware and accepting of
cultural differences, (2) have the capacity for cultural
self-assessment, (3) be conscious of the dynamics in-
herent when cultures interact, (4) have relevant cul-
tural knowledge of the targeted group, and (5) have
skills that promote adaptation to diversity. Other au-
thors, such as Corcoran and Robinson (1994), assert that
public health professionals need to actively include the
community by establishing planning teams composed
of key community leaders and that staff be willing to
redefine the project as community needs change.
  Furthermore, persons designing and implement-
ing tobacco control programs ideally should determine
whether theoretical models and approaches originally
developed for certain populations would be relevant
to the racial/ethnic groups being targeted. Most cur-
rent theoretical approaches to health promotion have
been developed by white researchers who work pri-
marily with white populations. Some researchers have
questioned the overall validity and usefulness of these
theoretical approaches because the approaches that are
developed do not necessarily reflect the cultural
values shared by other racial/ethnic groups and do
not consider how variables such as acculturation, rac-
ism, and poverty may affect peoples' health behaviors
(Prochaska 1992; Robinson and Sutton, in press). This
concern can be addressed only through an empirical
approach that analyzes the usefulness of theories ini-
tially developed for groups other than the ones being
targeted by an intervention (Orlandi 1992).

Information Needs

  To ensure that prevention and cessation programs
will provide members of a racial/ethnic minority group
with the information that they need most, program
designers must find out three things. (1) Do members
of the community need basic information about the
harmful health effects of tobacco use? (2) What culture-
specific experiences directly influence the role of tobacco
and the tobacco industry and how can they be addressed
in health promotion messages? (3) Which media and
information sources would be most effective in convey-
ing information to the targeted group?
  Because information about the dangers of cigarette
smoking has been provided to the public for more than
30 years, most U.S. citizens and residents are well aware
of these health consequences. American Indians, for ex-
ample, tend to have a high level of knowledge about the
hazards of smoking. In a study of 1,369 northern Cali-
fornia American Indians who were patients at IHS clin-
ics, Hodge and colleagues (1995) found that most Ameri-
can Indians knew about the health effects of tobacco use,
particularly its relationship with cancer and the dangers
of smoking while pregnant.

  Conversely, this basic information may not have
reached persons who have limited English proficiency,
who have recently arrived in the United States, or who
may not have been exposed to media and information
sources that traditionally have carried messages about
the dangers of cigarette smoking. It is possible for ex-
ample, that Asian Americans, Pacific Islanders, and
Hispanics who have recently immigrated to the United
States are not familiar with the dangers of cigarette
smoking. Less acculturated Asian Americans, Pacific
Islanders, and Hispanics who have resided in the
United States for several years may not have benefited
from large-scale public education campaigns directed
at persons who are proficient in English and those who
interact frequently with mainstream society. To help
address this need, the Agency for Health Care Policy
and Research translated the consumer cessation guide
"You Can Quit Smoking" into Cambodian, Laotian,
Vietnamese, Tagalog, Korean, and Chinese (U.S. Depart-
ment of Health and Human Services [USDHHS] 1996
and 1997). Chen and colleagues (1993) reported that less
than 40 percent of Cambodian, Laotian, and Vietnam-
ese smokers in Columbus, Ohio, had heard that smok-
ing caused heart disease. Earlier, Jenkins and colleagues
(1990) reported that only 74 percent of Vietnamese
adults surveyed in San Francisco knew that smoking
caused cancer. Nevertheless, Campbell and Kaplan
(1997) found that both less acculturated and more ac-
culturated Hispanic women (as measured by language
orientation) agreed that cigarette smoking is harmful

262 Chapter 5

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

to children's health. However, less acculturated His-
panic women were more likely to agree that it is safe to
smoke for a year or two.

  Even long-term U.S. residents who have been
receiving information on the dangers of tobacco smoke
for many years may have limited or incorrect infor-
mation. For example, in a study of Chicago women
living in subsidized housing, 46 percent of African
American women agreed that the chances of getting
lung cancer were the same for smokers and nonsmok-
ers, compared with 27 percent of white women
(Manfredi et al. 1992). In that study, African Ameri-
can women also reported that the causes of lung can-
cer were unknown or that lung cancer was the result
of environmental pollution (Lacey et al. 1993). Con-
versely, in a multivariate analysis, African Americans
compared with whites were found to have higher lev-
els of knowledge about the benefits of not using to-
bacco and the health consequences of tobacco use, but
blue collar status emerged as the most significant pre-
dictor of lower levels of knowledge (Robinson et al.
1991). In another study, African American residents
of urban Missouri areas recognized the harmful effects
of ETS but were less likely than whites to know the
health risks associated with active smoking, particu-
larly its link with heart disease (Brownson et al. 1992).

  In a 1989 survey of Hispanic and white clients of
a San Francisco health maintenance organization
(HMO), Hispanics had numerous misconceptions
about the causes of cancer, but a similar proportion of
Hispanics (97.5 percent) and whites (98.4 percent)
knew that cigarette smoking caused cancer (Perez-
Stable et al. 1992). Similarly, Vander Martin and
colleagues (19901 surveyed patients of primary care
physicians and found that African Americans (87.8
percent) and Asian Americans (86.5 percent) were
significantly less likely than whites (92.1 percent) and
Hispanics (91.6 percent) to recognize that cigarettes
had harmful health effects. They also found that Afri-
can American (58.9 percent), Asian American (56.3 per-
cent), and Hispanic (60.1 percent) smokers were less
likely than white smokers (80.3 percent) to recognize
that they were addicted to cigarettes. In the 1992 NHIS,
members of racial/ethnic groups were generally less
likely than whites to indicate concern over the carci-
nogenic characteristics of cigarette smoking, although
they expressed the same level of agreement as whites
regarding the need for pregnant women not to smoke
and about the harmfulness of ETS (Table 2) (NCHS,
1992 Cancer Control Supplement, public use data
tape). In addition, racial/ethnic group members were
less likely than whites to believe that there were health
benefits to quitting smoking.

  Once program planners decide what information
needs to be conveyed, they must consider which me-
dia would be most effective in reaching the targeted
audience. Many researchers have suggested employ-
ing the media most frequently used by the targeted
ethnic group. To reach African American smokers, for
example, Stotts and colleagues (1991) suggest that
smoking cessation programs should use African
American broadcast and print media to address this
group's information and motivational needs.

  Moreover, prevention and cessation programs
should use the information channels (e.g., radio, tele-
vision, and newspapers) and information sources (e.g.,
physicians, peers, and actors) that members of the
targeted racial/ethnic group perceive to be trustwor-
thy and reliable. Unfortunately, little is known about
how credible the various media and information
sources are perceived to be by members of racial/
ethnic groups. In one of the few studies focusing on
this issue-research involving African Americans in
Columbia, South Carolina; Durham, North Carolina;
Hartford, Connecticut; and Springfield, Massachu-
setts-television was perceived as the most trustwor-
thy information channel (by 70 percent of participants),
followed by newspapers (59 percent), radio (53 per-
cent), and magazines (53 percent) (Cernada et al. 1989-
1990). A recent study among Hispanics (Marin 1996)
showed that the most credible channels for dissemi-
nating information about cigarette smoking among
Hispanics are (in descending order) books, newspa-
per articles, pamphlets, magazine articles, and televi-
sion news shows; the least credible were fotonovelas
(illustrated comic-book type of booklet targeting
adults) and telenovelas (Spanish-language soap operas).
The same study found that the most credible sources
of cigarette smoking information among Hispanics
were (in descending order) a physician, a cancer pa-
tient, and a peer of the respondent; the least credible
sources of information were a politician, a singer, an
actor, and a child.

Research and Development Limitations

  In a recent analysis of racial/ethnic minority
groups' expertise for engaging in tobacco control ef-
forts, Robinson and colleagues (1995) suggested that
African American, American Indian, Alaska Native,
Asian American, Pacific Islander, and Hispanic groups
all have been significantly limited in conducting re-
search and developing program and policy initiatives
for tobacco control. According to Robinson and col-
leagues, these limitations may exist, in part, because
racial/ethnic groups tend to have fewer resources for
tobacco control activities than whites.

Tobacco Control and Education Efforts  263


Surgeon General's Report

Table 2.  Adults' beliefs about the health effects of smoking, by race/ethnicity, gender, and smoking status,
    National Health Interview Survey, United States, 1992

Characteristic

African     American Indians/  Asian Americans/
Americans     Alaska Natives    Pacific Islanders   Hispanics     Whites

%   3sI"     %    &Cl      %     KI     %    KI     %   KI

Overall
Total
Men
Women

Nonsmokers
Total
Men
Women

Smokers
Total
Men
Women

Overall
Total
Men
Women

Nonsmokers
Total
Men
Women

Smokers
Total
Men
Women

Overall
Total
Men
Women

Nonsmokers
Total
Men
Women

Smokers
Total
Men
Women

So many things cause cancer that it does not really matter if you smoke.

28.6 3.0
27.8 4.7
29.3 3.6


25.2 3.6
23.7 6.2
26.3 4.1


38.2 5.6
36.4 7.9
40.2 7.3

25.6 9.6     27.3 7.0     30.7 3.0
30.7    14.1      25.2    10.5     28.1 4.3
21.3    11.3     29.3     8.4     33.2 3.9


18.7 7.8     22.9 6.6     25.4 3.1
19.9    14.6      15.3    9.2     23.3 4.6
17.7    11.0      28.1     8.6     27.3 4.1


39.4   21.9     47.6    18.9     50.5 7.0
54.1    28.5     45.9    21.0     43.3 9.2
27.4   24.2      64.9    34.7     58.8 9.9

Smoking by a pregnant woman may harm the baby.

16.5 1.0
18.0 1.5
15.2 1.2


10.9 1.0
11.8 1.5
10.0 1.2


32.5 2.3
33.7 3.2
31.2 3.1

90.7 1.7     90.8 6.1      92.3    3.9     92.0 1.9    92.5 0.7
90.5 2.6     86.0    10.4      91.9    6.3     92.9 2.7    91.4 1.0
90.9 2.0     94.9 6.4     92.6 4.7     91.2   2.4    93.5 0.8


92.6 1.7     94.5 5.2      92.2 4.5     93.2 2.0    94.9 0.6
92.2 2.7     87.8    10.5      91.1     8.8     92.5 3.2     93.7 1.0
92.9   2.2    100.0    0.0      93.0     4.8     93.8 2.4    96.0 0.7


90.1 2.9     89.1    11.6      94.3 6.1     92.1 4.2    89.5 1.5
90.1 4.0     92.7   14.3     95.6     6.1     95.0 4.7    88.5 2.2
90.2 3.8     86.2   17.4     81.2    24.7     88.8 6.9    90.5 1.8

      The smoke from other people's cigarettes is harmful to you.

82.1 2.2     79.8 9.1      80.3    6.2     86.7 2.2    85.2 0.9
81.5 3.4     77.1    16.2     83.8 7.4     85.4 3.4    82.8 1.4
82.7 2.7     82.2    10.9      76.9     9.4     87.9 2.7    87.4 1.1


89.7 2.0     94.9 4.2     81.1     7.1     89.8 2.3    91.6 0.8
90.0 3.2     92.8 6.0     86.1     9.4     88.9 3.5    89.7 1.3
89.4 2.4     96.6 6.5      77.6     9.8     90.6 2.8    93.4 0.9


66.8 5.2     57.6   20.8     78.4    11.7     80.0   5.1    71.0 2.2
67.8 7.0     57.8   29.7     80.6    12.5     76.3 7.9    68.4 3.1
65.7 7.5     57.4   29.5      56.4    36.4     84.3 6.1     73.7 2.9

95% confidence interval.

Source: National Center for Health Statistics, 1992 Cancer Control Supplement, public use data tape.

264 Chapter 5

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

Table 2.  Continued

Characteristic

African     American Indians/  Asian Americans/
Americans     Alaska Natives    Pacific Islanders   Hispanics      Whites

%   51       %     XI      %     %I     %    KI     %   XI

Overall
Total
Men
Women

Nonsmokers
Total
Men
Women

Smokers
Total
Men
Women

Overall
Total
Men
Women

Nonsmokers
Total
Men
Women

Smokers
Total
Men
Women

Most deaths from lung cancer are caused by cigarette smoking.

73.7 2.9     79.3    10.4      77.1     6.1     77.4 2.8    75.0 1.1
74.9 4.6     75.5    15.6     79.9 8.4     76.7   4.3    73.9 1.7
72.8 3.4     82.6    10.5      74.3     8.7     78.2 3.5    76.1 1.3


80.0 2.9     84.6 9.0      79.1     6.8     79.4 3.2    81.7 1.1
81.6 5.2     71.2   18.0      83.4    10.2     78.5 4.9    80.3 1.7
78.8   3.5     95.6    5.8      76.1     8.8     80.3 3.7    82.9 1.4


61.5   5.6     74.1    18.4      69.4    14.2     73.8 6.2    59.8 2.3
64.6 7.6     91.2    16.8      74.5    14.6     71.8 8.8    60.4 3.5
57.7 7.7     60.3    28.6      19.1    25.3     76.2 7.8    59.3 3.1

     Even if a person has smoked for more than 20 years, there is a
              health benefit to quitting.

82.6 2.5     81.3 9.1      78.2     6.3     80.9 2.9    91.4 0.4
82.0 3.9     80.7    11.2      78.6    8.7     82.0 4.2     91.1 1.0
83.0 3.0     81.7    14.1      77.8 9.1     79.8 3.5    91.7 0.9


85.5 2.8     79.6    12.3      78.9 7.1     82.1 3.1    93.9 0.7
85.5   4.6     81.8    11.9      80.6    10.8     82.2 4.6    94.0 1.0
85.4   3.3     77.8    19.8      77.7 9.3     82.1 3.9    93.8 1.0


79.0 4.5     88.2    11.0      76.6    13.1     80.3 5.8    88.0 1.7
77.7 6.8     87.8   17.0      76.0    14.6     82.9 8.2    86.9 2.4
80.7 5.9     88.5    14.0      81.9    24.3     77.2 8.0    89.2 2.0

  Overcoming these limitations will be imperative
in future years because the need for culturally appro-
priate tobacco control programs will likely grow.
Numerous researchers have argued that culturally ap-
propriate health promotion efforts need to be devel-
oped for racial/ethnic groups (Rogler et al. 1987;
Edwards and MacMillan 1990; Nestle and Cowelll990;
Gonzalez et al. 1991; Robinson et al. 1991; Uba 1992;
Vega 1992; Alcala y et al. 1993; Marin 1993). Early out-
come data on interventions targeting racial/ethnic
groups further indicate the need for such strategies
(Chen et al. 1994; Perez-Stable et al. 1994; Marin and
PQez-Stable 1995). Moreover, in a National Cancer
Institute (NCI) analysis of self-guided strategies for
smoking cessation, Glynn and colleagues (1990) sup-

ported the need for targeted programs and suggested
that the availability of self-guided smoking cessation
materials tailored to the needs of a racial/ethnic group
"enhances their adoption and may positively affect
quit rates" (p. 11). Therefore, culturally appropriate
interventions may prove to be more acceptable and
easier to implement and also may have increased effec-
tiveness (Fiore et al. 1996). Cultural values, in fact, often
support the messages given in effective tobacco control
programs. In addition, if the development process in-
cludes community leaders and researchers who repre-
sent the community, the process itself will enhance the
existing tobacco control infrastructure (Robinson et al.
1995).

Tobacco CoMrol and Education Efforts  265


Surgeon General's Report

Primary Prevention Efforts

  Most of the programs that seek to prevent tobacco
use among racial/ethnic minority groups focus on
children and adolescents. These interventions include
efforts to restrict minors' access to tobacco products,
school-based health education programs, and mass
media efforts.

Efforts to Restrict Youth Access to Tobacco

  A comprehensive national effort to address the
problem of minors' access to tobacco was made in 1992
with the passage of the Synar Amendment to the Al-
cohol, Drug Abuse, and Mental Health Administra-
tion Reorganization Act (Public Law 102-321), which
amended the Public Health Service Act. The draft
regulations were made final in 1996. These regula-
tions require the 50 states, the District of Columbia,
and U.S. jurisdictions to enact and enforce legislation
restricting the sale and distribution of tobacco prod-
ucts to minors, as a condition of receiving federal block
grant funds for substance abuse and treatment. As a
result, all states now designate an agency to enforce
their minimum-age laws on purchase of tobacco prod-
ucts. Many local governments have attempted over
the years to limit access to tobacco among youths un-
der the age of 18 years by enacting or strictly enforc-
ing legislation that limits minors' ability to purchase
tobacco over the counter and through vending
machines, whereas others have opted to educate re-
tailers and encourage them to voluntarily comply with
legislation that limits the sale of tobacco products to
minors (Lynch and Bonnie 1994; USDHHS 1994). Stud-
ies show that over-the-counter sales of tobacco to
adolescents under the age of 18 years are indeed wide-
spread, although all states prohibit such sales (Altman
et al. 1989; Jason et al. 1991; NC1 1991; DiFranza and
Brown 1992; Forster et al. 1992). Despite laws in every
state that prohibit the sale of tobacco products to per-
sons under 18 years of age, underage buyers in 1996
were able to purchase tobacco products from retail
outlets a median of 40 percent of the time, according
to reports from states, compared with rates ranging
from 60 to 90 percent in previous studies WSDHHS
1998).

  In addition to requirements of the Synar Amend-
ment, the recent regulations on tobacco products pro-
posed by the Food and Drug Administration (FDA)
and made final on August 23,1996, sought to reduce

266 Chapter 5

both minors' access to tobacco products and the
appeal those products have to minors (see Efforts to
Control Tobacco Advertising and Promotion later in
this chapter). Three key provisions address minors'
access to tobacco: (1) requiring vendors to check a pho-
tograph identification as proof of age and prohibiting
sales to those under age 18, (2) prohibiting most vend-
ing machines and self-service displays of cigarettes
except in facilities totally inaccessible to persons un-
der age 18, and (3) prohibiting free samples of ciga-
rettes and sales of individual cigarettes or packs of
fewer than 20 cigarettes (so-called kiddie packs). Both
the Synar Amendment and the FDA regulations hold
promise for reducing tobacco use by all young people,
including those who are members of racial/ethnic
groups.

  In general, adults in the four racial/ethnic groups
perceive that minors have fairly easy access to tobacco
products. In the 1992-1993 Current Population Sur-
vey,' a greater proportion of white respondents (55.6
percent) said that it was very easy for minors to pur-
chase tobacco products, compared with American In-
dians and Alaska Natives (52.6 percent), Hispanics (49.8
percent), African Americans (49.0 percent), and Asian
Americans and Pacific Islanders (44.3 percent) (Table
3) (U.S. Bureau of the Census, NC1 Tobacco Use Supple-
ment, public use data tapes, 1992-1993). Men and non-
smokers were more likely than women and smokers to
think that minors had easy access to tobacco products.
Data from the 1989 Teenage Attitudes and Practices
Survey (TAPS) showed that most youths 12-18 years
old who reported cigarette smoking bought their ciga-
rettes primarily at small stores or through cigarette
vending machines (Allen et al. 1993). For example, 86.9
percent of white adolescents reported often or some-
times buying their cigarettes from small stores, com-
pared with 80.0 percent of African Americans and 90.0

' The Current Population Survey (CPS) is a continuous monthly
survey conducted by the U.S. Bureau of the Census and focuses
primarily on labor force indicators for the civilian noninstitu-
tionalized US. population aged 15 years and older. Questions on
smoking and tobacco use (NC1 Tobacco Use Supplement) were
added to the CPS for the September 1992, January 1993, and May
1993 surveys. About 57,000 eligible households are surveyed
each month and yield approximately 110,000 interviews;
interviews are conducted with a knowledgeable household
respondent who responds for all household members aged 15
years and older. The knowledge, attitude, and belief questions
described in this report were asked only of self-respondents.


Tobacco Use Among U.S. RacialJEfhnic Minority Groups

percent of Hispanics. In contrast, 51.4 percent of white   and age showed that African Americans were less
smokers reported often or sometimes buying cigarettes   likely than whites to have ever been asked to show
from large stores, compared with 56.6 percent of His-   proof of age when buying or trying to buy cigarettes;
panics and 39.8 percent of African Americans.      Hispanics were less likely than non-Hispanics to ever
  Data from a 1993 follow-up survey (TAPS-II) that   have been asked to show proof of age (CDC 1996).
were statistically adjusted for participant correlation   In 1989, 12- to 17-year-old whites who smoked were

Table 3.  Adults' beliefs about minors' ease in purchasing cigarettes and other tobacco products,* by race/
    ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993

Characteristic

African     American Indians/    Asian Americans/
Americans     Alaska Natives     Pacific Islanders

%   ?C1+      %    WI        %     ?CI

Hispanics     Whites

%    KI %    &CI

Total
Very easy
Somewhat easy
Men
Very easy
Somewhat easy
Women
Very easy
Somewhat easy
All nonsmokers
Very easy
Somewhat easy
All smokers
Very easy
Somewhat easy

Nonsmokers
Men
Very easy
Somewhat easy
Women
Very easy
Somewhat easy

Smokers
Men
Very easy
Somewhat easy
Women
Very easy
Somewhat easy

49.0
15.4

52.6    3.3        44.3    1.6
15.9    2.4        16.6    1.2

52.5
16.1


46.8
14.9


50.9
16.1


44.2
13.4

0.7
0.5


1.2
0.9


0.9
0.7


0.9
0.6


1.4
1.0

55.6
14.5


50.1
17.0


51.4
16.2


54.2
15.4

54.8    1.4     52.2
16.7    1.0     14.3


48.6    1.1     50.7
15.7    0.8     17.5

47.8
14.8

41.0
12.2

2.1
1.5


1.9
1.3

59.3
14.9


49.1
15.9

4.9        46.0
3.5        17.6

4.5        42.6
3.4        15.7

4.2        44.1
3.1        17.2

5.3
3.8

6.6        46.4
4.6        18.5

5.6        42.3
4.2        16.1

7.4
5.3

7.5        45.8
5.5        11.3

45.5
13.8

45.4
14.9

2.3
1.8


2.2
1.6


1.7
1.3


4.1
2.8

49.8
15.4


51.9
15.7

48.1
15.2


50.4
15.5


47.1
15.1

0.9
0.6


1.3
1.0


1.2
0.9

1.0
0.7


2.1
1.5

2.6     53.3    1.5
2.0     15.6    1.1


2.3     48.3    1.3
1.7     15.5    0.9

4.9
3.5


7.5
4.7

47.7    2.7   53.6    0.8
16.3    2.0   18.0    0.6

46.4    3.3   48.4    0.8
13.2    2.3   16.0    0.6

55.6
17.6


57.4
18.7

54.0
16.7


57.2
17.9


50.9
17.0

58.9
19.0

55.7
16.9

0.3
0.2

0.4
0.3


0.4
0.3


0.3
0.2


0.6
0.4

0.5
0.4


0.4
0.3

*In response to the question, "In your opinion, how easy is it for minors to buy cigarettes and other tobacco
products in your community ?" Response categories included "very easy," "somewhat easy," "somewhat
difficult," " very difficult," and "don't know."
+95% confidence interval.
Source: U.S. Bureau of the Census, public use data tapes, 1992-1993.

Tobacco Control and Education Efforts  267


Surgeon General's Report

more likely (58.7 percent) than same-aged African
Americans who smoked (43.3 percent) to report that
they usually bought their own cigarettes. By 1993,
however, 62.1 percent of whites who smoked and 64.1
percent of African Americans who smoked reported
that they usually bought their own cigarettes. In 1989,
12- to 17-year-old non-Hispanics who smoked were
more likely (59.0 percent) than Hispanics of the same
age who smoked (41.3 percent) to report that they usu-
ally bought their own cigarettes. By 1993, however,
62.4 percent of non-Hispanics who smoked and 59.1
percent of Hispanics who smoked reported that they
usually bought their own cigarettes (CDC 1996). In a
study in San Bernardino and Riverside Counties, Cali-
fornia, Klonoff and colleagues (1994) found that the
purchase of single cigarettes by minors was more fre-
quent in ethnic communities (71.2 percent of minors)
than in white neighborhoods (34.4 percent of minors).
  Klonoff and colleagues (1997) used a factorial
design to study the sale of cigarettes to minors in 72
stores in African American, Hispanic, and white com-
munities. Purchase attempts (N = 1,296) were made
in 24 stores in each community. There were two par-
ticipants in each age (ages 10, 14, and 16 years),
gender, and race/ethnicity category.
  Sales were made most often to 16-year-old African
Americans, regardless of gender. A gender effect ex-
isted for Hispanics, and more frequent sales occurred
to Hispanic girls. Another report based on the same
data analyzed purchase attempts by 14- and 16-year-old
African American and white participants in African
American and white communities (Landrine et al. 1997).
Racial- and ethnic-specific sales rates were similar in
white communities. In African American communities,
however, sales rates were higher for African American
youths than for white youths. Of the 41 packs of ciga-
rettes sold to African American youths, only 7 percent
were sold by African American vendors. The rest were
sold by Asian (67 percent), white (13 percent), and His-
panic (13 percent) vendors, according to participants'
reports. Unfortunately, vendor-specific sales rates and
comparable sales data by vendor race/ethnicity for the
white community were not provided. A limitation of
this study is that the apparent age of the minors, an im-
portant correlate of sales (DiFranza et al. 1996), was not
assessed by independent raters.

  A community-based study conducted after pas-
sage and enforcement of legislation limiting minors'
access to tobacco products showed a reduction in the
proportion of merchants who sell cigarettes to minors
and the proportion of adolescents who smoke (Jason
et al. 1991; Jason et al. 1996). Nevertheless, many
merchants-fully aware of legislation prohibiting sales

of tobacco to minors-continue to sell these products
to underage customers. For example, in a 1991 study
of 156 tobacco retailers in central Massachusetts, 80
percent of the merchants who displayed state-
mandated warning signs specifying that it was illegal
for minors to purchase tobacco products were still will-
ing to illegally sell cigarettes to youths (DiFranza and
Brown 1992). Likewise, a 1994 Massachusetts study
reported the ineffectiveness of the tobacco industry-
sponsored "It's the Law" voluntary compliance
program for stores to prevent underage youths from
purchasing tobacco (DiFranza et al. 1996). The results
of surveys and sting operations conducted by com-
munity action groups affiliated with such organiza-
tions as Stop Teenage Addiction to Tobacco (STAT)
show that before public awareness campaigns, 32 to
87 percent of U.S. adolescents who tried to buy ciga-
rettes in various communities were able to do so. These
figures decreased dramatically (by 10 to 93 percent)
when merchants were informed of the law, fined for
selling tobacco products to minors, or told that their
behavior would be monitored by law enforcement
agents (Altman et al. 1989; Feighery et al. 1991; Forster
et al. 1992).

  Some of the campaigns aimed at increasing mer-
chants' awareness of the law's provisions have con-
centrated on small, urban convenience stores where
many youths purchase their own cigarettes (Davis
1991). As a result of a merchant public awareness cam-
paign in San Diego County, tobacco sales to minors
declined in Hispanic and Asian American neighbor-
hoods but not in African American communities (Keay
et al. 1993). Additional data are needed to determine
the reasons that shopkeepers sell tobacco to minors
(Landrine et al. 1994) and also the effectiveness of vari-
ous approaches among youths of different racial/
ethnic minority groups and among owners of conve-
nience stores located in racial/ethnic neighborhoods.
Information about the tobacco-purchasing patterns
among youths of various racial/ethnic groups also is
limited; additional research in this area would be par-
ticularly useful in designing programs to curtail
youths' access to tobacco products.

  Cigarette vending machines are another way
minors obtain tobacco products, because the machines
are rarely supervised by adults. Tobacco control ad-
vocates have recommended banning cigarette vend-
ing machines, locking them, or moving them to places
where adults could check the ages of purchasers. Re-
sults from the 1992 California Tobacco Survey showed
that a large proportion of Hispanics (93.8 percent),
African Americans (91.1 percent), Asian Americans
and Pacific Islanders (87.9 percent), and whites (84.2

268 Chapter 5

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

percent) were willing to ban cigarette vending ma-
chines that are accessible to minors (Pierce et al. 1994a).

  Strong support for banning cigarette vending
machines accessible to youths also was found in the
1994 Robert Wood Johnson Foundation (RWJF) Youth
Access Survey, a national household survey to assess
public attitudes about policy alternatives for limiting
youths' access to tobacco products. This survey of
2,345 adults, including 486 African Americans, 402
Hispanics, and 1,341 whites, showed that there was
willingness to ban cigarette vending machines acces-
sible to youths (Table 4) and strong support for ban-
ning all cigarette vending machines (Nancy Kaufman
et al., unpublished data).

  Although most adults believe that it is relatively
easy for youths to obtain cigarettes, the RWJF Youth
Access Survey found that African Americans (57.5
percent) were somewhat less likely than Hispanics
(67.4 percent) and whites (70.0 percent) to believe that
tobacco products were very or somewhat easy for
youths to buy in their communities. Even so, African
Americans and Hispanics were more supportive than
whites of increasing retailing restrictions that would
limit youths' access to tobacco, with Hispanics being
the most supportive.  The retail measure with the
broadest public support is the proposal to eliminate
self-service tobacco displays, requiring retailers to keep
tobacco products behind the counter. Hispanics and
African Americans differ from whites in their beliefs
about the potential results of raising the age at which
tobacco products can be legally purchased. Sixty-five
percent of Hispanics and 61.4 percent of African Ameri-
cans, compared with only 44.3 percent of whites, be-
lieve that raising the age of legal purchase to 21 would
prevent smoking initiation. Similar results were
observed when 19 was proposed as the legal age of
purchase.

School-Based Health Education
Approaches

  In the past decade, numerous programs to pre-
vent tobacco use have been developed for use in
schools with a substantial number of white students
(Lynch and Bonnie 1994). Rather than consider the
specific cultural characteristics of targeted students,
most of these programs have been theory-driven or
intuitively designed and directed toward students at
large. Although youths from various racial/ethnic
groups have been included in numerous studies, their
responses and behaviors have rarely been separately
analyzed or reported in the literature. In a review of
school-based smoking-prevention programs, an NC1

panel of experts concluded that, in general, children
from the major racial/ethnic groups and those of low-
socioeconomic status were the least likely to have been
reached by smoking-prevention programs in schools
(Glynn 1989). In 1991, the NC1 Advisory Panel on
Tobacco-Use Reduction Among High-Risk Youth
(Glynn et al. 1991) recommended that entire schools
be the target of efforts to identify high-risk youth and
that a broader approach (such as identifying a school
with a large proportion of economically disadvantaged
youth) may be more cost-effective and reach the great-
est number of high-risk youth without detrimentally
labeling individuals the way a more focused approach
might. To support the development of effective school-
based interventions, the CDC published a set of guide-
lines for school health programs to prevent tobacco
use and addiction (CDC 1994). These guidelines
incorporate findings from a number of studies on
tobacco use and addiction, call for school-based
tobacco-use prevention programs to be provided for stu-
dents from all racial/ethnic groups, and indicate that
such programs should be "sensitive to, and representa-
tive of, a student population that is multicultural,
multiethnic, and socio-economically diverse" (p. 4).

  One significant challenge is the difficulty of
implementing a targeted, culturally appropriate inter-
vention in a typical urban classroom that includes stu-
dents from many cultural and racial/ethnic groups.
Another problem with school-based interventions is
that teachers in most school districts are overworked
and do not have the time, resources, or training to per-
form these additional activities as part of their daily
lessons (Perry et al. 1990). Teachers often have diffi-
culty making tobacco control a high-priority area for
instruction when they must also deal with basic edu-
cational issues and serious community problems such
as crime, illegal drug use, and substandard housing.
In addition, high dropout rates in some racial/ethnic
minority communities make it impossible for school-
based programs to reach many children. For example,
a recent analysis of 1990 census data (U.S. General
Accounting Office [GAO] 1994) showed that a large
proportion of Hispanic dropouts have abandoned for-
mal schooling within the grades (sixth through ninth)
when adolescents are vulnerable to cigarette smoking
initiation (USDHHS 1994). The GAO report showed
that among all Hispanic dropouts, 14 percent had left
formal school by the fourth grade and 56 percent had
left by the ninth grade.

  To overcome these challenges, new school-based
tobacco control programs continue to be developed
and implemented. ASSIST, the American Stop Smok-
ing Intervention Study, for example, has a youth com-
ponent, and at some sites such as North Carolina, the

Tobacco Cotztrol and Education Efforts  269


Surgeon General's Report

Table 4. Public support for and beliefs about policies regarding tobacco access and marketing, by selected
   characteristics, Robert Wood Johnson Foundation Youth Access Survey, 1994

                           African American*    Hispanic        White*
                              (N = 486)       (N = 402)      (N = 1,341)

Characteristic                          %   KI+        %   &CI        %   =I

Favor banning the sale of cigarettes
in vending machines

Favor banning cigarette vending
machines that are accessible to youths

Think retailers should keep tobacco
products behind the counter to prevent
shoplifting by minors

Favor allowing the sale of cigarettes only in
certain stores, just as is done with alcohol

Believe that restricting the sale of cigarettes
to persons aged 21 years and older will help
reduce the number of kids under 21 who
begin smoking

Believe that restricting the sale of cigarettes
to persons aged 19 years and older will help
reduce the number of kids in high school
who begin smoking

Favor banning tobacco product
advertising on billboards

Favor banning tobacco product advertising
in newspapers or magazines

Think tombstone advertising would
make smoking less appealing to youths

Favor requiring plain packaging to make
cigarettes less attractive to youths

Favor not allowing coupons in cigarette packs
to obtain promotional items appealing to youths

Favor not allowing coupon promotions
to obtain free cigarettes by mail

Favor not allowing tobacco companies to sponsor
sporting or entertainment events in which
their brand names are featured

Think that it is very or somewhat easy
for youths to buy cigarettes

74.9

93.7

82.6

46.9

61.4

56.9

61.8

57.4

72.1

48.0

76.5

79.5

65.1

57.5

3.5

2.0

3.0

4.0

3.9

3.9

3.9

3.9

3.6

4.0

3.4

3.2

3.8

3.9

84.5 3.1

93.0 2.2

88.9 2.7

72.9 3.9

65.4 4.2

66.5 4.1

68.9 4.1

62.3 4.3

74.9 3.8

61.8 4.3

82.1 3.4

89.8 2.7

71.7 3.9

67.4 4.1

72.5 3.1

90.7 2.0

75.5 3.0

43.1 3.4

44.3 3.4

47.1 3.5

57.3 3.4

49.1 3.5

72.8 3.1

44.9 3.5

67.8 3.3

80.4 2.8

51.9 3.5

70.0 3.2

`Non-Hispanic.
`95% confidence interval.

Source: Nancy Kaufman et al., unpublished data. Ethnic differences in public attitudes about policy alternatives
for limiting youth access to tobacco products: results of a national household survey, 1994.

270 Chapter 5

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

program teaches students to serve as peer counselors
who can provide information on smoking prevention
and cessation to other high school students. However,
little information is available on the counselors' suc-
cess in racial/ethnic communities.

  Some of the largest experimental school-based
programs that have included children from racial/
ethnic minority groups are briefly described in this sec-
tion. This listing is not exhaustive because previous
reports have reviewed this type of program (Lynch and
Bonnie 1994; USDHHS 1994). These interventions rep-
resent the variety of school-based approaches used in
racial/ethnic neighborhoods.

Project SMART (Self-Management and Resistance
Training)

  Project SMART is an in-school program designed
to encourage junior high school students to resist pres-
sure to use cigarettes and other drugs by teaching them
stress-reduction skills, social-resistance skills, and
personal decision-making skills. Implemented in 12
sessions, Project SMART provides the students with
role-playing opportunities and offers specific tech-
niques for resisting cigarettes, alcohol, marijuana, and
other drugs. In an assessment of this program, Gra-
ham and colleagues (1990) interviewed seventh grad-
ers in 16 California schools between 1982 and 1986.
Approximately 6 percent of the participants were Asian
American, 20 percent were African American, 31 per-
cent were Hispanic, and 43 percent were white. The
program materials, dissemination channels, and evalu-
ation procedures were not tailored specifically for any
of these racial/ethnic groups. Differential effects for
cigarette smoking on the basis of participants' gender
and racial/ethnic minority background were found.
Overall, seventh-grade girls were more positively af-
fected by the program than were seventh-grade boys,
and Asian Americans were more likely than other
racial/ethnic groups to be affected by the intervention.
Hispanics and whites were marginally affected by the
program, whereas African Americans did not appear
to be affected at all.

Life Skills Training Program

  The Life Skills Training (LST) Program is a
tobacco-use prevention curriculum that teaches ado-
lescents positive life options and social-resistance skills.
The program aims to help students enhance their self-
esteem, resist tobacco advertising appeals, cope with
anxiety, and develop verbal and nonverbal communi-
cation skills as well as social and assertiveness skills,
including techniques to resist social pressures to smoke

(Botvin et al. 1989a, 1992; Dusenbury and Botvin 1992).
Program lessons focus on (1) tobacco information, (2)
social skills, (3) personal skills, and (4) self-improvement.
Each program includes instruction, behavior model-
ing and rehearsal, and group feedback. The LST cur-
riculum was initially developed for use with white
youths, but the curriculum was later modified for use
with Hispanics and African Americans, following con-
sultations with psychologists, educators, reading spe-
cialists, and urban adolescents from various racial/
ethnic groups. To assess its feasibility, acceptability,
and effectiveness in an urban African American popu-
lation, the LST curriculum was tested in a pilot study
involving 608 African American seventh-graders in
New Jersey (Botvin et al. 1989a). The study found that
the curriculum was acceptable to African American
teachers and students and could be implemented with
little difficulty in an urban setting. Three months after
the intervention, investigators found a 56 percent re-
duction in the proportion of adolescents who reported
that they had smoked in the previous 30 days. In an
earlier study, Botvin and colleagues (1989b) found that
the use of the LST curriculum was feasible and accept-
able among Hispanic seventh-graders attending urban
schools in northern New Jersey and in New York City.

  More recently, researchers studied the LST
curriculum's effectiveness among Hispanic students
in the New York City area and found significant
changes in knowledge, smoking behavior, and norma-
tive expectations concerning peer and adult smoking
among students in the schools targeted by the inter-
vention, compared with students in control schools
that did not implement the curriculum (Botvin et al.
1992). Consistency in the findings varied, however,'
because of implementation difficulties across schools.
General problems, such as limited resources and stress-
ful conditions in urban schools, may have contributed
to these difficulties.

Project SHOUT (Students Helping Others
Understand Tobacco)

  Project SHOUT was a three-year tobacco-use
prevention program that began in 1988 and targeted
San Diego students who were in the seventh grade at
the beginning of the program (Sallis et al. 1990; Elder
et al. 1993b). About 51 percent of the students who
participated in the program for all three years were
white, and 28 percent were Hispanic. The program
consisted of lessons and activities, led by college un-
dergraduate students, on such topics as the conse-
quences of tobacco use, refusal and decision-making
skills, and the antecedents and social consequences of
tobacco use. Efficacy of the program was measured

Tobacco Control and Education Efforts  271


Sturgeon General's Report

with preintervention and postintervention question-
naires administered to students at the end of grades
seven, eight, and nine. In addition, the efficacy of the
program was tested by using a physiological measure-
ment to detect cigarette smoking and an audiotaped
skills assessment of the students' ability to refuse of-
fers of cigarettes (Sallis et al. 1990). Follow-up
telephone calls and mailings were made during the
last year of the intervention to reinforce the program.
The proportion of Project SHOUT students who re-
ported smoking in the previous month increased from
8.3 percent at the end of the seventh grade to 13.2 per-
cent at the end of the ninth grade. In comparison, 9.2
percent of control students reported smoking in the
previous month at the end of the seventh grade, and
19.8 percent reported smoking in the previous month
at the end of the ninth grade. When researchers used
logistic regressions to analyze the prevalence of ciga-
rette smoking during the previous month among ninth
graders, comparing control and experimental groups,
the results were statistically significant for whites but
not for Hispanics (Elder et al. 1993b). When research-
ers considered cigarette smoking during the previous
week, they found statistically significant results for
both Hispanic and white respondents. When offered
a cigarette in a mock situation, students who received
refusal skills training provided more appropriate re-
sponses than those who did not receive the training
(Sallis et al. 1990).

Southwestern Cardiovascular Curriculum Project
and Pathways to Health

  In 1990, the University of New Mexico began a
series of projects designed to educate Navajo and
Pueblo youths about cardiovascular health and the
prevention of cancer.  The Southwestern Cardiovas-
cular Curriculum Project, founded by the National
Heart, Lung, and Blood Institute, provides fifth-grade
Navajo and Pueblo youths with information on the
health effects of tobacco use and helps them develop
skills to resist social pressures (Davis et al. 1995b). An
evaluation of the program showed that among stu-
dents who had tried cigarette smoking at baseline, boys
who were randomly assigned to the program reported
decreasing their cigarette smoking more than those not
participating.

  The Pathways to Health program, developed
with funding from the NCI, involves fifth and seventh
graders in nine Navajo and Pueblo schools in rural
northwest New Mexico (Davis et al. 1995a). This
16-lesson curriculum is designed to improve Navajo
and Pueblo Indian children's decision-making

abilities regarding health (Cunningham-Sabo and
Davis 1993). The curriculum includes skill acquisition,
self-discovery, and class discussion, and it blends tra-
ditions of Navajo and Pueblo Indians. Overall, the
project promotes a diet low in fat and high in fiber,
fruits, and vegetables, and it teaches students to avoid
both cigarettes and smokeless tobacco (Cunningham-
Sabo and Davis 1993). Results of the baseline testing
showed that a large proportion of fifth (30.6 percent)
and seventh (60.4 percent) graders had tried cigarette
smoking (Davis et al. 1995a). Although 64.5 percent
of fifth-grade girls and 41.0 percent of fifth-grade boys
expressed intentions to never smoke, by the time they
became seventh graders, only 37.8 percent of seventh-
grade girls and 24.5 percent of seventh-grade boys re-
ported intentions to never smoke. Tribal differences
were also noted. Pueblo students reported higher use
of cigarettes, and Navajos reported higher use of
chewing tobacco and snuff.

Other Primary Prevention and
Intervention Efforts

  Other primary prevention and intervention pro-
grams have been relatively small in scale and have
directly targeted members of a given racial/ethnic
minority group. For example, Cella and colleagues
(1992) recently designed a smoking-prevention cur-
riculum for 309 mostly African American (57 percent)
and Hispanic (19 percent) sixth- and seventh-graders
from the Chicago area. The program included two
assemblies that were attended by all students. The
first assembly featured a rap video developed by Af-
rican American adolescents in Richmond, California,
and a talk by an African American oncologist on the
health risks of smoking and social pressures to smoke.
The second assembly featured a rap contest in which
students performed original rap songs they had writ-
ten to convey messages about smoking prevention.
After the first assembly, students who participated in
small follow-up groups were found to have more nega-
tive attitudes toward smoking, compared with stu-
dents attending the larger assembly. There were no
differences in attitudes towards smoking between stu-
dents who decided to participate in the rap contest and
those who did not. No data were collected on the
intervention's possible effects on rates of smoking ini-
tiation or continuation.

  Another small-scale tobacco-use prevention
effort targeted American Indian children from two
Washington State reservations (Schinke et al. 1988).
American Indian children participating in the project,
who were an average of 11.8 years of age, received

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

training in communication, coping, and cognitive
decision-making skills from a bicultural perspective.
At a six-month follow-up, children who participated
in the program were less likely than children in a con-
trol group to report that they had smoked tobacco or
used smokeless tobacco within the previous 14 days.

  A prevention project now under way in Ameri-
can Indian communities in the northeastern United
States involves 260 American Indian adolescents in an
after-school cancer education program (Schinke et al.
1996). The intervention merges tribal culture with an
educational approach that uses storytellers and role
models from the community. The curriculum provides
students with information on problem-solving skills,
the historical use of tobacco among northeastern In-
dian tribes, and health and media literacy to show how
lifestyle habits are heavily promoted through mass
media. Problem-solving skills, the historical use of
tobacco among northeastern Indian tribes, and Ameri-
can Indians' heritage are celebrated through such
activities as making story bags (bags containing me-
mentos that are reminders of the story) and dance
sticks. A preliminary evaluation of the project has
shown that American Indian youths who received the
tobacco use curricula or the combined tobacco use and
dietary curricula had more knowledge and under-
standing of the health problems associated with to-
bacco use. In addition, students receiving the tobacco
use or the combined curricula were more aware of the
role of peers, relatives, and the media in shaping
people's dietary and tobacco preferences (Schinke et
al. 1996). In another program, involving American
Indian children in the northwestern states, Moncher
and Schinke (1994) have shown that a culturally
appropriate skills-learning curriculum can be more
effective when combined with community involve-
ment in the prevention of tobacco use.

  Schinke and colleagues (1994) recently developed
a program targeting American Indian youths. Based
on a legend of the Seneca Nation, the program fea-
tures an interactive software package entitled Boy and
Woman Bear, which provides culturally appropriate
information on how young people can reduce their risk
of cancer via good nutrition and only very limited,
nonhabitual use of tobacco. The effectiveness of the
software was measured with 368 American Indian
youths, aged 10-14 years, in the southeastern United
States. As expected, the youths who participated
in the program were more knowledgeable about
nutrition and tobacco-related facts than were nonpar-
ticipants. Further research by these authors (Schinke
et al. 1996) has shown the strong effects of multitopic
interventions with American Indians.

  The Alaska Area Native Health Service of the
Public Health Service conducted a pilot study of a
school-based intervention targeting 240 Alaska Native
children in grades two through six in three Eskimo
villages (Bruerd et al. 1994). The curriculum, a modi-
fication of previously developed programs, was de-
livered in 12-15 lessons and involved the children's
families in some of the activities. The evaluation of
the program showed a decrease in cigarette smoking
and in the use of snuff in two of the three villages that
participated. The program was most effective when
teachers attended training sessions and fully imple-
mented the curriculum. Another program sponsored
by the Alaska Area Native Health Service, the Great
Alaska Spit-Out, educates Alaska Native schoolchil-
dren and adults about the health risks associated with
smokeless tobacco use (Burhansstipanov and Dresser
1993). Schoolchildren in rural Alaska communities
prepare essays and public service announcements re-
garding the health problems associated with tobacco
use. All children who submit entries receive certifi-
cates. Monetary awards are given for the best essays,
and trips to Washington, D.C., are awarded to the first-
place winners.

  As an adjunct to tobacco control curricula, ciga-
rette smoking bans on school grounds have been im-
posed in some states (recent federal legislation, Public
Law 103-227, Part C, mandates that schools receiving
federal monies be tobacco-free). Although some states
and school districts have prohibited students from
using tobacco on school campuses, they have excluded
administrators, teachers, and volunteers from such
policies, most likely because some adults are resistant
to tobacco-use bans. Data from the 1992 California
Tobacco Survey showed that a relatively low propor-
tion of California adults and youths favored banning
cigarette smoking on school grounds (Pierce et al. 1994a).
Whites (22.3 percent) were the most willing to ban
smoking on school grounds, followed by Asian Ameri-
cans and Pacific Islanders (16.5 percent), African Ameri-
cans (16.3 percent), and Hispanics (11.1 percent).

Mass Media Efforts to Prevent Tobacco Use

  A few programs have developed mass media
materials to prevent tobacco use among children in
racial/ethnic minority groups. Most of these programs
use television commercials and videotapes to present
prevention messages in a targeted fashion. Stop Before
You Drop, a lo-minute videotape developed by Afri-
can American adolescents in Richmond, California
(American Lung Association [ALA] 1990b), presents a

Tobacco Control and Education Efforts  273


Surgeon General's Report

preventive message through stories, rap songs, and
dancing; this videotape is available through local af-
filiates of the ALA. It's No Joke, Don't Smoke! is a
30-minute videotape that openly discusses tobacco use
among children and young adolescents in racial/
ethnic minority groups (California Department of
Health Services, Tobacco Control Section 1993). Other
mass media prevention approaches include theatrical
works presented at school assemblies or during com-
munity events and the distribution of newsletters and
newspapers in schools and through other community
outlets.

   No data on the effectiveness of these and similar
prevention efforts are available because these activi-
ties are relatively new. Although these efforts incor-
porate the musical preferences of young adolescents
(for example, as reflected in programming on MTV
[Music Television]) and feature actors from the racial/
ethnic groups being targeted, rarely do the messages
properly reflect the attitudes, expectations, and nor-
mative beliefs of the targeted children. Instead, most
of these efforts have allowed untrained scriptwriters
(often children from the targeted group) to produce
the text. Although this approach benefits from the use
of words and expressions that are familiar to the tar-
geted children, it fails to incorporate attitudinal change
strategies and the results of studies identifying pre-
dictors of tobacco use (see Chapter 4).

  Also problematic is the lack of information re-
garding the best media outlet to use in presenting
smoking-prevention campaigns to youths in various
racial/ethnic groups, both in terms of frequency of use
and in their perceived credibility and motivating
power. In a study of 349 Chicago youths aged 5-15

Smoking Cessation Programs

years, Blosser (1988) found differences across racial/
ethnic groups in the quantity, frequency, and access to
various media. For example, 70.8 percent of African
Americans in the sample reported watching television
during dinner, compared with 64.6 percent of Puerto
Ricans, 58.8 percent of whites, and 58.1 percent of
Mexican Americans. Racial/ethnic group differences
were also found for access to various media; large pro-
portions of youths reported that they owned a televi-
sion set (100 percent of whites, 99.0 percent of African
Americans, and 97.7 percent of Hispanics), but vary-
ing proportions of youths reported that they owned
an audiocassette player (80.0 percent of whites, 77.1
percent of Mexican Americans, 62.5 percent of African
Americans, and 54.8 percent of Puerto Ricans). In a
recent survey of Los Angeles children 8-12 years of
age, Raymond J. Gamba (unpublished data) found that
children perceived some media channels to be more
believable than others when information on tobacco
was presented. Overall, respondents perceived talks
at school (63 percent), books and pamphlets (54
percent), television programs (54 percent), radio com-
mercials (52 percent), and television commercials (52
percent) to be highly credible in presenting informa-
tion about tobacco use. Students' perceptions varied
by ethnic group. For example, a large proportion of
African Americans perceived books and pamphlets to
be the most credible channels of information, followed
by billboards, posters, newspapers, and television pro-
grams and commercials. A large proportion of Asian
Americans and Hispanics, however, perceived talks
at school to be highly credible, followed by television
and radio commercials.

  Most structured smoking cessation programs
directed at members of racial/ethnic minority groups
have emphasized a self-help approach with some sup-
portive adjuncts, such as motivational messages in the
mass media or the use of peers or relatives as motiva-
tors and supporters (Stotts et al. 1991). This emphasis
on self-help may be a direct result of the fact that most
smokers quit on their own (Fiore et al. 1990). Some
programs have successfully used materials developed

for whites, with little or no adaptation for the racial/
ethnic group being targeted. Though there is currently
little research on the development of culturally appro-
priate smoking cessation programs, culture-specific
tailoring or the development of culturally appropri-
ate programs may be necessary in order to enhance
effectiveness. At a minimum, programs must be com-
municated in a language understood by the target au-
dience (Fiore et al. 1996).

274 Chapter 5

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

  In this section, six major intervention approaches
are described: (1) self-help programs, (2) group pro-
grams, (3) community interventions, (4) programs in
health care settings, (5) employer-sponsored programs,
and (6) nontraditional provider interventions. When
available, the results of outcome evaluations of the
projects or strategies are mentioned. Because most of
these projects are relatively new, there is a paucity of
research measuring the effectiveness of the various
strategies and programs. These descriptions provide
an overview of the different approaches that have been
used; the list is not complete and does not necessarily
represent the most effective interventions or model
programs. Future research efforts should consider the
components of culturally appropriate interventions
(Marin 1993) and conduct proper process and outcome
evaluations to provide a better understanding of the
effectiveness of various targeted intervention
approaches.

Self-Help Approaches

  In the United States, most people who quit smok-
ing do so without the help of formal programs, therapy,
or nicotine replacement (Pierce et al. 1989; Fiore et al.
1990; Stotts et al. 1991). Members of racial/ethnic mi-
nority groups, however, generally seem to have less
success with self-help approaches than whites. For
example, recent analyses of the 1986 Adult Use of
Tobacco Survey showed that African Americans
tended to be less successful at quitting smoking than
whites (Fiore et al. 1990).

  A number of self-help cessation materials and
programs have been developed for members of racial/
ethnic groups who want to quit on their own. Some
of these materials and programs are adaptations of
materials and programs previously developed for
whites, usually by federal agencies such as the NC1 or
voluntary associations such as the ALA. Other pro-
grams and materials have been developed specifically
for members of these racial/ethnic groups; however,
only a few studies report on the success of these pro-
grams in helping members of racial/ethnic groups quit
smoking.

  Smokers from racial/ethnic minority groups tend
to favor relying on willpower alone to quit smoking.
In a 12-state survey of 1,163 low- to middle-income
African American insurance policyholders aged 21-60
years, Orleans and colleagues (1989) found that 89.3
percent of those who were former smokers reported
relying primarily on willpower to quit smoking and 21.7
percent reported relying primarily on prayer and medi-
tation. These former smokers also reported seldom

using cessation aids of any type, including smoking ces-
sation groups (0.4 percent) or books and guides (3.2 per-
cent). Likewise, Hispanic smokers surveyed in San
Francisco perceived willpower as the most effective
technique for quitting smoking (Marin et al. 1990a).

Rompa Con el Vicio: Una Guia Para Dejar de
Fumar (Break the Habit: A Guide to Stop Smoking)

  The first self-help manual designed specifically
for a U.S. racial/ethnic group was developed in 1988
in San Francisco as part of the Programa Latin0 Para
Dejar de Fumar (Hispanic Program to Quit Smoking).
The manual was distributed by the NC1 under the
name Guia Para Dejar de Fumar (Sabogal et al. 1988)
and was based on a significant number of studies that
identified group-specific attitudes, norms, expectan-
cies, and values related to cigarette smoking and smok-
ing cessation among Hispanics and whites (Mar-in et
al. 1990a,b). Initial versions of the manual (hereafter
referred to as the Guia) were thoroughly pretested to
identify optimal formats, designs, photographs, type-
faces, and publication format and size. In 1991, a re-
vised version, El Fumar, Un Juego Peligroso: Guia Para
Dejar de Fumar, was published and distributed in Cali-
fornia with funding from Proposition 99 tax revenues
earmarked for tobacco control activities (Programa
Latin0 Para Dejar de Fumar de San Francisco 1992).
In 1993, the NC1 published and distributed nationally
the third edition, Rompa Con el Vicio: Una Guia Para
Dejar de Fumar (Programa Latin0 Para Dejar de Fumar
de San Francisco 1993).

  The Guia is a 24-page, 8 1/z-by-11-inch, full-color
booklet printed on glossy paper and featuring
photographs of numerous Hispanic individuals dem-
onstrating various cessation techniques as well as their
testimonials about quitting smoking. All text is in
broadcast Spanish- that is, conversational Spanish
used by television broadcasters and easily understood
by all Spanish-speaking Hispanics. The first section
of the Guia describes the short- and long-term effects
of cigarette smoking, including health problems among
smokers and their relatives and the negative social ef-
fects, such as bad breath and bad-smelling clothes. The
second section presents possible methods a smoker can
follow to quit, particularly approaches that Hispanic
smokers perceive to be effective (Marin et al. 1990a).
In addition, this section offers suggestions and verbal
scripts for dealing with social pressures to smoke as
well as for dealing with stress or depression. The third
section presents strategies to follow after a relapse. The
final section lists ways relatives and friends can moti-
vate and support smokers who are trying to quit.

Tobacco Control and Education Efforts  275


Surgeor General's Report

   The effectiveness of the first edition of the Gufa
was evaluated in a study of 431 Hispanic smokers who
volunteered to participate after they picked up the
manual at community stores or clinics in San Francisco
(Perez-Stable et al. 1991). More than 21 percent of the
participants reported that they had quit smoking 2.5
months after reading the Guia; however, this percent-
age declined to 18.6 percent after more than 8 months
and to 13.7 percent after 14 months.

Pathways to Freedom

  Pathways to Freedom: Winning the Fight Against
Tobacco is a self-help manual targeting African Ameri-
cans (Robinson et al. 1992). The manual and a com-
panion 12-minute videotape were developed by the
Fox Chase Cancer Center in Philadelphia with fund-
ing from the NC1 and assistance from a number of
African American churches and other community
groups. The manual was designed to emphasize quit-
ting and community mobilization. In the early stages
of the manual's development, focus group participants
and community leaders who were interviewed sug-
gested that the manual should include graphics de-
picting African Americans representing everyday
people of all ages, should provide strong visuals illus-
trating the health consequences of cigarette smoking,
and should target smokers and nonsmokers. Persons
in the interviews and focus groups also suggested that
the manual and videotape include information on tar-
geted advertising and that they identify the tobacco
industry as the enemy.

  The resulting manual, Pathways to Freedom, is a
36-page, 8 I/Z-by-11-inch, glossy publication with nu-
merous color photographs and line drawings. The first
part of the manual discusses the characteristics of ciga-
rette smoking among African Americans; the tobacco
industry's influence on the community through adver-
tising and promotional campaigns; and the effects of
stressors, such as unemployment and racism, that pro-
mote cigarette smoking behavior. The second part pro-
vides instructions on how to quit smoking and help
smokers quit, and the third part shows how communi-
ties can combat tobacco dependence by working
together. The manual addresses the tobacco-related
concerns of African American smokers as well as
other community members. It covers such topics as
cigarette-smoking patterns among African Americans,
culturally appropriate strategies to quit smoking,
messages that nonsmoking friends and relatives can
use to help smokers quit, and the role of prayer and
faith in helping people quit and avoid a relapse. The
manual was distributed nationally as part of the

Legends campaign carried out in 1993 and 1994 by CDC
and the National Medical Association (NMA). As part
of an American Cancer Society Pathways to Freedom
Community Demonstration Project launched in 1992,
285 African American smokers who received the
manual agreed to participate in postintervention evalu-
ations. About 71 percent of respondents read some or
all of the guide, and 56 percent of those who did re-
ported trying to quit smoking. Approximately 75 per-
cent of those who tried to quit reported being able to
stay off cigarettes for at least 24 hours. Most respon-
dents reported that the manual was easy to read, that
the graphics were appropriate, and that it was useful
overall (C. Tracy Orleans et al., unpublished data). For
more information on the evaluation project, see the
discussion later in this chapter under "Community
Approaches."

Lbm TM N&o E@Bb Htit ThuB'c? (How to Quit
Smoking)

tim Th? Nrio Dd Bz Htit ThuB'c? is a self-help,
smoking cessation manual developed in 1990 to help
Vietnamese smokers quit (Vietnamese Community
Health Promotion Project 1990). The 30-page, 81/2-by-
11-inch manual was developed as part of the Vietnam-
ese Community Health Promotion Project based at the
University of California, San Francisco. The manual's
format is similar to that of the Guia and covers topics
such as reasons for quitting smoking, the health ef-
fects of cigarette smoking, approaches to quitting, di-
etary concerns while quitting, and suggestions for
avoiding and coping with relapse. The manual, avail-
able through the California Department of Health Ser-
vices' Tobacco Control Section, features full-color
photographs.

It's Your Life--It's Our Future

  It's Yo14r Life-It's Our Future is a 28-page smoking
cessation, self-help manual targeting American Indian
adults (American Indian Cancer Control Project 1991).
The manual was developed by the American Indian
Cancer Control Project in Berkeley, California, with
NC1 funding. The two-color, spiral-bound manual is
printed on high-quality paper. The first section of the
manual provides motivational information on quitting
smoking, including the negative effects of smoking and
the positive effects of quitting. The second section
presents techniques to help smokers reduce the num-
ber of cigarettes smoked per day and offers sugges-
tions on what to do before and after quitting and how
to deal with withdrawal symptoms. The last section

276 Chapter 5

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

of the manual provides suggestions on how to stay
free of cigarettes, such as how to deal with pressure to
smoke from family and friends, how to control stress,
and how not to gain weight. The contents of the
manual, the presentation of the materials, and the
approach to quitting that is promoted in this manual
reflect the values of American Indians and their em-
phasis on the family and the community The manual
is formatted for easy reading; for example, the sections
have bulleted headings, and the text is printed in large
type. American Indian artwork and pictures are fea-
tured throughout the manual. A 16-minute videotape
was produced to further motivate smokers to quit and
to remain smoke-free (American Indian Cancer Con-
trol Project 1991).

Victo y Over Smoking-A Guide to Smoking
Cessation for You and Your Family

  The Chinese Community Smoke-Free Project of
the Chinese Hospital in San Francisco produced a 46-
page smoking cessation manual entitled Victory Over
Smoking (Chinese Community Smoke-Free Project
1992) with funding from California's Proposition 99
tobacco tax initiative. The 8 $-by-11-inch manual is
printed on glossy paper and has black-and-white
photographs of Chinese Americans and line drawings.
The manual is written in Chinese, and it describes a
number of suggested attitudes and behaviors that are
specific to and consonant with Chinese culture. For
example, "living long enough to see one's grandchil-
dren grow" is presented as a possible benefit to
quitting, and martial arts is suggested as a possible
alternative to smoking. The five-part manual was pre-
tested with focus groups of San Francisco's Chinese
American residents. The first section describes ciga-
rette smoking among Chinese Americans, and the
second section describes common health effects of
cigarette smoking. The third section presents steps
smokers can take as they prepare to quit. The next
section describes alternatives to smoking as well as
techniques and activities for remaining smoke-free.
The final section provides suggestions on how to main-
tain abstinence, such as through physical exercise, deep
breathing exercises, and diet.

Smoking: Facts and Quitting Tips Series

  In 1992, the NC1 produced two small brochures,
Smoking: Facts and Quitting Tips for Black Americans
(NC1 1992b) and Smoking: Facts and Quitting Tips for
Hispanics (NC1 1992a). Despite the difference in titles,
the brochures are basically identical in content. The

major difference between the brochures is that the one
targeting Hispanics includes text in both English and
Spanish. No information is yet available on their
effectiveness.

Hot Lines

  Hot lines for smokers who want to quit provide
callers with short-term counseling over the telephone
and self-help materials via the mail. Probably the most
prominent of these hot lines is the Cancer Information
Service (CIS), funded by the NCI, which provides ser-
vices and information to persons wishing to quit smok-
ing. The CIS provides services in English as well as in
Spanish in states with high concentrations of Hispan-
ics. The CIS also provides Spanish-speaking counse-
lors and callers with Spanish-language materials,
including copies of the Guia.

  Some states have implemented their own smok-
ing cessation hot lines. For example, California re-
cently funded a hot line to help smokers quit by
providing short-term telephone counseling. Between
August 1992 and December 1993, the California hot
line received calls from more than 18,000 smokers
(Pierce et al. 1994b). Most of these calls came from
whites (56.8 percent), followed by Hispanics (20.6 per-
cent), African Americans (16.1 percent), and Asian
Americans (2.4 percent). These figures show that the
proportion of African American and Hispanic smok-
ers reached by the California hot line was similar to or
higher than the proportion of African American smok-
ers (7.0 percent) and Hispanic smokers (18.6 percent)
in the state, whereas the proportion of Asian Ameri-
can smokers reached by the hot line was lower than
the proportion of Asian American smokers in Califor-
nia (5.0 percent).

Group Approaches

  In general, smoking cessation programs that are
group-based have had difficulty attracting participants,
and attrition rates are often high. The scant data avail-
able for racial/ethnic groups indicate that similar diffi-
culties may exist to an even greater extent. For example,
Hispanics and Asian Americans rarely participate in
smoking cessation groups (Perez-Stable et al. 1993). The
same is true for African Americans (Hymowitz et al.
1996). The possible reasons are varied (Glynn 1989;
Stotts et al. 1991; Lichtenstein and Glasgow 1992):

o  They may have difficulty accessing primary health
care facilities that offer smoking cessation services
(because of eligibility criteria or physical distance).

Tobacco Control and Education EJforts  277