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

African Americans
American Indians and Alaska Natives
Asian Americans and Pacific Islanders
Hispanics

A Report of the
Surgeon General

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health


Suggested Citation

U.S. Department of Health and Human Services. Tobmx~ Usr Among U.S. Racinl/Ethic
Milmrity Group-Africarl A~~wrimm, Aurerknr~ Iudinrls nud Alnsh7 Nntiws, Asinrz Avwicam
all[f Pn&c IsI~rzil~w; ~7nd His~~o~~ics: A Rcyrt (?f flw SLI~L'OII Gtwrml. Atlanta, Georgia: U.S.
Department of Health and Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health Promotion, Office on Smok-
ing and Health, 1998.

For sale by the Superintendent of Documents, U.S. Government Printing Office, Washing-
ton, D.C., 20402, S/N 017-001-00527-4.

Use of trade names is for identification only and does not constitute endorsement by the
U.S. Department of Health and Human Services.


THE SECRETARY OF HEALTH AND HUMAN SERVICES
           WASHINGTON. D c 20201

The Honorable Newt Gingrich
Speaker of the House of Representatives
Washington, D.C.   20515

Dear Mr. Speaker:

I am pleased to transmit to the Congress the Surgeon General's report
on the health consequences of smoking,  entitled Tobacco Use Among U.S.
Racial/Ethnic Minority Groups.  This report is mandated by Section
8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law
91-222) and includes the health effects of smokeless tobacco products,
as mandated by Section 8(a) of the Comprehensive Smokeless Tobacco
Health Education Act of 1986 (Public Law 99-252).  The report was
prepared by the Centers  for Disease Control and Prevention.

This is the first Surgeon General's report to focus on tobacco use
among four U.S.  racial/ethnic minority groups:  African Americans,
American Indians and Alaska Natives, Asian Americans and Pacific
Islanders,  and Hispanics.  It provides a single, comprehensive source
of data on each racial/ethnic group's patterns of tobacco use,
physical effects related to tobacco smoking and chewing, societal and
psychosocial factors associated with tobacco use, and a selection of
specific tobacco control programs.  Armed with accurate data, health
professionals can plan appropriate programs to address more
effectively the health needs of these groups.

Smoking is the leading cause of preventable death in the United
States.  Certain racial/ethnic minority populations remain at
high risk for using tobacco and often bear a disproportionate
share of the human and economic cost of tobacco use.   For
instance, African Americans suffer the highest death rates from
several diseases caused by smoking.  Although some recent
declines in lung cancer trends are encouraging, we have reason
for great concern about recently reported increases in rates of
smoking among African-American and Hispanic high school students.

According to estimates from the U.S. Bureau of the Census, over
the next 50 years,  the size of these four racial/ethnic minority
groups is expected 'to increase dramatically, becoming almost half
of the U.S. population by the year 2050.  This projection clearly
indicates the need to develop effective strategies to prevent
tobacco-related disease and death in these four minority
population groups.

Enclosure


THE SECRETARY OF HEALTH AND HUMAN SERVICES
           WtTSHINGTON. D c 20201

The Honorable Albert Gore, Jr.
President of the Senate
Washington, D.C.   20510

Dear Mr.  President:

I am pleased to transmit to the Congress the Surgeon General's report
on the health consequences of smoking,  entitled Tobacco Use Among U.S.
Racial/Ethnic Minority Groups.  This report is mandated by Section
8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law
91-222) and includes the health effects of smokeless tobacco products,
as mandated by Section 8(a) of the Comprehensive Smokeless Tobacco
Health Education Act of 1986 (Public Law 99-252).  The report was
prepared by the Centers  for Disease Control and Prevention.

This is the first Surgeon General's report to focus on tobacco use
among four U.S. racial/ethnic minority groups:  African Americans,
American Indians and Alaska Natives, Asian Americans and Pacific
Islanders,  and Hispanics.  It provides a single, comprehensive source
of data on each racial/ethnic group's patterns of tobacco use,
physical effects related to tobacco smoking and chewing, societal and
psychosocial factors associated with tobacco use, and a selection of
specific tobacco control programs.  Armed with accurate data, health
professionals can plan appropriate programs to address more
effectively the health needs of these groups.

Smoking is the leading cause of preventable death in the United
States.  Certain racial/ethnic minority populations remain at
high risk for using tobacco and often bear a disproportionate
share of the human and economic cost of tobacco use.   For
instance, African Americans suffer the highest death rates from
several diseases caused by smoking.  Although some recent
declines in lung cancer trends are encouraging, we have reason
for great concern about recently reported increases in rates of
smoking among African-American and Hispanic high school students.

According to estimates from the U.S. Bureau of the Census, over
the next 50 years, the size of these four racial/ethnic minority
groups is expected to increase dramatically, becoming almost half
of the U.S. population by the year 2050.  This projection clearly
indicates the need to develop effective strategies to prevent
tobacco-related disease and death in these four minority
population groups.

Enclosure


Foreword

   The United States of America is a rich blend of cultures. This diversity
demands close attention from the agencies and individuals responsible for pro-
tecting the public's health. For too long in tobacco control, attention to diversity
has been less consistent than is necessary for planning and developing effective
health programs. As a result, we sometimes lack sufficient information on which
to base tobacco control interventions. With this report, we begin to address such
problems and point the way to filling these gaps in knowledge.

   Tobacco use causes devastating disease and premature death in every
population in the United States. For four major U.S. racial/ethnic minority groups-
African Americans, American Indians and Alaska Natives, Asian Americans and
Pacific Islanders, and Hispanics-patterns of tobacco use, adverse health effects,
and the effectiveness of interventions need to be understood in terms of tobacco's
cultural and socioeconomic effects on the members of these groups. This report
describes the complex factors that play a part in the growing epidemic of diseases
caused by tobacco use in these four groups.

   Since 1964 when the first Surgeon General's report on smoking and health
was released, this report is the first to focus exclusively on tobacco use among
members of these four racial/ethnic groups. Together these groups constitute about
25 percent of the U.S. population, and that proportion is growing rapidly. Public
health programs must effectively address the health needs of this significant pro-
portion of people. Such action is of paramount importance to reducing tobacco
use in the United States and meeting national health objectives for the year 2000.
We hope that this report will provide the basis for renewing our commitment to
develop more effective tobacco control programs and policies for people of every
racial and ethnic background. In addition, the report can be used by parents and
communities as a tool to develop their own solutions. With continued diligence,
we shall strive to reach and exceed whenever possible our stated health goals by
the year 2000 and reduce the enormous health burden caused by tobacco products.

Claire V. Broome, M.D.
Acting Director
Centers for Disease Control and Prevention
and
Acting Administrator
Agency for Toxic Substances and Disease Registry


Preface

    from the Surgeor Gewral,
U.S. Department of Health and Humau Services

  Effective strategies are needed to reduce tobacco use among members of U.S.
racial/ethnic groups and thus diminish their burden of tobacco-related diseases
and deaths. Cigarette smoking is the leading cause of preventable disease and
death in the United States. There is enormous potential to reduce heart disease,
cancer, stroke, and respiratory disease among members of racial and ethnic groups,
who make up the most rapidly growing segment of the U.S. population.

  This Surgeon General's report is the first to address the diverse tobacco
control needs of the four major U.S. racial/ethnic minority groups-African
Americans, American Indians and Alaska Natives, Asian Americans and Pacific
Islanders, and Hispanics. This report is also the only single, comprehensive source
of data on each group's patterns of tobacco use, physical effects related to tobacco
smoking and chewing, and societal and psychosocial factors associated with
tobacco use.

  The findings detailed in this report indicate that if tobacco use is not reduced
among members of these four racial/ethnic groups, they will experience increas-
ing morbidity and mortality from tobacco use. The toll is currently highest for
African American adults. Findings also suggest that some close, long-term rela-
tionships between tobacco companies and various racial/ethnic communities could
hamper U.S. efforts to lower rates of tobacco use by the year 2000. Also notable is
the support that members of racial/ethnic groups have shown for legislative
efforts to control tobacco use, sales, advertising, and promotion.

  As this report goes to press, discouraging news comes from a report
published by the Centers for Disease Control and Prevention on the Youth Risk
Behavior Survey about tobacco use among African American and Hispanic high
school students. Past-month smoking increased among African American students
by 80 percent and among Hispanic students by 34 percent from 1991 through 1997.
The consistent decline once seen among young African Americans has sharply
reversed in recent years. Past-month smoking prevalence increased from 13 per-
cent to 23 percent among African Americans and from 25 percent to 34 percent
among Hispanics.

  Although cancer remains common in Americans of all racial and ethnic groups,
the pattern of increasing lung cancer deaths in the 1970s and 1980s among African
American, Hispanic, and some American Indian and Alaska Native subgroups
has been halted or reversed for some groups from 1990 through 1995. Some en-
couraging news from Carrcer kideuce arzd Mortality, 1973-l 995: A Report Card for
the U.S. was just published by the American Cancer Society, the National Cancer
Institute, and the Centers for Disease Control and Prevention. The report described
lung cancer trend data from 1990 through 1995 for African Americans, Asian Ameri-
cans and Pacific Islanders, and Hispanics. Lung cancer death rates declined
significantly for African American men and for Hispanic men and women from


1990 through 1995; death rates did not change significantly for African American
women or for Asian American and Pacific Islander men or women. Although lung
cancer trends may continue to decline among some racial/ethnic groups for sev-
eral more years, recent increases in smoking prevalence among adolescent African
Americans and Hispanics and among Asian American and Pacific Islander adoles-
cent males, coupled with the lack of decline among American Indian and Alaska
Native adults, do not bode well for long-term trends in lung cancer.

   One purpose of this report is to guide researchers in their future efforts to
garner more information needed to develop effective prevention and control pro-
grams. Several significant research questions need to be addressed. For example,
why are African American youths smoking cigarettes in lower proportions than
youths in other racial/ethnic groups ? How does acculturation affect patterns of
tobacco use among immigrants to the United States? What are the differential
effects of gender on tobacco use among members of certain racial/ethnic groups?
What racial- and ethnic-specific protective factors and risk factors will promote
the development of culturally appropriate interventions to prevent and control
tobacco use? And to what extent are culturally specific tobacco control programs
necessary to curb tobacco use among racial/ethnic populations? While research-
ers are redirecting their focus, federal, state, and private tobacco control partners
need to address program issues, such as how to develop and evaluate culturally
appropriate prevention and cessation interventions.

   This report includes examples of numerous racial- and ethnic-specific
tobacco control programs used in communities across the country. These and other
racial/ethnic group-specific programs must be disseminated to all areas of the
country, where program planners can develop their own strategies, taking into
consideration the cultural attitudes, norms, expectations, and values of the
targeted cultural groups.

   In each of these endealrors, we ivill succeed only if we are sensitive to our
cultural differences and similarities. I challenge federal and state agencies as well
as researchers and practitioners in the social, behavioral, public health, clinical,
and biomedical sciences to join me in the pursuit of effective strategies to prevent
and control tobacco use among racial/ethnic groups. By meeting this challenge,
we will progress totvard achieving the nation's year 2000 tobacco-related health
objectives and will help to prevent the unnecessary disability, disease, and deaths
that result from tobacco use.

David Satcher, M.D., Ph.D.
Surgeon General
and
Assistant Secretary for Health


Tobacco Use Amoq U.S. RaciallEtkic Mirlority Groups

Acknowledgments

This report was prepared by the U.S. Department of
Health and Human Services under the general direc-
tion of the Centers for Disease Control and Preven-
tion, National Center for Chronic Disease Prevention
and Health Promotion, Office on Smoking and Health.

Claire V. Broome, M.D., Acting Director, Centers for
Disease Control and Prevention, Atlanta, Georgia.

James S. Marks, M.D., M.P.H., Director, National
Center for Chronic Disease Prevention and Health Pro-
motion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Virginia `3. Bales, M.P.H., Deputy Director, National
Center for Chronic Disease Prevention and Health Pro-
motion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Michael I? Eriksen, Sc.D., Director, Office on Smoking
and Health, National Center for Chronic Disease Pre-
vention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

The editors of the report were

Gerard0 Marin, Ph.D., Senior Scientific Editor, Profes-
sor, Department of Psychology, University of San Fran-
cisco, San Francisco, California.

Gayle Lloyd, M.A., Managing Editor, Office on Smok-
ing and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Valerie R. Johnson, Senior Editor, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Anne M. Pritchett, Technical Editor, Cygnus Corpora-
tion, Rockville, Maryland.

Contributing authors were

Neal L. Benowitz, M.D., Professor and Chief, Division
of Clinical Pharmacology, Departments of Medicine,
Pharmacy, and Psychiatry, School of Medicine, Uni-
versity of California, San Francisco, California.

Alan Blum, M.D., Associate Professor, Baylor College
of Medicine, Houston, Texas.

Ronald L. Braithwaite, Ph.D., Associate Professor, Di-
vision of Behavioral Sciences and Health Education,
Emory University School of Public Health, Atlanta,
Georgia.

Felipe G. Castro, M.S.W., Ph.D., Director, Hispanic
Research Center, and Associate Professor, Department
of Psychology, Arizona State University, Tempe,
Arizona.

Moon S. Chen, Jr., Ph.D., M.P.H., Professor, Depart-
ment of Preventive Medicine, Ohio State University,
Columbus, Ohio.

David B. Coultas, M.D., Associate Professor of Medi-
cine, School of Medicine, University of New Mexico,
Albuquerque, New Mexico.

Luis G. Escobedo, M.D., M.P.H., Medical Epidemiolo-
gist, Office on Smoking and Health, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Dorothy L. Faulkner, Ph.D., M.P.H., Epidemiologist,
Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Larri L. Fredericks, Ph.D., M.P.H., Associate Scientist,
American Indian Cancer Control Project, Medical Re-
search Institute, Berkeley, California.

Gary A. Giovino, Ph.D., Chief, Epidemiology Branch,
Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Sandra W. Headen, Ph.D., Assistant Professor, Depart-
ment of Health Behavior and Health Education, School
of Public Health, University of North Carolina, Chapel
Hill, North Carolina.

Felicia Schanche Hodge, Dr.I?H., Principal Investiga-
tor and Director, Center for American Indian Research
and Education, Berkeley, California.

Nancy J. Kaufman, R.N., M.S., Vice President, Robert
Wood Johnson Foundation, Princeton, New Jersey.


Juliette S. Kendrick, M.D., Medical Epidemiologist,
Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Gary King, Ph.D., Assistant Professor and Coordina-
tor, Urban Health Research Program, School of Medi-
cine, University of Connecticut Health Center,
Farmington, Connecticut.

Beverly S. Kingsley, Ph.D., M.P.H., Epidemiologist,
Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Rod Lew, M.P.H., Health Education Director, Asian
Health Services, Oakland, California.

Ann M. Malarcher, Ph.D., Epidemiologist, Office on
Smoking and Health, National Center for Chronic Dis-
ease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Robert K. Merritt, M.A., Health Scientist, Division of
Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Michael D. Newcomb, Ph.D., Professor, Department
of Psychology, University of California, Los Angeles,
California.

John I? Peddicord, M.S., Computer Scientist, Office on
Smoking and Health, National Center for Chronic Dis-
ease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Richard Pollay, Ph.D., Professor of Marketing, and
Curator, History of Advertising Archives, University
of British Columbia, Vancouver, British Columbia,
Canada.

Amelie G. Ramirez, Dr.P.H., Associate Professor, De-
partment of Family Practice, University of Texas, and
Director, South Texas Health Research Center, San
Antonio, Texas.

Patricia A. Richter, Ph.D., M.P.H., Toxicologist, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Robert C. Robinson, Dr.P.H., Associate Director for
Program Development, Office on Smoking and Health,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.

Richard B. Rothenberg, M.D., M.P.H., Professor, De-
partment of Family and Preventive Medicine, Emory
University School of Medicine, Atlanta, Georgia.

Jonathan M. Samet, M.D., Chairman, Department of
Epidemiology, School of Hygiene and Public Health,
The Johns Hopkins University, Baltimore, Maryland.

Michael W. Schooley, M.P.H., Epidemiologist, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Dana Shelton, M.P.H., Epidemiologist, Office on Smok-
ing and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Michael B. Siegel, M.D., M.P.H., Assistant Professor,
Boston University School of Public Health, Boston,
Massachusetts.

Charyn D. Sutton, President, The Onyx Group, Bala
Cynwyd, Pennsylvania.

Scott L. Tomar, D.M.D., Dr.P.H., Assistant Professor,
Department of Dental Public Health and Hygiene,
School of Dentistry, University of California, San Fran-
cisco, California.

Bao-Ping Zhu, M.S., M.B.B.S., Ph.D., Visiting Scientist,
Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Reviewers were

Jasjit S. Ahluwalia, M.D., M.P.H., MS., Assistant Pro-
fessor of Medicine, Emory University School of Medi-
cine, Atlanta, Georgia.

David G. Altman, Ph.D., Associate Professor, Depart-
ment of Public Health Sciences, Bowman Gray School
of Medicine, Wake Forest University, Winston-Salem,
North Carolina.


Tobnccn Use Amon~q U.S. Racirzl/Ethic Minority Groups

Glen Bennett, M.P.H., Coordinator, Office of Preven-
tion, Education, and Control, National Heart, Lung,
and Blood Institute, National Institutes of Health,
Bethesda, Maryland.

Gilbert J. Botvin, Ph.D., Director, Institute for Preven-
tion Research, Department of Public Health, Cornell
University Medical College, New York, New York.

L. Jackson Brown, Director, Epidemiology and Oral
Disease Prevention Program, National Institute of
Dental Research, National Institutes of Health,
Bethesda, Maryland.

Linda Burhansstipanov, Dr.P.H., Director, Native
American Cancer Research Program, American Medi-
cal Center Cancer Research Center, Denver, Colorado.

David Burns, M.D., Professor of Medicine, University
of California at San Diego Medical Center, San Diego,
California.

W. Michael Byrd, M.D., M.P.H., Visiting Research Fel-
low, Department of Health Policy and Management,
Harvard School of Public Health, Boston, Massachusetts.

Portia S. Choi, M.D., M.P.H., District Health Officer, Dr.
Ruth Temple Health Center, Los Angeles, California.

Nathaniel Cobb, M.D., Director, Cancer Prevention and
Control Program, Indian Health Service Headquarters
West, Albuquerque, New Mexico.

Janet L. Collins, Ph.D., Director, Division of Nutrition
and Physical Activity, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Robert J. Collins, D.M.D., Chief Dental Officer, U.S.
Public Health Service, Rockville, Maryland.

Linda S. Crossett, R.D.H., Research Scientist, Division
of Adolescent and School Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

K. Michael Cummings, Ph.D., Director, Smoking Con-
trol Program, Roswell Park Cancer Institute, New York
State Department of Health, Buffalo, New York.

Dorynne J. Czechowicz, M.D., Associate Director for
Medical and Professional Affairs, Division of Clinical
Research, National Institute on Drug Abuse, National
Institutes of Health, Rockville, Maryland.

Ronald M. Davis, M.D., Director, Center for Health
Promotion and Disease Prevention, Henry Ford Health
System, Detroit, Michigan.

Richard A. Daynard, Ph.D., J.D., Chairman, Tobacco
Products Liability Project, Northeastern University
School of Law, Boston, Massachusetts.

Jane L. Delgado, Ph.D., President and Chief Executive
Officer, National Coalition of Hispanic Health and
Human Services Organization, Washington, D.C.

John Elder, Ph.D., M.P.H., Professor, Graduate School
of Public Health, San Diego State University, San Di-
ego, California.

Harmon Eyre, M.D., Deputy Executive Vice President
for Medical Affairs and Research, American Cancer
Society, Atlanta, Georgia.

Michael C. Fiore, M.D., M.P.H., Director, Center for
Tobacco Research and Intervention, University of Wis-
consin Medical School, Madison, Wisconsin.

Adele M. Franks, M.D., Assistant Director for Science,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.

Harold P. Freeman, M.D., Director of Surgery, Harlem
Hospital Center, New York, New York.

Thomas J. Glynn, Ph.D., Chief, Prevention Control
Extramural Research Branch, National Cancer Insti-
tute, National Institutes of Health, Rockville, Mary-
land.

Michael G. Goldstein, M.D., Associate Professor of
Psychiatry and Human Behavior, Brown University
School of Medicine, Providence, Rhode Island.

Robert A. Hahn, Ph.D., M.P.H., Epidemiologist, Epi-
demiology Program Office, Centers for Disease Con-
trol and Prevention, Atlanta, Georgia.

Betty Lee Hawks, M.A., Special Assistant to the Direc-
tor, Office of Minority Health, U.S. Department of
Health and Human Services, Rockville, Maryland.

Clark W. Heath, Jr., M.D., Vice President for Epidemi-
ology and Surveillance Research, American Cancer
Society, Atlanta, Georgia.

Jack E. Henningfield, Ph.D., Vice President, Pinney
Associates, Bethesda, Maryland.


John H. Holbrook, M.D., Director of Internal Medicine,
University of Utah Hospital, Salt Lake City, Utah.

Thomas Houston, M.D., Director, Department of Pre-
ventive Medicine and Public Health, American Medi-
cal Association, Chicago, Illinois.

Rudolph S. Jackson, Dr.P.H., Professor, Department of
Health Education, North Carolina Central University,
Durham, North Carolina.

Elaine M. Johnson, Ph.D., Director, Center for
Substance Abuse Prevention, Substance Abuse and
Mental Health Services Administration, Rockville,
Maryland.

Nora L. Keenan, Ph.D., Epidemiologist, Office of Sur-
veillance and Analysis, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Monina Klevens, D.D.S., M.P.H., Medical Officer, Di-
vision of HIV/AIDS, National Center for Infectious
Diseases, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Norman A. Krasnegor, Ph.D., Chief, Human Learning
and Behavior Branch, Center for Research for Moth-
ers and Children, National Institute of Child Health
and Human Development, National Institutes of
Health, Bethesda, Maryland.

Leonard E. Lawrence, M.D., President, National Medi-
cal Association, University of Texas Health Sciences
Center at San Antonio, San Antonio, Texas.

Edward Lichtenstein, Ph.D., Research Scientist, Oregon
Research Institute, Eugene, Oregon.

Douglas S. Lloyd, M.D., M.P.H., Associate Adminis-
trator for Public Health Practice, Health Resources and
Services Administration, U.S. Department of Health
and Human Services, Rockville, Maryland.

Judith Mackay, M.B.E., J.P., F.R.C.P., Director, Asian
Consultancy on Tobacco Control, Kowloon, Hong
Kong.

Audrey F. Manley, M.D., M.P.H., President, Spelman
College, Atlanta, Georgia.

Alfred McAlister, Ph.D., Associate Professor and As-
sociate Director, Center for Health Promotion Research
and Development, The University of Texas at Austin,
Austin, Texas.

J. Michael McGinnis, M.D., Scholar-in-Residence,
National Academy of Sciences, Washington, D.C.

Bertha MO, Ph.D., M.P.H., Senior Program Officer, In-
ternational Development Research Centre, Ottawa,
Ontario, Canada.

C. Tracy Orleans, Ph.D., Senior Program Officer,
The Robert Wood Johnson Foundation, Princeton, New
Jersey.

Terry F. Pechacek, Ph.D., Visiting Scientist, Office on
Smoking and Health, National Center for Chronic Dis-
ease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Cheryl L. Perry, Ph.D., Professor, Division of Epi-
demiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.

John P. Pierce, Ph.D., Sam M. Walton Professor for
Cancer Research, Department of Family and Preven-
tive Medicine, University of California, San Diego,
California.

Donald H. Reece, Tobacco Control Coordinator, Indian
Health Service, Albuquerque, New Mexico.

Patrick Remington, M.D., M.P.H., Chief Medical Officer,
Wisconsin Division of Health, Madison, Wisconsin.

Irene Reveles-Chase, M.P.H., Health Education Con-
sultant, Tobacco Control Section, California Depart-
ment of Public Health, Sacramento, California.

Nancy A. Rigotti, M.D., Director, Quit Smoking Ser-
vice, General Internal Medicine Unit, Massachusetts
General Hospital, Boston, Massachusetts.

Donald J. Sharp, M.D., Medical Epidemiologist, Of-
fice on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Donald R. Shopland, Coordinator, Smoking and To-
bacco Control Program, National Cancer Institute,
National Institutes of Health, Bethesda, Maryland.

Beverly R. Singer, M.A., Research Staff Associate,
School of Social Work, Columbia University, New York,
New York.


Jesse L. Steinfeld, M.D., Surgeon General, U.S. Public
Health Service, 1969-1973, San Diego, California.

Jonathan R. Sugarman, M.D., M.P.H., Medical Epide-
miologist, Portland Area Indian Health Service, Seattle,
Washington.

Michael J. Thun, M.D., Director, Analytic Epidemiol-
ogy, American Cancer Society, Atlanta, Georgia.

Michael H. Trujillo, M.D., M.P.H., Director, Indian
Health Service, Rockville, Maryland.

Kenneth E. Warner, Ph.D., Richard D. Remington Col-
legiate Professor of Public Health, Department of
Health Management and Policy, School of Public
Health, University of Michigan, Ann Arbor, Michigan.

Raymond Weston, Ph.D., Postdoctoral Fellolz; Memo-
rial Sloan-Kettering Cancer Center, Division of I'sychia-
try, New York, New York.

Judith Wilkenfeld, J.D., Assistant Director, Division of
Advertising Practices, Federal Trade Commission,
Washington, D.C.

Jerome Williams, Ph.D., Professor of Marketing, Penn-
sylvania State University, University Park, Pennsylvania.

Ernst L. Wynder, M.D., President, American Health
Foundation, New York, New York.

Other contributors were

Marco Andujar, Telecommunications Specialist, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Ruth Atchison, Proofreader, Cygnus Corporation,
Rockville, Maryland.

Cheryl Baldwin, Graphic Artist/Desktop Publishing
Specialist, High 5 Design, Gaithersburg, Maryland.

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

Chapter 1. Introduction and Summary of Conclusions  3

Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups  29

Introduction 21
Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups  22
Retrospective Analyses of Smoking Prevalence Among African Americans and

Hispanics 74

Effects of Education and Race/Ethnicit; on Cigarette-Smoking Behavior  83
Exposure to Environmental Tobacco Smoke  86
Comparisons Between Racial,/Ethnic Minority Groups in Current Tobacco Use  87

Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic
Minority Groups 135
Introduction 137
Lung Cancer 137
Other Cancers 149

Chronic Obstructive Pulmonary Disease  7 55
Coronary Heart Disease 160
Cerebrovascular Disease 164
Smoking and Pregnancy  7 66
Summary of Health Consequences from Active Cigarette Smoking  172
Effects of Exposure to Environmental Tobacco Smoke  2 72
Effects of Smokeless Tobacco Use  174
Nicotine Addiction and Racial/Ethnic Differences  175

Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic
Minority Groups 205

Introduction 207
Historical Context of Tobacco  208
Economic Influences 223
Advertising and Promotion 220
Psychosocial Determinants 225

Chapter 5. Tobacco Control and Education Efforts Among Members of Four
Racial/Ethnic Minority Groups 257

Introduction 259

Primary Prevention Efforts 266
Smoking Cessation Programs 274
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

List of Tables and Figures  311
Glossary 319
Index 321


Chapter 1
Introduction and Summary of Conclusions

Introduction 5

Major Conclusions 6

Preparation of This Report  7
Terms Related to Race and Ethnicity  7
Terms Related to Tobacco Use  8
Demographic Characteristics of the Four Racial/Ethnic Minority Groups  8
Effects of Racial/Ethnic Background on Health  22

Chapter Conclusions 12

Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups
Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic
Minority Groups 12

Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic
Minority Groups 13

Chapter 5. Tobacco Control and Education Efforts Among Members
of Four Racial/Ethnic Minority Groups  Z-1

12

References 15

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

Introduction

  This Surgeon General's report on tobacco use
summarizes current information on risk factors and
patterns related to tobacco use among members of four
major racial and ethnic minority groups in the United
States: African Americans, American Indians and
Alaska Natives, Asian Americans and Pacific Island-
ers, and Hispanics. In addition, this report presents
information on national and regional efforts to curtail
consumption of tobacco products among members of
these four groups. Previous Surgeon General's reports
on smoking and health have briefly summarized find-
ings related to one or more of the racial/ethnic groups
covered in this report, but this is the first Surgeon
General's report to concentrate specifically on the four
major racial/ethnic groups in the United States.

  Several factors prompted the development of this
report. First, the information in this report has never
before been compiled in one source. Consequently,
policymakers, community leaders, researchers, and
public health workers have had difficulty determin-
ing the extent of the problem, identifying gaps in in-
formation regarding tobacco use among members of
the four groups, or being aware of existing tobacco con-
trol programs that have demonstrated effectiveness.
Thus, incorporating such information into the design
and implementation of culturally appropriate services
has been difficult.

  Second, the four racial/ethnic groups currently
constitute about one-fourth of the population of this
country, and the Bureau of the Census projects that by
2050 the non-Hispanic white population in the United
States will total only 53 percent (Day 1996). Prevent-
ing health problems related to tobacco use among the
individuals in racial and ethnic groups will be inte-
gral to achieving U.S. public health objectives, such as
those proposed in Healthy People 2000: National Health
Promotion and Disease Prevention Objectives (U.S. Depart-
ment of Health and Human Services [USDHHS] 1991,
1995; National Center for Health Statistics [NCHS]
1994).

  This report contributes essential knowledge that
must be incorporated into efforts to accomplish the
Healthy People 2000 objectives, particularly these six
goals:

o  Objective 3.1. Reduce coronary heart disease deaths
to no more than 100 per 100,000 people. (Age-
adjusted baseline: 135 deaths per 100,000 people

in 1987.) Among African Americans, reduce the
number from 168 to 115 deaths per 100,000 people
between 1987 and the year 2000 (Objective 3.la).

o  Objective 3.2. Slow the rise in lung cancer deaths
to achieve a rate of no more than 42 per 100,000
people. (Age-adjusted baseline: 38.5 deaths per
100,000 people in 1987.) Among African Ameri-
can males, slow the rise from 86.1 to 91 deaths per
100,000 people between 1990 and the year 2000
(Objective 3.2b).

o  Objective 3.4. Reduce the prevalence of cigarette
smoking to no more than 15 percent among people
aged 18 years and older. (Baseline: 29 percent in
1987 [31 percent for men and 27 percent for
women].) Particular year 2000 objectives include
lowering the prevalence of smoking to 18 percent
among African Americans (Objective 3.4d), 15 per-
cent among Hispanics (Objective 3.4e), and 20 per-
cent among American Indians and Alaska Natives
(Objective 3.4f) and Southeast Asian men (Objec-
tive 3.4g).

o Objective 3.5. Reduce the initiation of cigarette
smoking by children and youths so that no more
than 15 percent have become regular cigarette
smokers by the age of 20 years. (Baseline: 30 per-
cent of youths had become regular cigarette smok-
ers by the ages of 20-24 years in 1987.)

.

Objecfive 3.9. Reduce the prevalence of smokeless
tobacco use among males aged 12-24 years to no
more than 4 percent. (Baseline: 6.6 percent among
males aged 12-17 years in 1988; 8.9 percent among
males aged 18-24 years in 1987.) A specific objec-
tive is to lower the prevalence of smokeless tobacco
use among American Indian and Alaska Native
young adults to 10 percent by the year 2000 (Ob-
jective 3.9a).

o  Objective 3.18. Reduce stroke deaths to no more
than 20 per 100,000 people. (Age-adjusted baseline:
30.4 deaths per 100,000 people in 1987.) Among
African Americans, reduce the number from 52.5
to 27.0 deaths per 100,000 people between 1987 and
the year 2000 (Objective 3.18a).

Introduction and Summary  5


  This report of the Surgeon General also responds
to the need to thoroughly analyze the smoking-related
health status of racial/ethnic groups and to determine
if there is a differential risk for tobacco addiction (Chen
1993). High risk might derive from personal charac-
teristics but also from social factors, such as migratory
patterns, acculturation, and the tobacco industry's his-
torical involvement in the racial/ethnic communities
and targeted advertising and promotion of tobacco
products (see Chapter 4).

  In addition, this report is needed to document
how patterns of health, disease, and illness among
people in the various racial/ethnic minority groups
differ from patterns in the rest of the U.S. population.
These differences reflect the groups' exposure to to-
bacco products, as well as the heterogeneity of the
groups' lifestyles, cultural beliefs and practices, genetic
backgrounds, and environmental exposures. This re-
port illustrates how patterns of tobacco use differ
among and within the four racial/ethnic groups
(Chapter 2). It compares the groups in terms of the
incidence and the prevalence of death rates for
diseases commonly associated with tobacco use and
presents data from case-control and cohort studies
whenever possible (Chapter 3).

   The health status of members of racial and eth-
nic groups in this country has also been the focus of
previous federal reports, such as the Health Sfot~ of
Minorities nrzd Lo7~~-Im~11zc Grou~75 (Health Resources
and Services Administration [HRSAI 19851, the Report
of the Secretnry's Task Force OH BInck mzd Minority Henlth
(USDHHS 19851, and CIrroizic Disense in Mifforify Pop~l-
lations (Centers for Disease Control and Prevention
[CDC] 1994). This Surgeon General's report supports
initiatives such as the Hispanic Health and Nutrition
Examination Survey in the early 1980s; the Surgeon
General's National Hispanic/Latin0 Health Initiative
(Novello and Soto-Torres 1993); special funding ini-
tiatives from federal agencies such as the CDC, the
National Cancer Institute, the National Institute on
Alcohol Abuse and Alcoholism, the National Institute
on Drug Abuse, the National Heart, Lung, and Blood
Institute (1994), and the National Institute of Mental
Health (National Institutes of Health 1993);
the Department of Health and Human Services's
1996 Hispanic Agendn for Action: lmprouiug Stwiccs to
Hispanic Americans, and the 1998 President's Race Ini-
tiative, which includes special funding initiatives for
the CDC, the Indian Health Service, and the Health
Resources and Services Administration.

Major Conclusions

1.  Cigarette smoking is a major cause of disease and
death in each of the four population groups stud-
ied in this report. African Americans currently
bear the greatest health burden. Differences in the
magnitude of disease risk are directly related to
differences in patterns of smoking.

2.  Tobacco use varies within and among racial/
ethnic minority groups; among adults, American
Indians and Alaska Natives have the highest
prevalence of tobacco use, and African American
and Southeast Asian men also have a high preva-
lence of smoking. Asian American and Hispanic
women have the lowest prevalence.

3.  Among adolescents, cigarette smoking prevalence
increased in the 1990s among African Americans
and Hispanics after several years of substantial de-
cline among adolescents of all four racial/ethnic
minority groups. This increase is particularly strik-
ing among African American youths, who had the
greatest decline of the four groups during the 1970s
  and 1980s.

4.  No single factor determines patterns of tobacco use
among racial/ethnic minority groups; these pat-
terns are the result of complex interactions of mul-
tiple factors, such as socioeconomic status, cultural
characteristics, acculturation, stress, biological el-
ements, targeted advertising, price of tobacco
products, and varying capacities of communities
  to mount effective tobacco control initiatives.

5.  Rigorous surveillance and prevention research are
needed on the changing cultural, psychosocial, and
  environmental factors that influence tobacco use
to improve our understanding of racial/ethnic
smoking patterns and identify strategic tobacco
control opportunities. The capacity of tobacco
control efforts to keep pace with patterns of to-
bacco use and cessation depends on timely recog-
nition of emerging prevalence and cessation
patterns and the resulting development of appro-
priate community-based programs to address the
  factors involved.


Preparation of This Report

  This report of the Surgeon General was prepared
by the Office on Smoking and Health, National Cen-
ter for Chronic Disease Prevention and Health Promo-
tion, Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services, as part of
the Department's mandate, under Public Laws 91-222
and 99-252, to report to the U.S. Congress current in-
formation about the health effects of tobacco use.

  The report was produced with the assistance of
experts in the behavioral, epidemiological, medical,
and public health fields. Initial background papers
were produced by more than 25 scientists w~ho \vere
selected because of their expertise and familiaritv M'ith
the topics covered in this report. Their various contri-
butions were summarized into five major chapters that
were reviewed by 28 peer revie\vers. The entire manu-
script was then sent to 13 scientists and experts, wrllo
reviewed it for its scientific integritv. Subsequently,
the report was reviewed by various institutes and
agencies within the Department of Health and Human
Services.

Terms Related to Race and Ethnicity

  Race and ethnicity are classifications currently
used for various purposes, such as tracking morbidity
and mortality statistics, defining group characteristics
(as is done in many studies and by most federal and
state agencies, including the U.S. Bureau of the Cen-
sus), and exploring the health characteristics of indi-
viduals and groups. Most extant data consider four
rack! groups in the United States (African American
or black, American Indian and Alaska Native, Asian
American and Pacific Islander, and white) as well as
two etlr,ric categories (Hispanic and non-Hispanic).

  Specific choices have been made in selecting the
labels used to identify individuals who share a given
race, tradition, culture, or ethnicity. These labels dif-
fer somewhat from those published in the Race and
Ethnic Standards for Federal Statistics and Adminis-
trative Reporting, more commonly known as Direc-
tive 15 (U.S. Department of Commerce 1978). This di-
rective presents rules for classifying persons into four
racial groups (American Indian or Alaskan Native,
Asian or Pacific Islander, black, and white) and two
ethnic categories (Hispanic origin and not of Hispanic
origin). The labels in this report were chosen to reflect
current preferred use by many members of each group
and researchers as well as to more clearly identify

Tobacco Use Amo~lg U.S. Ra&l/Ethic Minority Groups

members of a given group. Nevertheless, because of
differences in the way in which ethnicity has been as-
certained in the various studies, some overlap and
misclassification may exist, particularly with regard
to Hispanic origin (for example, Hispanics of African
background may be classified as African Americans,
or Hispanics may be classified as non-Hispanic
whites). In addition, the terms used in this report do
not always precisely depict the racial/ethnic group
studied (for instance, this report consistently uses the
term American I,diall and Alaska Ndiue, even when de-
scribing studies of Nofive Americnm-a category that
in some cases excludes Alaska Natives). Moreover,
the terms used here do not reflect the fact that some
studies were conducted in the 48 contiguous states and
may exclude a substantial number of Alaska Natives
and Native Hawaiians. Throughout this report, the
following labels and definitions are used, with the ref-
erents basically agreeing with those of Directive 15:

Afrimll Americau. Individuals who trace their an-
cestry of origin to Sub-Saharan Africa.

Aliwricnn Idinn ~nrl AInska Nntiue. Persons who
have origins in any of the original peoples of North
America and who maintain that cultural identifi-
cation through self-identification, tribal affiliation,
or community recognition.

Asin~ American amI Pacific lslnnder. Individuals
who trace their background to the Far East, South-
east Asia, the Indian subcontinent, or the Pacific
Islands.

His[JaJ7iC. Persons who trace their background to
one of the Spanish-speaking countries in the
Americas or to other Spanish cultures or origins.

Wlzite. Persons who have origins in any of the
original peoples of Europe, North Africa, or the
Middle East. Throughout most of this report,
white refers to non-Hispanic whites.

  Finally, this report avoids using such labels as
/""FJk of color, spa%/ p0p741nti017s, Jntdticdtural pOp7dLP
from, or diverse popzrlntinm because some people con-
sider them inaccurate, improper, or pejorative. With-
out question, not everyone will agree with the terms
used in this report because no universally accepted
labels exist. These terms will continue to evolve with
time.


Terms Related to Tobacco Use

  Throughout this report, F?rezlnle?zce of smking ces-
sation is used to describe the proportion of persons who
had ever smoked and who were former smokers at
the time of survey (this term is used instead of quit
ratio or quit rate). Definitions related to smoking
status-ever smokers, never smokers, current smok-
ers, and former smokers-are presented later in this
report (see Chapter 2).

Demographic Characteristics of the Four
Racial/Ethnic Minority Groups

  In the 1990 U.S. Census, the four racial and eth-
nic groups that are the focus of this report accounted
for 24 percent of the population, or more than 60 mil-
lion people (Table 1). African Americans were the larg-
est group, followed by Hispanics, Asian Americans
and Pacific Islanders, and American Indians and
Alaska Natives. Although these groups constitute a
minority of the total population, their overall growth
of 32 percent between 1980 and 1990 far exceeds the 4-
percent increase among whites (Table 1). Asian Ameri-
cans and Pacific Islanders had the largest growth
during that period, followed by Hispanics, American
Indians and Alaska Natives, and African Americans.
Because of this rapid growth, racial and ethnic popu-
lations tend to be younger than the white majority.

  Demographic characteristics vary significantly
when the four racial and ethnic groups are compared
with whites, according to 1990 census data (Table 2;
within-group variability is masked because all sub-
groups th.at make up a given racial or ethnic group are
considered together) (U.S. Bureau of the Census 1993~).
The median ages of Hispanics (25.6 years), as well as
American Indians and Alaska Natives (26.9 years), are
lower than those of the other racial/ethnic group mem-
bers. Hispanics have the lowest proportion of high
school graduates (49.8 percent) of all groups and the
highest proportion of people who speak a language
other than English (77.8 percent). Asian Americans
and Pacific Islanders (38.4 percent) as well as Hispan-
ics (39.4 percent) have the largest proportions of indi-
viduals who feel they do not speak English "very well."
They also have the highest proportions of foreign-born
persons. American Indians and Alaska Natives, Afri-
can Americans, and Hispanics have significantly
higher levels of unemployment and poverty as well
as substantially lower household incomes than Asian
Americans, Pacific Islanders, or whites. In all four
groups, a majority of members live in urban environ-
ments; however, American Indians and Alaska Natives
have the lowest proportion of urban residents.

  Differences in the demographic characteristics of
each of the various racial and ethnic groups are related
to variations in national background and immigration
history. Asian Americans and Pacific Islanders, for
example, include approximately 32 different ethnic and

Table 1. U.S. population distribution, by racelethnicity and Hispanic origin and percentage change,
      1980-1990

                               1980              1990
                       (in millions)       (in millions)       70 Change


White*                          180.26            188.42               4

African American*                   26.10             29.28               12

Hispanic

Asian American and Pacific Islander         3.50              7.23             107

American Indian and Alaska Native%         1.42              2.02              42

*Excludes persons of Hispanic origin.
*Excludes 3.5 million Hispanics in Puerto Rico.
$Includes Eskimos and Aleuts.
Source: U.S. Bureau of the Census 1983,1993c.

8 Clzaytrr 1

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

Table 2.  Selected demographic characteristics for the U.S. population, by racelethnicity, 1990

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

Population            29,930,524     2,015,143       7,226,986    21,900,089 188,424,773

Women (percentage)

Median age (years)
Foreign born (percentage)

52.8         50.4           51.2         49.2      51.3

28.2         26.9           30.1         25.6      34.9

4.9          2.3           63.1         35.8       3.3

Education (percentage
of persons aged 225 years)
High school education
Bachelor's degree or higher

English-language ability
(percentage of persons
aged 25 years)
Speak a language other than
English

Do not speak English
"very well"

Number of persons per family
Percentage of families with own
children aged ~18 years
Employment statust
(percentage of persons
aged 216 years)
Employed

Unemployed
Percentage of employed
persons aged 216 years in a
managerial/professional
occupation

Household income in 1989 ($)
Median
Mean

Per capita income in 1989 ($)
Poverty rate (percentage)
Families
Persons

Urban residents (percentage)

63.1         65.5           77.5         49.8      79.1
11.4          9.3           36.6         9.2      22.1

6.3

2.4

3.5



56.5

62.7         62.1           67.5        67.5      65.3
12.9         14.4            5.3         10.4       5.0

23.8           73.3         77.8       5.7


9.2           38.4         39.4       1.8

3.6            3.7         3.8       3.0

60.7           59.5         64.5      45.2

18.1         18.3           30.6         14.1      28.5

19,758      20,025        36,784      24,156    31,672
25,872      26,602        46,695      30,301    40,646

8,859       8,328         13,638       8,400    16,074

26.3         27.0           11.6         22.3       7.0
29.5        30.9           14.1         25.3       9.2

87.2         56.0           95.4         91.4      70.9

*Excludes persons of Hispanic origin. The population figures for African Americans in Tables 1 and 2 are different
because the population cited in Table 2 includes African Americans of Hispanic origin, while the African
American population cited in Table 1 excludes persons of Hispanic origin.
tThese figures do not include several categories of people who were not in the civilian labor force for various
reasons, such as students, housewives, retired workers, seasonal workers in an off season who were not looking
for work, institutionalized persons,
during the reference week).    and persons doing only incidental unpaid family work (less than 15 hours

Source: U.S. Bureau of the Census 1993a,c.


national groups and speak nearly 500 languages and
dialects (Chen 1993). They trace their background to
areas as diverse as Mongolia to the north, Indonesia
and the South Pacific Islands to the south, India to the
west, and Japan to the east. Hispanics include indi-
viduals who trace their background to the original set-
tlers of large areas in what is now the Southwest United
States as well as recent immigrants from any of the 18
Spanish-speaking countries in Latin America. The
American Indian and Alaska Native population in the
United States is likewise composed of a richly diverse
group of indigenous cultures of indigenous cultures,
over half of whom do not live on a reservation (U.S.
Bureau of the Census 1993~). More than 500 federally
recognized tribes and an additional 100 nonfederally
recognized tribes are concentrated primarily in 25 res-
ervation states (U.S. Bureau of the Census 1992a).
American Indians and Alaska Natives continue to
speak more than 150 languages. (For additional infor-
mation, see U.S. Bureau of the Census reports on Asian
Americans and Pacific Islanders [1993a], Hispanics
[1993b], and American Indians and Alaska Natives
[ 1993~1.) Most African Americans in the United States
can trace their ancestry to territories that include the
modern states of Benin, Burkina Faso (formerly

Upper Volta), Cameroon, the Congo Republic, Cote
d'lvoire (Ivory Coast), the Democratic Republic of the
Congo (formerly Zaire), Gabon, Gambia, Ghana,
Guinea, Liberia, Nigeria, Senegal, Sierra Leone, and
Togo (Ploski and Williams 1989). The mode of entry
for practically all Africans who entered the United
States in the seventeenth, eighteenth, and nineteenth
centuries (until 1865) was as slaves (see Chapter 4 for
further historical discussion). Many recent immigrants
came from the Caribbean islands and Sub-Saharan
Africa. This report excludes data on the 3.5 million
residents of Puerto Rico as well as data on residents of
other territories and associated states of the United
States; however, many of the issues discussed in this
report are relevant to these individuals because they
have been influenced by the events taking place in the
50 states.

  Over the next 50 years, the population of the four
groups is expected to increase dramatically, reaching
close to one-half of the country's population by the
year 2050 (Table 3), according to estimates from the
U.S. Bureau of the Census (1992b). These estimates
underscore the need to develop appropriate interven-
tions to avert disturbing tobacco addiction patterns in
this large segment of the population.

Table 3.  Estimated percentage distribution of the U.S. population, by race/ethnicity and Hispanic origin,
      1990-2050

Year

African
American

     Non-Hispanic

Asian American/     American
Pacific Islander      Indian*

White       Hispanic

1990            11.8            2.8            0.7           75.7           9.0


1995            12.1           3.5            0.7           73.6          10.1


2000            12.3            4.2            0.8           71.6           11.1


2005            12.6            `I.9            0.8           69.6          12.2


2010            12.8           5.5            0.8           67.6           13.2


2020           13.3           6.8           0.9           63.9          15.2


2050           15.0           10.1           1.1            52.7          21.1

*Includes Eskimos and Aleuts.
Source: U.S. Bureau of the Census 1992b.

10 Chapter 2


Tblmco Uw Amorzg U.S. Rncid/Ethnic Minority Groups

Effects of Racial/Ethnic Background on
Health

   Extensive research has been conducted on the
relationship between health and race/ethnicity (see,
for example, Harwood 1981; Polednak 1989;
Braithwaite and Taylor 1992; Young 1994). Published
reports of these studies tend to show different rates of
illness across racial/ethnic groups. Some of these dif-
ferences may be explained by variations in each
group's beliefs and attitudes, traditional health-related
practices, normative behaviors, social conditions, lev-
els of access to high-quality health care, experiences
with discrimination and racism, living env,ironments,
competing causes of death, and genetic backgrounds.
Genetic factors may contribute to certain differences
among groups of people; however, culture, degree of
acculturation, and socioeconomic factors are probably
far more significant determinants of health status in
the United States (Freeman 1993; Adler et al. 1994).

  Culture is a broad concept (Kroeber and
Kluckhohn 1963)-its influence encompasses all as-
pects of daily life, including beliefs and practices about
health and illness as well as norms that dictate behav-
iors. Most contemporary societies include many dif-
ferent cultures, which may be defined by historical,
geographic, economic, social, and political elements
(Helman 1985). The United States has always been a
nation of immigrants and coexisting cultures.

  Acculturation-the process of learning the val-
ues, beliefs, norms, and traditions of a new culture
(Marin 1992)-allows individuals to make choices and
to learn of new worldviews, while keeping their origi-
nal views (biculturalism) or modifying their initial
perspectives to be more consonant with those of the
new culture (assimilation). In multicultural societies
such as the United States, acculturation occurs among
immigrants (as they learn the host culture) as well as
among individuals born in the United States (as they
learn the culture of immigrants). Despite the signifi-
cance of acculturation's link with human behavior, few
studies have focused on how acculturation might
affect the health status and behavior of ethnic groups
in the United States. Part of the problem has been the
difficulty in designing appropriate measuring instru-
ments (Marin 19921, although recent research has
begun to assess the role that acculturation plays in

determining the health status of members of U.S.
racial/ethnic groups (Perez-Stable 1994; Vega and
Amaro 1994; Williams and Collins 1995).

  Socioeconomic characteristics, which are power-
ful determinants of health and disease (USDHHS 1985,
1991; Liberatos et al. 1988; HRSA 1991; Williams and
Collins 1995), differ markedly among the racial and
ethnic groups of the United States (Table 2). Levels of
income and education may directly and indirectly af-
fect the health status of individuals (Council on Ethi-
cal and Judicial Affairs 1990; Weissman et al. 1991).
Jncome, for example, often is a determinant of access
to health care as well as of the quantity and quality of
health care available. Persons with low incomes, re-
gardless of race or ethnicity, are more likely to be
uninsured (American College of Physicians 19901, to
encounter delays in seeking or receiving care or to be
denied care (Tallon 1989), to rely on hospital clinics
and emergency rooms for health services (NCHS 19851,
and to receive substandard care (Burstin et al. 1992).
Level of education may influence health beliefs and
behaviors, which determine whether and how indi-
viduals seek health care, make treatment choices, and
comply with treatment suggestions. Because the lit-
erature reviewed in this report has often failed to con-
sider the role of socioeconomic factors in the health
status of members of racial/ethnic groups, under-
standing the significance of the results is difficult.
Nevertheless, these published reports indicate that
access to health care and the type of care received are
partly determined by the race and ethnicity of the pa-
tient and that members of minority groups are less
likely than whites to receive adequate care (e.g.,
Blendon et al. 1989; CDC 1989; Todd et al. 1993; Wil-
liams and Collins 1995).

  The information summarized in this report re-
flects the role of race, ethnicity, and culture in shaping
tobacco use among members of the four population
groups. Unfortunately, currently available methods
do not help delineate the role of acculturation, socio-
economic conditions, and societal problems such as
racism, prejudice, and discrimination (e.g., Osborne
and Feit 1992; Freeman 1993; Pappas 1994). Never-
theless, efforts were made here to discern the possible
role of these variables in explaining tobacco use among
racial/ethnic minority group members.


Surgeon General's Report

Chapter Conclusions

  Following are the specific conclusions for each
chapter in this report.

Chapter 2. Patterns of Tobacco Use Among
Four Racial/Ethnic Minority Groups

1.

2.

3.

4.

5.

6.

7.

In 1978-1995, the prevalence of cigarette smoking
declined among African American, Asian Ameri-
can and Pacific Islander, and Hispanic adults.
However, among American Indians and Alaska
Natives, current smoking prevalence did not
change for men from 1983 to 1995 or for women
from 1978 to 1995.

Tobacco use varies within and among racial/
ethnic groups; among adults, American Indians
and Alaska Natives have the highest prevalence
of tobacco use; African American and Southeast
Asian men also have a high prevalence of smok-
ing. Asian American and Hispanic women have
the lowest prevalence.

In all racial/ethnic groups discussed in this report
except American Indians and Alaska Natives, men
have a higher prevalence of cigarette smoking than
women.

In all racial/ethnic groups except African Ameri-
cans, men are more likely than women to use
smokeless tobacco.

Cigarette smoking prevalence increased in the
1990s among African American and Hispanic ado-
lescents after several years of substantial decline
among adolescents of all four racial/ethnic minor-
ity groups. This increase is particularly striking
among African American youths, who had the
greatest decline of the four groups during the 1970s
and 1980s.

Since 1978, the prevalence of cigarette smoking has
remained strikingly high among American Indian
and Alaska Native women of reproductive age and
has not declined as it has among African Ameri-
can, Asian American and Pacific Islander, and
Hispanic women of reproductive age.

Declines in smoking prevalence were greater
among African American, Hispanic, and white
men who were high school graduates than they

8.

9.









10.

were among those with less formal education.
Among women in these three groups, education-
related declines in cigarette smoking were less
pronounced.

Educational attainment accounts for only some of
the differences in smoking behaviors (current
smoking, heavy smoking, ever smoking, and
smoking cessation) between whites and the racial/
ethnic minority groups discussed in this report.
Other biological, social, and cultural factors are
likely to further account for these differences.
Compared with whites who smoke, smokers in
each of the four racial/ethnic minority groups
smoke fewer cigarettes each day. Among smok-
ers, African Americans, Asian Americans and Pa-
cific Islanders, and Hispanics are more likely than
whites to smoke occasionally (less than daily).
The data in general suggest that acculturation in-
fluences smoking patterns in that individuals tend
to adopt the smoking behavior of the current
broader community; however, the exact effects of
acculturation on smoking behavior are difficult to
quantify because of limitations on most available
measures of this cultural learning process.

Chapter 3. Health Consequences of
Tobacco Use Among Four Racial/Ethnic
Minority Groups

1.  Cigarette smoking is a major cause of disease and
death in each of the four racial/ethnic groups stud-
ied in this report. African Americans currently
bear the greatest health burden. Differences in the
magnitude of disease risk are directly related to
differences in patterns of smoking.

2.  Although lung cancer incidence and death rates
vary widely among the nation's racial/ethnic
groups, lung cancer is the leading cause of cancer
death for each of the racial/ethnic groups studied
in this report. Before 1990, death rates from malig-
nant neoplasms of the respiratory system increased
among African American, Hispanic, and American
  Indian and Alaska Native men and women. From

12 Chapter 1


3.






4.









5 L









6.









7.








8.

1990 through 1995 death rates from respiratory can-
cers decreased substantially among African Ameri-
can men, leveled off among African American
women, decreased slightly among Hispanic men
and women, and increased among American Indian
and Alaska Native men and women.

Rates of tobacco-related cancers (other than lung
cancer) vary widely among members of racial/
ethnic groups, and they are particularly high
among African American men.

The effect of cigarette smoking (as reflected by
biomarkers of tobacco exposure) on infant birth
weight appears to be the same in African American
and white women. As reported in previous Sur-
geon General's reports, cigarette smoking increases
the risk of delivering a low-birth-weight infant.

No significant racial/ethnic group differences have
been consistently demonstrated in the relationship
between smoking and infant mortality or sudden
infant death syndrome (SIDS); cigarette smoking
has been associated with increased risk of SIDS
and remains a probable cause of infant mortality.

Future research is needed and should focus on 110~
tobacco use affects coronary heart disease, stroke,
cancer, chronic obstructive pulmonary disease, and
other respiratory diseases among members of
racial/ethnic groups. Studies also are needed to
determine how the health effects of smokeless to-
bacco use and exposure to environmental tobacco
smoke vary across racial/ethnic minority groups.

Persons of all racial/ethnic backgrounds are vul-
nerable to becoming addicted to nicotine, and no
consistent differences exist in the overall severity
of addiction or symptoms of addiction across
racial/ethnic groups.

Levels of serum cotinine (a biomarker of tobacco
exposure) are higher in African American smok-
ers than in white smokers for similar levels of daily
cigarette consumption. Further research is needed
to clarify the relationship between smoking prac-
tices and serum cotinine levels in U.S. racial/
ethnic groups. Variables such as group-specific
patterns of smoking behavior (e.g., number of
puffs per cigarette, retention time of tobacco smoke
in the lungs), rates of nicotine metabolism, and
brand mentholation could be explored.

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

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

1.

2.

3.

4.

5.

6.

The close association of tobacco with significant
events and rituals in the history of many racial/
ethnic communities and the tobacco industry's
long history of providing economic support to
some racial/ethnic groups-including employ-
ment opportunities and contributions to commu-
nity groups and leaders-may undermine
prevention and control efforts.

The tobacco industry's targeted advertising and
promotion of tobacco products among members
of these four U.S. racial/ethnic groups may un-
dermine prevention and control efforts and thus
lead to serious health consequences.

The high level of tobacco product advertising
in racial/ethnic publications is problematic be-
cause the editors and publishers of these publica-
tions may omit stories dealing with the damaging
effects of tobacco or limit the level of tobacco-use
prevention and health promotion information in-
cluded in their publications.

Although much of the original research on psy-
chosocial factors that influence tobacco use reflects
general processes that may apply to racial/ethnic
populations, documenting such generalizability
requires further research.

The initiation of tobacco use and early tobacco use
among members of the various racial/ethnic mi-
nority groups seem to be related to numerous cat-
egories of variables-such as sociodemographic,
environmental, historical, behavioral, personal,
and psychological-although the predictive power
of these categories or of specific risk factors is not
known with certainty because of the paucity of
research.

Cigarette smoking among members of the four
racial/ethnic groups is associated with depression,
psychological stress, and environmental factors
such as advertising and promotion and peers who
smoke, as is also the case in the general popula-
tion. The role of these factors in tobacco use among
members of these racial/ethnic groups deserves
attention by researchers and persons who develop
smoking prevention and cessation programs.


Chapter 5. Tobacco Control and Education
Efforts Among Members of Four Racial/
Ethnic Minority Groups

1.

More research is needed on the effect of culturally
appropriate programs to reduce tobacco use
among racial/ethnic minority groups. Interven-
tions should be language appropriate; addressing
psychosocial characteristics such as depression,
stress, and acculturation may increase the accep-
tance of programs by members of racial/ethnic
groups.

2.  To be culturally appropriate, tobacco control pro-
grams must reflect the targeted racial/ethnic
group's cultural values, consider the group's
psychosocial correlates of tobacco use, and use
strategies that are acceptable and credible to mem-
bers of the group. Culturally competent program
staff must be aware and accepting of cultural dif-
  ferences, be able to assess their own cultural val-
ues, be conscious of intercultural dynamics when
persons of different cultures interact, be aware of
a racial/ethnic group's relevant cultural charac-
teristics, and have the skills to adapt to cultural
diversity.

3.  Numerous strategies are needed to control tobacco
use among racial/ethnic youths: restricting mi-
nors' access to tobacco products, establishing cul-
turally appropriate school-based programs, and
designing mass media efforts geared to young
people's interests, attitudes, expectations, and
norms. Recent provisions of the Synar Amend-
ment, designed to prevent minors' access to to-
bacco products, and the FDA regulations aimed
at reducing the access to and appeal of tobacco
products to young people are intended to reduce
tobacco use among all youth, including members
of racial/ethnic minority groups.

4.  Members of racial/ethnic groups are less likely
than the general population to participate in smok-
ing cessation groups and to receive cessation ad-
vice from health care providers. Barriers to ethnic
group participation include limited cultural com-
petence of health care providers and a lack of trans-
portation, money, and access to health care.

5.  Available data indicate that racial/ethnic groups
support smoking restrictions, such as increasing
cigarette excise taxes, banning cigarette advertise-
ments, restricting access to cigarette vending ma-
chines, raising the legal age of purchase,
prohibiting sponsorship of events by tobacco com-
panies, and establishing clean indoor air regula-
  tions. Additional research is needed to evaluate
how best to build on this base of public opinion
support to strengthen existing tobacco prevention
and control programs within racial/ethnic
  communities.

6.  Prevention and cessation efforts in racial/ethnic
communities are limited by underdeveloped to-
  bacco control infrastructures and low levels of re-
sources for research, program development, and
program dissemination. Greater resources are
needed in racial/ethnic minority communities to
  build tobacco control infrastructures and to
develop initiatives.

14 Chapter 1


Tc7bacco USP Amoilg U.S. Racial/Ethnic Minority Groups

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Il7troduction and Summary  17


Chapter 2
Patterns of Tobacco Use Among Four
Racial/Ethnic Minority Groups

Introduction 21

Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups  22

African Americans 22
Prevalence of Cigarette Smoking  22
Number of Cigarettes Smoked Daily  23
Quitting Behavior 25
Women of Reproductive Age  26
Young People 28

American Indians and Alaska Natives  44
Prevalence of Cigarette Smoking  44
Number of Cigarettes Smoked Daily  45
Quitting Behavior 46
Women of Reproductive Age  48
Young People 49
Regional and Tribal Tobacco Use  50
Asian Americans and Pacific Islanders  56
Prevalence of Cigarette Smoking  56
Number of Cigarettes Smoked Daily  56
Quitting Behavior 57
Women of Reproductive Age  57
Young People 59
State and Local Smoking Estimates  60
Cigarette Smoking in Asian Countries  65
Hispanics 66

Prevalence of Cigarette Smoking  66
Number of Cigarettes Smoked Daily  69
Quitting Behavior 70
Women of Reproductive Age  71
Young People 72

Retrospective Analyses of Smoking Prevalence Among African Americans
and Hispanics  74

Prevalence of Cigarette Smoking Among Successive Birth Cohorts  74
African Americans 74
Hispanics 75

Long-Term Trends in Cigarette-Smoking Initiation  78
African Americans 78
Hispanics 78

Cigarette Brand Preferences 79


Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior  83

Current Smoking 85
Smoking Cessation 85
Heavy Smoking 85
Ever Smoking 85
Occasional Smoking 86

Exposure to Environmental Tobacco Smoke  86

Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use  87
Cigarette Smoking 87
Pipe and Cigar Use  92
Use of Smokeless Tobacco  94

Conclusions 94

Appendix 1. Sources of Data  95

National Health Interview Survey (NHIS)  95
Hispanic Health and Nutrition Examination Survey (HHANES)  9.5
Behavioral Risk Factor Surveillance System (BRFSS)  95
Adult Use of Tobacco Survey (AUTS)  96
Monitoring the Future (MTF) Surveys  96
Youth Risk Behavior Survey (YRBS)  96
Teenage Attitudes and Practices Survey (TAPS)  96

Appendix 2. Measures of Tobacco Use  97

Cigarette Smoking and Cessation  97
Number of Cigarettes Smoked Daily  97
Use of Cigars, Pipes, and Smokeless Tobacco  97

Appendix 3. Patterns of Cigarette Use Among Whites  98

Appendix 4. Patterns of Cigarette Use Among African Americans  722

Appendix 5. Validation of the Retrospective Assessment of Smoking Prevalence  122

References 12.5


TC~JOCCO Use Anrorzg U.S. Racial/Ethic Mixority Groups

Introduction

  Over the past 15 years, the prevalence of ciga-
rette smoking has generally declined among adult
African Americans, Asian Americans and Pacific
Islanders, and Hispanics. Nevertheless, rates of ciga-
rette smoking and other tobacco use are still
high among certain racial/ethnic minority groups
compared with among the overall population,
particularly American Indians and Alaska Natives.
Designing more successful public health efforts to
reduce tobacco-related diseases and deaths in racial /
ethnic populations requires greater understanding of
these racial/ethnic patterns of tobacco use. This
chapter summarizes bon smoking beha\?ors such as
current tobacco use, cigarette consumption, and quit-
ting behavior among adults vary within and among
racial/ethnic groups.  In addition, for all racial/
ethnic groups, the prel.alence of cigarette smoking is
examined for two groups of special interest, xvomen
of reproductive age and adolescents.

  The purpose of this chapter is to summarize in
one source the reported trends and patterns of tobacco
use among members of the four racial/ethnic minor-
ity groups, by gender, age, and level of education. In
addition, newly compiled information is presented on
smoking patterns by birth cohort (based on year of
birth) for African Americans and Hispanics. The rela-
tionship between racial/ethnic group and education
as predictors of cigarette smoking is explored, and
data on cigarette brand preference and exposure to
environmental tobacco smoke are presented. The in-
fluence of acculturation on smoking behavior is ex-
amined among the two fastest growing immigrant
groups to the United States-Asian Americans and
Pacific Islanders and Hispanics. Although reports of
the effects of acculturation vary widely in the litera-
ture, it is an important correlate of behavior despite
limitations in conceptualization, operationalization,
and measurement.

  The analyses presented in this chapter incorpo-
rate data from national and state-specific population-
based surveys of adults, national population-based

surveys of adolescents, and local and international
surveys of various adult and adolescent populations.
The national studies cited in this chapter include the
National Health Interview Survey (NHIS) (197%1995),
which garners yearly data on cigarette smoking; the
Behavioral Risk Factor Surveillance System (BRFSS)
(1987-1992), which collects information on behavioral
risks among adults in the United States; the Adult Use
of Tobacco Survey, which has been conducted periodi-
cally since 1964; the Hispanic Health and Nutrition
Examination Survey (HHANES), which gathered de-
mographic and cigarette-smoking information from
Hispanics between 1982 and 1984; the Monitoring the
Future (MTF) surveys, which have been conducted in
high schools annually since 1975; and the Teenage
Attitudes and Practices Survey (TAPS), conducted in
1989 and 1993. Appendix 1 describes these major
data sources, and Appendix 2 details the various
measures of tobacco use. Appendix 3 presents data
on patterns of cigarette use among whites that can be
compared with the racial/ethnic group data presented
in the chapter. Appendix 4 presents supplementary
data on patterns of tobacco use among African
Americans, and Appendix 5 describes how the authors
validated one of the analytic techniques used to retro-
spectively estimate smoking prevalence.

  The analyses in this chapter update and expand
on previous Surgeon General's reports that describe
tobacco use among racial/ethnic groups; most of these
previous reports have focused on cigarette smoking
only among African Americans (U.S. Department
of Health, Education, and Welfare [USDHEW]
1979; U.S. Department of Health and Human
Services [USDHHS] 1983,1988,1989,1990a). For some
analyses reported here, small sample sizes limit the
precision of the estimates. The patterns described
in the text generally use point estimates, but confi-
dence intervals presented in most tables can be referred
to when the precision of the estimates needs to be
defined.

P~ttcrns of Tohcco Use  21


Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups

African Americans

Prevalence of Cigarette Smoking

  The overall prevalence of cigarette smoking
among African Americans declined from 37.3 percent
in 197881980 to 26.5 percent in 1994-1995, according
to data from the NHIS (Table 1) (National Center for
Health Statistics [NCHSI, public use data tapes, 1978-
1995). Between 1978 and 1995, the prevalence of cur-
rent smoking among African American men fell from
45.0 to 31.4 percent, whereas the prevalence among

African American women fell from 31.4 to 22.7 per-
cent. Although the prevalence of smoking among
African American men remained consistently higher
than that among African American women, the gen-
der differential in smoking prevalence narrowed over
the 18-year period. Similar patterns have been
observed since 1965 among both African Americans
and whites (Figure 1) (Centers for Disease Control and
Prevention [CDC] 1994~).

  Magnitudes of decline in smoking prevalence
also differed by age (Table 1). Between 1978 and 1995,

Table 1.  Percentage of adult African Americans who reported being current cigarette smokers,* overall and
    by gender, age, and education, National Health Interview Surveys, United States, 1978-1995
    aggregate data
               1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic              7%  KI$ %   I-c1    7%   KI    %   KI %   +c1 %   fC1


Total                  37.3  1.7   35.3  1.4   32.3  1.1   27.9  1.1   27.0  1.5   26.5  1.7

Gender
Men
Women

45.0  2.5   40.2  2.2   37.6  1.8   34.1   1.8   32.4  2.5   31.4  2.7
31.4  1.8   31.4  1.7   28.0  1.4   22.9  1.3   22.6  1.6   22.7  1.9

Age (years)
18-34                38.7 2.8 34.7  2.1    32.0 1.7 26.0 1.7   22.1  2.2 21.0  2.4
35-54               43.9 2.4 42.2  2.7   37.2 1.9 35.6 1.9   35.9  2.7 34.2  3.0
255                 26.5 2.4 27.8  2.4   26.1 2.0 20.0 2.0   22.3  2.8 23.5  2.8

Education5
Less than high school      36.4 2.3 38.7  2.1   36.3 2.0 33.1 2.2   34.2  3.4 34.8  3.3
High school            42.1 2.6 39.4  2.8   38.8 2.1 33.5 1.9   31.9  2.7 31.3  3.1
Some college            36.7 5.5 34.8  3.4   33.0 2.7 28.9 2.8   27.5  3.2 26.4  3.7
College               34.6 6.7 28.4  4.3   19.7 3.2 17.8 2.9   18.2  4.2 16.7  3.8

*Excludes African Americans who reported they were of Hispanic origin. For 1978-1991, current cigarette
smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the
time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported
smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked
every day or on some days.
`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
t95% confidence interval.
41ncludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.


African Americans 18-34 years of age experienced the
largest decline in smoking prevalence, from 38.7 to 21.0
percent, whereas African Americans aged 55 years and
older experienced the smallest decline, from 26.5 to
23.5 percent. In the years 1978-1980, persons 18-34
years of age were nearly 1.5 times more likely to smoke
than those 55 years of age or older. By 1994 and 1995,
however, because of the differential decline in smok-
ing prevalence, the prevalence of smoking among
younger adults was as low as that among their older
counterparts.

  The prevalence of cigarette smoking among Af-
rican Americans decreased most among college gradu-
ates (Table 11-a pattern that has been found in the
nation as a whole (Pierce et al. 1989). Among African
American college graduates, the smoking prel'alence
fell from 34.6 percent in 1978-1980 to 16.7 percent in
1994-1995. In comparison, smoking pre\.alence among
African Americans with less than 12 years of educa-
tion was 36.4 percent in 1978-1980 and 34.8 percent in
1994-1995. In the years 1978-1980, the prevalence of

smoking varied little by level of education. However,
by 1994 and 1995, an inverse relationship had emerged.
As the level of education increased, the prevalence of
cigarette smoking decreased.

Number of Cigarettes Smoked Daily

  The percentage of African American smokers
who reported that they were light smokers (smoking
fewer than 15 cigarettes per day) increased from 56.0
percent in 19781980 to 63.9 percent in 1994-1995, ac-
cording to the NHIS data (Table 2) (NCHS, public use
data tapes, 1978-l 993). This upward trend was found
across all sociodemographic groups, with men, per-
sons less than 35 years of age, and college graduates
experiencing the largest increases in light smoking.

  Throughout the l&year period, African Ameri-
can I~~omen ~`110 smoked were consistently more likely
than their male counterparts to smoke fewer than 15
cigarettes per day (Table 2). African American smok-
ers 18-34 years of age were slightly more likely than

Figure 1.  Trends in the prevalence of cigarette smoking among African American and white men and
     women, National Health Interview Surveys, United States, 1965-1995

60-

0 (
1965

I
1970

I
1975

  I
1980

Year

I           I          I
1985      1990      1995

    African
- American
     men

    African
- American
     women

White

men

111, White
     women

Source: National Center for Health Statistics, public use data tapes, 1965, 1966, 1970, 1974, 1976, 1977, 1978, 1979,
1980,1983,1985,1987,1988,1990,1991,1992,1993,1994, and 1995.


Table 2.  Percentage of adult African American 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  *c1$ %   KI    %   fC1 %   +c1 %   +c1 %   +c1

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

2 55
< 15 cigarettes
15-24 cigarettes
225 cigarettes

56.0 2.2   55.4 2.5   58.8 2.0   60.6 2.2   63.3 3.0   63.9 3.5
33.6 2.2   35.2 2.4   32.8 1.9   31.9 2.1   31.1 2.8   28.4 3.2
10.4 1.7    9.4 1.6    8.4 1.2    7.5 1.2    5.6 1.3    7.6 2.1

50.4 3.2   52.3 3.8   53.2 3.1   55.2 3.1   59.3 4.5   61.1 5.1
37.1 3.6   36.3 3.4   37.0 3.1   35.6 3.1   34.4 4.2   28.6 4.7
12.5 2.3   11.4 2.6    9.8 1.7    9.2 1.9    6.3 2.0   10.3 3.7

62.2 3.2   58.6 3.1   65.0 2.7   67.1 2.6   67.9 3.8   67.1 4.2
29.8 2.8   34.1 2.8   28.2 2.4   27.5 2.5   27.4 3.6   28.3 4.0
8.1 2.3    7.3 1.5    6.8 1.3    5.4 1.3    4.7 1.5    4.6 1.7

59.8 3.6   56.9 3.7   64.1 2.9   67.2 3.4   69.5 5.1   70.0 5.5
31.7 3.3   34.4 3.3   28.5 2.7   26.6 3.2   25.5 4.8   23.3 5.3
8.5 2.3    8.7 2.3    7.4 1.7    6.2 1.8    5.1 2.1    6.7 2.7

51.2 3.4   31.0 4.1   52.1 3.1    54.6 3.4   60.4 4.3   58.9 5.2
35.6 3.7   37.7 3.9   37.7 3.1   36.9 3.2   33.2 4.1   32.2 4.8
13.2 2.7   11.3 2.5   10.2 1.7    8.5 1.9    6.3 2.1    8.9 3.6

55.3 5.4   60.4 5.6   59.1 5.2   60.4 4.8   59.0 6.5   66.7 6.6
34.8 5.6   32.3 5.9   33.6 5.0   31.9 4.7   36.3 6.4   27.3 6.0
9.9 4.8    7.4 3.1    7.3 2.5    7.7 2.7    4.7 2.7    6.0 3.8

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

their older counterparts to be light smokers (except
for the years 1983-1985). An association between edu-
cation and light smoking became apparent
in 1990-1991. In 1990 and beyond, among smokers,
education was directly related to the proportion of

smokers who smoked fewer than 15 cigarettes per day.
As the level of education increased, the proportion
smoking lightly also increased.
  Throughout the 18-year period, the prevalence
of heavy smoking (smoking 25 or more cigarettes per

24 Cl7i7ytrr 2


i%bacco Use Amo7zg U.S. Racinl/Etlznic Minorify Groups

Table 2. Continued

197%1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic             7c  +c1* %   3x1 %   +c1    7c   +a Yc   KI x   KI

Education5
Less than high school
< 15 cigarettes
  15-24 cigarettes
225 cigarettes

High school
< 15 cigarettes
15-24 cigarettes
225 cigarettes

Some college
< 15 cigarettes
15-24 cigarettes
225 cigarettes

College
< 15 cigarettes
15-24 cigarettes
125 cigarettes

53.1 4.0   56.0 4.1    57.3 3.1   57.3 3.4   57.7 5.5   56.1 6.0
33.5 3.6   32.7 4.0   32.7 3.3   33.5 3.3   33.9 5.4   32.5 5.6
13.4 3.1    11.3 3.1   10.0 2.2    9.2 2.3    8.4 3.0   11.5 4.5

53.9 4.7   52.4 4.4   58.3 3.6   59.0 3.7   62.7 4.6   64.0 5.7
34.9 4.8   40.6 4.1   33.2 3.5   34.8 3.6   33.4 4.4   29.2 4.9
11.2 3.6    6.9 2.1    8.5 1.9    6.2 1.6    3.9 1.8    6.8 3.9

49.7 7.5   48.6 6.6   56.3 4.7   60.9 5.6   63.4 7.0   63.0 8.4
37.6 6.1   37.4 6.8   34.7 4.7   32.2 5.5   31.0 6.8   32.2 8.2
12.7 5.9   14.1 5.1    9.0 3.1    6.9 2.9    5.6 3.1    4.9 2.5

57.1 10.2   50.9 9.7   55.2 9.6   65.0 9.3   74.7 10.0   79.0 9.9
34.1 9.0   35.6 10.9   38.2 9.6   24.9 7.9   20.6 9.5   18.1 9.5
8.8 5.5   13.5 9.4    6.7 3.4   10.1 6.7    4.7 4.0    2.9 3.5

gIncludes persons aged 25 vears and older.
Source: National Center fir Health Statistics, public use data tapes, 1978-1995.

day) was higher among African American men than
among women, and it was higher among respondents
3554 years of age than among their younger and older
counterparts (Table 2). No clear patterns emerged in
the relationship between education and the prevalence
of heavy smoking.

Quitting Behavior

  Between 1978 and 1995, the overall prevalence
of smoking cessation (the percentage of persons who
have ever smoked 100 cigarettes and who have quit
smoking) among African Americans increased from
26.8 to 35.4 percent, according to data from the NHIS
(Table 3) (NCHS, public use data tapes, 1978-1995).
The prevalence of cessation generally increased over
time across all gender, age, and education categories.
The largest increases were among persons 55 years of
age or older and college graduates.

  Throughout the 18-year period, the prevalence
of smoking cessation remained higher among persons
55 years of age or older than among their younger
counterparts (Table 3). Since 1983, college graduates

have been generally more likely to quit smoking than
persons with less than 16 years of education.

  Attempts to quit smoking during the previous
year and short-term success at quitting were measured
in a multivariate analysis of the 1991 NHIS data (CDC
1993). After statistical control was made for gender,
age, education, and poverty status, African Americans
were more likely than whites to stop smoking for at
least one day during the previous year. However, Af-
rican Americans who had stopped smoking for at least
one day were less likely than whites to have quit for at
least one month.

   Data from the National Cancer Institute (NC11
Supplement of the 1992-l 993 Current Population Sur-
vey (CPS) indicate that among adults who were daily
smokers one year before being surveyed, African
Americans who had tried to quit for at least one day
were slightly more likely than whites to have relapsed
to daily smoking. African Americans were also slightly
more likely than whites to have become occasional
smokers (i.e., to be smoking on only some days) and
slightly less likely to have quit smoking (Table 4)
(U.S. Bureau of the Census, public use data tapes,

Patterns of Tobacco Use  25


Table 3.  Percentage of adult African American 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             9%  &CIS %   fC1 70   +c1 %   +c1

-

Total                  26.8 1.7   30.0 1.8   31.8 1.6   36.1 1.8

Gender
Men
Women

Age (years)
18-34
35-54
255

Educations
Less than high school
High school
Some college
College

28.7 2.0   33.5 2.6   33.9 2.3   36.8 2.5
24.5 2.5   26.2 2.5   29.4 2.1   35.2 2.4

17.9 2.8   20.2 2.8   18.8 2.3   21.0 2.6
27.7 2.6   29.5 2.9   33.1 2.6   35.2 2.6
42.3 4.0   47.0 3.6   49.2 3.0   57.3 3.6

32.6 2.7   32.7 2.5   35.0 2.5   38.0 3.3
24.4 3.4   28.8 3.6   27.3 2.7   32.4 2.6
32.4 5.9   35.0 4.7   36.6 4.0   38.1 4.4
29.8 8.6   37.0 6.9   50.2 6.1   51.3 6.1

%   tc1 %   XI

37.0 2.4   35.4 2.6



39.1 3.5   34.9 3.7
34.5 3.1   35.9 3.4



23.7 4.6   19.6 4.1
33.2 3.4   33.1 4.0
56.8 4.4   54.7 4.4



40.0 4.2   36.8 4.0
33.4 3.8   31.6 4.3
39.0 5.3   37.3 6.3
48.7 8.7   51.1 8.5

*Excludes African Americans who reported 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.
$95% confidence interval.
%cludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

1992-1993). Some data suggest that African Ameri-
cans may be more likely than whites to be dependent
on nicotine (see Chapter 3, Table 18, in the section
Racial/Ethnic Differences in Self-Reported Nicotine
Dependence; Royce et al. 19931, although a report by
Andreski and Breslau (1993) suggests the opposite.
African Americans appear to have comparatively lim-
ited access to preventive health services, including
smoking cessation services (USDHHS 1988; Hymowitz
et al. 1991).

Women of Reproductive Age

  Between 1978 and 1995, the prevalence of cur-
rent smoking among African American women of re-
productive age (18-44 years) declined from 35.4 to 23.4
percent, according to data from the NHIS (Table 5)

(NCHS, public use data tapes, 1978-1995). Women
who were college graduates experienced an over-
~~helming decline in smoking prevalence, from 37.0
to 10.8 percent, whereas women with less than a high
school education (~12 years) experienced a slight in-
crease in the prevalence of current smoking, from 41 .l
to 46.3 percent.

  In the years 1978-1980, the prevalence of smok-
ing vraried little by level of education. However, by
1994 and 1995, a marked inverse relationship between
smoking and educational level had emerged. As the
level of education increased, the prevalence of smok-
ing decreased. This inverse relationship has also been
found in other studies of women of reproductive age
(CDC 1991 a, 1994b).

  National data on tobacco use and pregnancy are
available from the 1967 and 1980 National Natality


Tobacco USC ~4tno~zg U.S. Racial/Ethnic Minority Groups

Table 4. Current cigarette smoking status among persons* who reported that they were daily smokers
    1 year before being surveyed, Current Population Survey National Cancer Institute Supplement,
      1992-1993

Currrent
smoking
status

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


x =I+    p% kc1    %kcI I   kc1 R   KI %   &CI

Smoke every day; did not
try to quit for at least one
day during the previous
year

Smoke every day; did try
to quit for at least one day
during the previous year

Smoke on some days
Do not smoke cigarettes;
abstinent for l-90 davs

Do not smoke cigarettes;
abstinent for 91-364 days

59.8   I.5    62.8   5.5   57.8   4.4   59.8  2.3   63.1   0.5   62.5  0.5

29.7   1.4    28.9   5.1   32.0   4.2    28.5  2.1   26.0   0.5   26.6  0.4

5.6   0.7     3.7   2.1    4.8   1.9    5.6  1.1    3.7  0.2    4.0  0.2

2.2   0.5     1.8   1.5    2.5   1.4    2.5  0.7    3.4   0.2    3.2  0.2



2.7   0.5     2.8   1.9    2.9   1.5    3.6  0.9    3.8   0.2    3.7  0.2

"Aged 18 years and older; N = 44,272.
`95% confidence interval.
Source: U.S. Bureau of the Census, public use data tapes, 1992-1993.

Surveys, the 1982 and 1988 National Surveys of Fam-
ily Growth, the 1985 and 1990 NHISs, the 1988 Na-
tional Maternal and Infant Health Survey (NMIHS),
and the 1992-1993 National Pregnancy and Health
Survey. Furthermore, since 1989, national trend data
on smoking and pregnancy have become readily avail-
able from information collected on the revised U.S.
Standard Certificate of Live Birth, which is included
as part of U.S. final natality statistics compiled each
calendar year (NCHS 1992, 1993, 1994; Ventura et al.
1994).

  Among the earliest sources of national trend data
on smoking during pregnancy were the National Na-
tality Surveys, which were administered to a national
sample of married mothers of live infants born in 1967
and 1980 (Kleinman and Kopstein 1987; USDHHS
1989). Among African American mothers ~20 years
of age, smoking rates remained virtually constant over
time at about 27 percent. The smoking prevalence

among African American mothers aged 220 years de-
clined from 33 percent in 1967 to 23 percent in 1980.
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 1982,29.2 percent of African American women re-
ported smoking during their most recent pregnancy,
compared with 23.4 percent in 1988 (Pamuk and
Mosher 1992; Chandra 1995). More recent data from
U.S. final natality statistics indicate that smoking rates
for African Americans during pregnancy declined
from 17.1 percent in 1989 to 10.6 percent in 1995 (Table
6). Smoking rates declined for African American teen-
aged mothers from 1989 through 1995 but remained
virtually unchanged for African American adult moth-
ers aged 2049 years during those years (NCHS 1992,
1993,1994; Ventura et al. 1994,1995,19961. In general,
African American adolescent mothers were less
likely to have smoked than mothers 20-49 years


Table 5.

Percentage of African
smokers,* overall and
aggregate data

American women of reproductive age who reported being current cigarette
by education, National Health Interview Surveys, United States, 1978-1995

Characteristic


Total

1978-1980+ 1983-1985+ 1987-1988+ lPPO-lPPl+ 1992-1993+ 1994-1995+

%  KIS %   KI %  *a %   KI %   _+CI %   _+CI


35.4  2.3   34.1  2.0   30.6  1.8   25.4  1.6   23.8   2.1   23.4  2.4

Education5
Less than high school      41.1  5.6   52.4  5.7   48.2  4.2   44.5  4.7   45.7   6.9   46.3  7.8
High school            36.3  4.0   36.8  3.8   34.5  3.0   31.6  3.0   30.0   3.8   28.4  4.3
Some college            37.1  4.8   32.3  5.0   30.6  3.8   26.4  3.4   26.2   4.7   26.1  5.6
College               37.0  10.2   21.8  6.5   20.0  4.3   17.3  4.3   13.1   5.0   10.8  4.9

*Excludes African American women who reported they were of Hispanic origin. For 1978-1991, current
cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives
and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include
women aged 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.
SIncludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

old-a finding that is consistent with previously
published data WSDHHS 1994).

  Data from the 1988 NMIHS indicate that 27 per-
cent of African American mothers sampled reported
smoking cigarettes in the 12 months before delivery
(Sugarman et al. 1994). The National Pregnancy and
Health Survey, conducted between October 1992 and
August 1993 and sponsored by the National Institute
on Drug Abuse (NIDA), provides nationally represen-
tative data on the prevalence of prenatal drug use
among females of reproductive age (1544 years). Ac-
cording to the National Pregnancy and Health Survey,
19.8 percent of African American women reported us-
ing cigarettes during their pregnancies (NIDA 1994).
In the 1985 and 1990 NHISs, questions related to smok-
ing were asked of women aged 18-44 years who had
given birth within the past five years. In 1985, 27.5
percent of African American women smoked during
the 12 months before the birth and 22.6 percent smoked
after learning of their pregnancy; in 1990, 19 percent
smoked during the year before the birth and 14.1 per-
cent after learning of their pregnancy (Floyd et al.
1993).

Young People

Cigarette Smoking

  In the 1970s and 198Os, the prevalence of ciga-
rette smoking declined among both maIe and femaIe
African American high school seniors, according to
data from the MTF surveys (Figure 2) (Bachman et al.
1991b). The prevalence of daily cigarette smoking,
based on two-year rolling averages (percentages cal-
culated by averaging the data for the specified year
and the previous year to increase racial subgroup
sample sizes and stabilize estimates), among African
American high school seniors was 24.9 percent in 1977,
4.1 percent in 1993, and 7.0 percent in 1996 (Figure 3)
(Johnston et al. 1996; Institute for Social Research,
University of Michigan, unpublished data from the
1996 MTF surveys). Between 1974 and 1991, signifi-
cant declines in the prevalence of cigarette smoking
also were observed among African American adoles-
cents participating in the National HousehoId Surveys
on Drug Abuse (NHSDAs) as well as among African
Americans 18 and 19 years of age who participated in
the NHISs (Nelson et al. 1995).

28 Chrzptcr 2


T3mCL) Use Ajnong U.S. Racial/Ethic Minority Groups

Table 6.  Percentage of live-born infants' mothers who reported smoking during pregnancy, by year and race/
    ethnicity, U.S. final natality statistics, 1989-1995

Race of mother*
African American
American Indian and Alaska Kative
Asian American and Pacific Islander'
Chinese
Filipino
Hawaiian and part Hawaiian
%I?yzian American or
Pacific Islander
White

17.1   15.9   14.6   13.8   12.7   11.4   10.6
23.0   22.4   22.6   22.5   21.6   21.0   20.9
5.7    5.5    5.2    4.8    4.3    3.6    3.4
2.7    2.0    1.9    1.7    1.1    0.9    0.8
5.1    5.3    5.3    4.8    4.3    3.7    3.4
19.3   21.0   19.4   18.5   17.2   16.0   15.9
8.2    8.0    7.5    6.6    6.7    5.4    5.2
4.2    3.8    3.8    3.6    3.2    2.9    2.9

20.4

Hispanic origin of mothert
Hispanic origin
Cuban
Central and South American
Mexican American
Other and unknown Hispanic
Puerto Rican
African American, non-Hispanic
White, non-Hispanic

8.0    6.7    6.3    5.8    5.0    4.6    4.3
6.9    6.4    6.2    5.9    5.0    4.8    4.1
3.6    3.0    2.8    2.6    2.3    1.8    1.8
6.3    5.3    4.8    4.3    3.7    3.4    3.1
12.1    10.8   10.7   10.1    9.3    8.1    8.2
14.5   13.6   13.2   12.7   11.2   10.9   10.4
17.2   15.9   14.6   13.8   12.7   11.5   10.6
21.7   21.0   20.5   19.7   18.6   17.7   17.1

Total                                   19.5

1989   1990   1991   1992   1993   1994   1995

19.4

18.4

18.8

17.8

17.9

16.9

16.8

15.8

15.6

14.6

15.0

13.9

*Includes data for 43 states and the District of Columbia (DC) in 1989,45 states and DC in 1990, and 46 states and
DC in 1991-1995. Excludes data for California, Indiana, New York (but includes New York City), and South
Dakota in 1994 and 1995; Oklahoma in 1989-1990; and Louisiana and Nebraska in 1989, which did not require the
reporting of mother's tobacco use during pregnancy on the birth certificate. White and African American racial
groups include persons of Hispanic and non-Hispanic origin.
+Maternal tobacco use during pregnancy was not reported on the birth certificates in California and New York,
which together accounted for 43-66 percent of the births in each Asian subgroup (except Hawaiian) during
1989-1991.
`Includes data for 42 states and DC in 1989,44 states and DC in 1990,45 states and DC in 1991-1992, and 46 states
and DC in 1993-1995. Excludes data for California, Indiana, New York (but includes New York City), and South
Dakota in 1994 and 1995; Oklahoma in 1989-1990; and Louisiana and Nebraska in 1989, which did not require the
reporting of either Hispanic origin of mother or tobacco use during pregnancy on the birth certificate. Persons of
Hispanic origin may be of any race.
Sources: National Center for Health Statistics 1996; Ventura et al. 1996, 1997.

  `The prevalence of cigarette smoking among Af-
rican American adolescents has been substantially
lower than the prevalence among white and Hispanic
adolescents (Figures 2 and 3) (Bachman et al. 1991b;
USDHHS 1994; CDC 1996; Johnston et al. 1996). Lo-
cal, more limited surveys have also shown similar
differences in cigarette smoking prevalence between

African American and white youths (for example,
Sheridan et al. 1993; Greenlund et al. 1996).
  In addition to the slight increases in the 1990s in
smoking prevalence among African American high
school seniors (Figures 2 and 3), CDC's Youth Risk
Behavior Survey (YRBS) detected an increase in the
prevalence of cigarette smoking from 1991 to 1995

Patterns of Tobacco Use  29


Figure 2.

35-

25-

Trends in daily smoking* among African American and white high school seniors,
by gender, United States, 1977-1996

0 ;    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I
   1977    1979    1981    1983    1985    1987    1989    1991    1993    1995

                          Year

- African American males -  African American females ----  White males - . - . . White females

Note: To increase racial subgroup sample sizes and stabilize estimates, the percentages were calculated
by averaging the data for the specified year and the previous year.
*Daily smoking is defined as smoking one or more cigarettes per day during the previous 30 days.
Source: Institute for Social Research, University of Michigan, unpublished data from the Monitoring the
Future surveys, 1976-1996.

among male African American high school students
(CDC 1996). The prevalence of previous-month
smoking among African American male high school
students increased from 14.1 percent in 1991 to 27.8
percent in 1995. Among female African American high
school students, prevalence was 11.3 percent in 1991
and 12.2 percent in 1995 (CDC 1996). Data from the
MTF surveys indicate that the prevalence of daily
smoking increased more rapidly from 1993 to 1996 for
male than for female African American high school
seniors (Figure 2) (Institute for Social Research,
University of Michigan, unpublished data from the
MTF surveys, 1976-19961. Yet even with this increase,
the prevalence of smoking among African American
high school seniors was still lower than that for
members of other racial/ethnic groups during 1990-
1994 (Table 7).

  The trend of lower smoking prevalences among
African American adolescents observed in recent years
has continued as these individuals age and become
young adults, according to the NHIS data. From 1978
through 1995, the prevalence of current smoking de-
clined more among African Americans aged 20-24 years
than among whites of the same ages, regardless of gen-
der (Table 8) or level of formal education (Table 9)
(NCHS, public use data tapes, 1978-1995). In addition,
among persons 25-29 and 30-34 years of age, recent
declines in smoking prevalence were greater for Afri-
can Americans than for whites (Table 8) (Figure 4).

  In addition to the recent increases seen among
African American high school seniors (Figures 2 and
31, the MTF surveys indicate that previous-month
smoking prevalence (based on two-year rolling aver-
ages) among eighth-grade African American students

30 Chnpfer 2


Figure 3.

35-

25-

Tobncco Use Among U.S. RncinllEtknic Minority Groups

Trends in daily smoking* among African American, Hispanic, and white high school
seniors, United States, 1977-1996

"I I I 19f9   I I I I I I I I I 19k9   I I I 19$3   I 1945   I
   1977          1981    1983    1985    1987          1991
                           Year

- African Americans         - Hispanics

mm-0 Whites

Note: To increase racial subgroup sample sizes and stabilize estimates, the percentages were calculated by
averaging the data for the specified year and the previous year.
*Daily smoking is defined as smoking one or more cigarettes per day during the previous 30 days.
Sources: Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data, 1996.

increased from 5.3 percent in 1992 to 9.6 percent in
1996; among ninth-grade African American students,
the prevalence increased from 6.6 percent in 1992 to
12.2 percent in 1996 (Johnston et al. 1996; Institute for
Social Research, University of Michigan, unpublished
data from the 1996 MTF surveys). These recent pat-
terns among African American adolescents suggest
that the progress seen among young adults (Table 8)
may reverse itself in the future.

  Possible biases. The accuracy of the finding that
African American youths have been smoking less than
white youths has been called into question. For ex-
ample, trends observed may have resulted from arti-
factual phenomena such as differential dropout rates
OT misclassification bias.

  Differrntirr2 dropout rates. Some investigators have
hypothesized that the data may be biased for two rea-
sons. First, the data from school-based surveys exclude

youths who are school dropouts. Second, because
African American youths have a higher dropout rate
than do white youths, the smoking prevalence rates
may be more biased for African American youths than
for white youths. However, this bias should only be
apparent in the school surveys. The proportion of
young adults (aged 25-29 years) who have completed
at least four years of high school increased from 74
percent in 1976 to 83 percent in 1993 for African Ameri-
cans; for whites, this proportion was 86 percent in 1976
and 87 percent in 1993 (Kominski and Adams 1994).
The increasing rate of completing at least four years of
high school among African American young adults,
relative to whites, is not consistent with the hypoth-
esis that the trend in smoking prevalence observed in
school surveys is related to the dropout rate. Further-
more, in household surveys, the trends in smok-
ing prevalence among African Americans have also

Potterm of Tobacco Use  31


Table 7.  Trends in the percentage of high school seniors who were previous-month smokers, by race/
    ethnicity and gender, Monitoring the Future surveys, United States, 1976-1979,1980-1984,
     1985-1989,1990-1994

1976-1979     1980-1984    1985-1989     1990-1994

Males
African American                  33.1        19.4        15.6         11.6
American Indian and Alaska Native      50.3        39.6        36.8        41.1
Asian American and Pacific Islander      20.7        21.5        16.8        20.6
Hispanic                        30.3        23.8        23.3        28.5
White                          35.0        27.5        29.8        33.4

Females
African American                   33.6        22.8         13.3         8.6
American Indian and Alaska Native      55.3        50.0        43.6        39.4
Asian American and Pacific Islander      24.4        16.0        14.3        13.8
Hispanic                       31.4        25.1        20.6         19.2
White                          39.1         34.2        34.0         33.1

Note: The Institute for Social Research usually reports the N (weighted), which is approximately equal to the
sample size. Cases are weighted to account for differential probability of selection and then normalized to average
1 .O. For males, the ranges of the N (weighted) for each of the cells in this table are 2,9164,393 for African
Americans, 342-587 for American Indians and Alaska Natives, 242-1,166 for Asian Americans and Pacific Islanders,
893-2,808 for Hispanics, and 24,931-31,954 for whites. For females, the ranges of the N (weighted) for each of the
cells in this table are 3,982-5,716 for African Americans, 299-586 for American Indians and Alaska Natives,
22%1,143 for Asian Americans and Pacific Islanders, 940-2,723 for Hispanics, and 25,627-31,933 for whites.
Sources: Bachman et al. 1991a; Institute for Social Research, University of Michigan, unpublished data.

become lower than those for whites (Nelson et al. 1995).
Finally, data from the 1989 TAPS have shown that Af-
rican American youths-both active students and
dropouts-are significantly less likely than white
youths to have smoked recently. Among students 17
and 18 years of age who remained in school, African
Americans (5.7 percent) were less likely than whites
(19.3 percent) to have smoked in the previous week
(CDC 1991b). Among youths who left school, 17.1
percent of African Americans and 46.1 percent of
whites had smoked in the previous week. Similarly,
1991 NHSDA data show that among youths 16-18
years old, 7.2 percent of African American high school
seniors and 27.7 percent of white high school seniors
had smoked in the previous month, compared with
30.4 percent of African American dropouts and 72.2
percent of white dropouts (Kopstein and Roth
1993). Thus, dropout status does not account for the
lower smoking prevalence among African American
youths.

  Differetltinl misclassifimtion bins. Other research-
ers have proposed that in recent years, African Ameri-
can youths may have been more likely to misclassify

their smoking status when questioned. No trend data
are available on differences in misclassification of
smoking status over time between African Americans
and whites. However, data from the 1976-1992 MTF
surveys have been used to compare the trends of high
school seniors' reports of smoking by their friends-a
measure for which they would have little reason to
underreport (Johnston et al. 1993b; USDHHS 1994).
Until 1993, the percentage of African American seniors
who reported that most or all of their friends smoke
declined substantially more than that of white seniors.
Since 1993, an increase in this measure has been ob-
served for African Americans, but not for whites
(Bachman et al. 1980a, 1980b, 1981, 1984, 1985, 1987,
1991a, 1993a, 1993b, 1997; Johnston et al. 1980a, 1980b,
1982,1984,1986,1991,1992,1993a, 1995b, 1997). This
observation may be limited by the fact that African
American and white youths have friends from several
ethnic groups.

  Bauman and Ennett (1994) recently assessed
misclassification bias in a household survey of ado-
lescents 12-14 years of age, using carbon monoxide
and salivary cotinine (a nicotine metabolite) as bioIogica1

32 Chapter 2


fi7bm~o USC Among U.S. Racial/Ethnic Minority Groups

Table 8.  Percentage of African Americans and whites 20-34 years of age who reported being current
    cigarette smokers,* by age group and gender, National Health Interview Surveys, United States,
    1978-1995 aggregate data

197&1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic             7c  +cP 7r   tc1 c/c   KI %   fCI 7%   fCI %   +CI

Aged 20-24 years
African Americans
   Total
   Men
   Women

Whites
Total
Men
Women

Aged 25-29 years
African Americans
   Total
   Men
   Women

Whites
Total
Men
Women

Aged 30-34 years
African Americans
   Total
   Men
   Women

Whites
Total
Men
Women

37.3 4.3   32.0 3.6   24.7 2.9   16.8 2.7   15.0 4.1   13.7 3.9
44.8 6.8   31.6 6.2   25.4 5.0   21.3 4.8   20.3 7.6   19.6 7.3
31.8 4.4   32.3 3.8   24.1 3.3   13.1 2.5   10.7 3.4    8.9 3.3

35.6 1.6   35.5 1.6   30.4 1.5   28.4 1.5   32.0 2.3   33.3 2.5
37.2 2.2   34.1 2.3   30.5 2.3   28.0 2.3   32.2 3.1   34.9 3.6
34.0 2.0   36.X 2.2   30.3 1.8   28.8 2.0   32.4 3.1   31.6 3.3

41.5 3.9   39.0 3.9   38.3 3.4   30.5 3.3   21.7 3.6   21.0 4.3
47.6 4.9   41.6 6.2   43.1 5.5   35.9 5.7   21.3 5.9   22.6 7.6
36.5 5.8   36.8 4.6   34.3 3.7   26.1 3.6   22.1 4.5   19.6 5.3

38.4 1.4   36.2 1.5   34.7 1.3   30.8 1.3   31.2 1.9   32.2 2.1
42.3 2.0   38.3 2.2   34.5 1.8   31.2 1.9   31.9 2.7   32.6 3.1
34.7 2.0   34.1 1.9   35.0 1.7   30.5 1.7   30.6 2.5   31.9 2.8

43.0 5.1   40.8 4.5   41.0 3.1   36.5 3.0   34.2 4.2   31.9 4.3
50.2 8.2   45.5 7.1   43.6 5.1   38.9 4.8   38.3 6.9   31.2 6.8
37.5 6.0   37.1 4.6   38.9 3.6   34.5 3.6   30.8 4.9   32.5 5.7

38.6 1.8   34.4 1.5   33.1 1.3   31.1 1.2   32.9 1.7   30.7 1.8
43.1 2.5   37.3 2.2   35.9 1.8   32.7 1.7   33.1 2.4   31.3 2.6
34.2 2.3   31.5 1.9   30.4 1.6   29.6 1.5   32.7 2.2   30.2 2.6

                                  -                                           -
*For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their
lives and who reported at the time of 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.
$95oic confidence interval.

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

markers for tobacco use. Among adolescents who re-   white adolescents were three times more likely than
ported that they did not smoke, African Americans   African American adolescents to test positive for car-
were more likely than whites to test positive for car-   bon monoxide, suggesting that whites in this study
bon monoxide and for cotinine. Overall, however,   were substantially more likely to smoke, regardless of

Przttrrm of Tobacco Use  33


Table 9.  Percentage of African Americans and whites 20-24 years of age who reported being current
    cigarette smokers,* by education and gender, National Health Interview Surveys, United States,
    1978-1995 aggregate data

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

Characteristic

%  +_c1t 7c   +c1 %   +c1 %   +c1 %   +c1 Yo   K-1

212 years' education
African Americans
  Total
  Men
  Women

Whites
  Total
  Men
  Women

41.9  5.2
49.1  7.9
35.9  6.3



45.2  1.8
47.8  2.8
42.7  2.6

213 years' education
African Americans
  Total
  Men
  Women

Whites
  Total
  Men
  Women

26.4  6.4
32.0  11.3
23.5  6.7



21.6  2.0
22.0  2.5
21.2  2.5

38.6 4.5   30.4 3.7   22.8 3.9   18.5 5.4   16.7 5.4
38.2 7.7   29.6 6.3   28.9 6.9   21.9 9.4   22.2 10.1
38.9 4.9   31.0 4.5   17.8 3.5   15.2 5.1   12.5 5.0

48.3 2.3   44.2 2.1   40.5 2.4   46.9 3.2   45.4 4.2
47.8 3.5   46.2 3.2   40.5 3.4   47.5 4.8   47.1 5.8
48.7 2.9   42.3 2.8   40.5 3.1   46.4 4.5   43.6 5.6

17.3 4.4   12.4 3.7    7.2 2.9    9.0 5.3    9.3 5.6
15.6 7.9   13.3 7.0    9.2 5.3   16.6 12.4   15.9 10.6
18.5 6.6   11.9 4.0    5.5 3.0    4.6 4.0    3.1 3.0

18.2 1.8   15.4 1.5   16.0 1.5   19.0 2.6   23.6 2.8
15.8 2.4   14.0 2.0   14.5 2.4   17.6 3.5   24.6 4.2
20.5 2.6   16.7 2.1    17.3 2.1   20.3 3.5   22.7 3.8

-

*For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their
lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers
include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of
survey that they currently smoked every day or on some days.
`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.

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

differential misclassification. In a study of young   reports of cigarette smoking with measured carbon
adults 18-30 years old, Wagenknecht and colleagues   monoxide from expired air. The investigators found
(1992) also found differential misclassification, with   that the sensitivity for self-reports was slightly lower
African Americans (5.7 percent) more likely than   for African Americans than for whites, but the magni-
whites (2.8 percent) to misclassify themselves as non-   tude of the effect was small. When self-reported smok-
smokers. However, these researchers suggested that   ing rates were adjusted for carbon monoxide values,
their results may have been influenced by differential   at every grade level African American students had
exposure to environmental tobacco smoke and by dif-   significantly lower smoking prevalences than whites.
ferences in nicotine metabolism. Using a sample of   Although the phenomenon of differential mis-
seventh- through tenth-grade New York State public   classification may need further investigation, no evi-
school students, Wills and Cleary (1997) compared self-   dence indicates that misclassification bias explains the

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

Figure 4. Trends in smoking* among African Americans and whites aged 20-34 years, United States,
       1978-1995

African Americans

0    I   III   II   `1   11 11   1   "  1 ""I"""""
1978-80              1983-85       1987-88 1990-91 1992-93 1994-95

Year

Whites

lo-

0   III'1 II I I ' l `1 " " ""J""""'
1978-80              1983-85        1987-88       1990-91   1992-93   1994-95

                             Year

a 8 m a  Aged 20-24      - Aged 25-29      - Aged 30-34

*For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in
their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current
smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the
time of survey that they currently smoked every day or on some days.
Source: National Health Interview Surveys, National Center for Health Statistics, public use data tapes,
1978-1995; see Table 8 for corresponding data.

Patterns of Tobacco Use  35


substantial decline in smoking prevalence reported by
African American youths.

  Possible behavioral, sociodemographic, and
attitudinal explanations. Exploring possible interac-
tions between the use of alcohol or other drugs and
changes in cigarette smoking among African American
and white adolescents may yield important scientific
data. Understanding the trends of smoking behavior
in the context of factors such as the age when youths
start smoking, background and lifestyle factors, and
attitudes about smoking may help program develop-
ers design better smoking prevention and control in-
terventions for these and other population subgroups.

  Differelztinl 115~ of dwr drugs. MTF data were ana-
lyzed to explore possible interactions between the use
of alcohol or other drugs and changes in cigarette
smoking among African American and white adoles-
cents (Table 10) (Figures 5 and 6) (Institute for Social
Research, University of Michigan, public use data
tapes, 1976-1994). Between 1976 and 1994, the per-
centage of African American adolescents who were
abstinent from (i.e., did not use in the previous month)
both cigarettes and other substances (Table 10) was
higher than for whites and tended to increase more
rapidly for African Americans than for whites in ev-
ery category of drug use. For example, 41.7 percent of
African American high school seniors surveyed in
1976-1979 were abstinent from cigarettes and alcohol,
compared with 64.1 percent in 1990-1994. Among
white seniors, 22.4 percent were abstinent from both
cigarettes and alcohol in 1976-1979, compared with
37.1 percent in 1990-1994. Concurrent use (i.e., use of
both substances in the past month) was lower and
tended to decrease more rapidly among African Ameri-
can seniors than among white seniors between 1976
and 1994. In addition, trends in the use of cigarettes,
alcohol, and other substances among high school se-
niors indicate that among both smokers and nonsmok-
ers, African Americans were generally less likely than
whites to use substances other than tobacco (Table 10).

  Age qfsnrokillg illitinfim. African American smok-
ers initiate smoking at slightly later ages than white
smokers, according to the findings of two national
studies (Escobedo et al. 1990; CDC 1991~). In addi-
tion, data from the 1994-1995 (combined) NHSDAs
indicate that among U.S. adults aged 30-39 years who
had ever smoked daily, the average ages for first try-
ing a cigarette and for becoming a daily smoker were
about one year higher for African American males than
for white males and about two years higher for African
American females than for white females (Table 11)
(USDHHS, Substance Abuse and Mental Health Services
Administration, public use data tapes, 1994-1995).

  These differences in the age of smoking initia-
tion are not large enough to suggest that the differ-
ences in smoking prevalence currently observed
among African American and white adolescents will
disappear as these populations age (CDC 1991~). The
data presented in Table 11 and by Escobedo and col-
leagues (1990) indicate that although African Ameri-
cans are more likely than whites to begin smoking in
their early 2Os, virtually all smokers in both groups
have begun by age 25. Furthermore, the prevalence
of cigarette smoking has decreased more rapidly
for African Americans than for whites among those
persons aged 20-24 years, 25-29 years, and 30-34
years (Table 8), suggesting that a birth cohort effect
has occurred.

  Backpourzd nnd lifestyle frzctnrs. Investigations of
background and lifestyle factors have not identified
characteristics that might account for the greater de-
cline in smoking among African American youths.
Wallace and Bachman (1991) analyzed the MTF data
and found that the difference was not explained
by factors such as parents' education, presence of
two parents in the household, location of residence,
college plans, academic performance, employment
status, religiousness, or political views. To assess the
incidence of cigarette smoking among African Ameri-
can and white adolescents, Faulkner and colleagues
(1996) analyzed longitudinal data from the 1989-1993
TAPS. The analvses were restricted to 3,531 African
Americans and whites aged 11-17 years who reported
in 1989 that they had never tried cigarettes. After
controlling statistically for variables that were
snciodemographic (sex, age, and parental education),
environmental (household smoking and number of
same-sex friends who smoke), personal (beliefs about
the perceived benefits of smoking), and behavioral (in-
tention to smoke, participation in organized physical
activity, and academic performance), the study found
that African Americans were significantly less likely
than whites to have tried cigarette smoking four years
later.

  Lowry and colleagues (1996) analyzed cross-
sectional data on 6,321 adolescents (aged 12-l 7 years)
from the YRBS supplement to the 1992 NHIS. African
Americans were significantly less likely than whites
to have smoked in the previous 30 days. This analysis
controlled statistically for the educational level of the
responsible adult, for family income, for the age and
sex of the adolescent, and for whether the adolescent
was in or out of school.

  Furthermore, the major declines in smoking
reported for African American high school seniors
have occurred regardless of parents' education; the

36 Clmpfcr 2

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

Table 10.  Percentage of African American and white high school seniors who reported recently using or
     not using cigarettes and other selected substances,* Monitoring the Future surveys, United
     States, 19761994 aggregate data

Cigarette use among African Americans+

Characteristic

1976-1979        1980-1984        1985-1989        1990-1994

Yes     No     Yes     No     Yes     No     Yes     No

Alcohol use
Yes
No

Marijuana use
Yes
No

Cocaine use
Yes
No

Any illicit drug use*
Yes
No

22.7     25.9     15.2     31.2     11.0     29.5      7.2     26.2
9.7     41.7     5.3     48.4      3.1     56.4      2.6     64.1

17.2     11.9     11.2     14.2     6.4      7.8      3.1      5.8
15.0     55.9     9.3     65.3      7.6     78.2      6.6     84.5

1.4      0.6      1.4      1.3      1.0      1.0      0.3      0.2
31.7     66.3     19.7     77.6     13.3     84.8      9.6     89.8

17.6     12.9     11.4     15.2      6.6     9.3     3.3     6.8
14.0     55.5     8.8     64.6      7.0     77.1      6.2     83.7

Cigarette use among whites5

Characteristic

1976-1979

Yes     No

1980-1984

Yes     No

1985-1989

Yes     No

1990-1994

Yes     No

Alcohol use
Yes
No

33.7     40.5     28.2     46.0     28.6     40.9     27.5     29.7
3.3     22.4      2.7     23.1      3.6     26.8      5.7     37.1

Marijuana use
Yes
No

22.4     13.7     16.9     12.8     14.4      8.1     11.8      4.4
14.3     49.6     13.8     56.5     17.5     60.0     21.3     62.5

Cocaine use
Yes
No

2.6      1.1      3.5      2.0      3.4      1.4      1.2      0.2
34.3     62.0     27.3     67.2     28.5     66.6     31.9     66.7

Any illicit drug uset
Yes
No

23.3     14.8     18.9     15.5     16.1     10.0     13.3     5.9
13.3     48.6     11.7     53.9     15.7     58.3     19.6     61.2

*Refers to use of these substances in the last 30 days.
`Entries are percentages of the entire African American high school senior population.
$Any illicit drug use includes any use of marijuana, hallucinogens, cocaine, or heroin or any use of other
opiates, stimulants, barbiturates, methaqualone, or tranquilizers not under a physician's orders. Methaqua-
lone is excluded from the definition of illicit drugs for the 1990-1994 survey data.
gEntries ar e p ercentages of the entire white high school senior population.
Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data tapes,
1976-1994.

Patterns of Tobacco Use  37


Surgeon General's Reporf

Figure 5.  Use of cigarettes and alcohol* among African American and white high school seniors,
     United States, 1976-1979 and 1990-1994

1976-1979

African
Americans

1   1 but no alcohol

Whites

Neither

*In the previous month.
Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data
tapes, 1976-1994; see Table 10 for corresponding data.

respondent's personal income; school performance; the
importance of religion to the respondent; geographic
region of residence; and, except for those who were
raised on a farm, the locale in which the respondent
grew up (Table 12) (Institute for Social Research, Uni-
versity of Michigan, public use data tapes, 1976-1994).

  Attitudes about smoking. One possible explana-
tion is that the attractiveness (or functional zdue) of
cigarette smoking has decreased more rapidly among
African American high school seniors than among
white seniors. For example, African American seniors
have, over time, become increasingly more likely than

white seniors to acknowledge the health risks of ciga-
rette smoking, to claim that smoking is a dirty habit,
and to claim that they prefer to date nonsmokers. From
1976 through 1989, African Americans were more likely
than whites to disagree with the statement, "I person-
ally don't mind being around people who are smok-
ing" (USDHHS 1994).

  African American youths also have been less
likely than white youths to believe that cigarette smok-
ing helps control weight. In anonymous surveys
of 659 students (with an average age of 16 years)
from two racially integrated high schools in the area

38 Chapter 2


Tobacco Use Among U.S. RaciallEfhnic Minority Groups

Figure 6.  Use of cigarettes and illicit drugs" among African American and white high school seniors,
     United States, 1976-1979 and 1990-1994

) 1 no illicit drugs

No cigarettes
but illicit drugs

Neither

Whites

*In the previous month.
Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data
tapes, 1976-1994; see Table 10 for corresponding data.

of Memphis, Tennessee, 46 percent of white females,
30 percent of white males, 10 percent of African Ameri-
can females, and 14 percent of African American males
endorsed the statement, "Smoking cigarettes can help
you control your weight/appetite" (Camp et al. 1993).
When respondents who smoked at least once a week
were asked whether they had smoked to control their
weight, 61 percent of the white girls and 16 percent of
the white boys said that they had smoked to control
their weight, whereas none of the African American
smokers reported that they smoked to control their
weight. Further research is needed to delineate the

role of weight control concerns in patterns of cigarette
smoking initiation among adolescents of ethnic groups.
One recent study suggests that African American ado-
lescent females prefer a significantly heavier ideal body
size than white adolescent females (Parnell et al. 1996),
a finding consistent with the notion that the potential
weight-controlling effects of cigarettes have less func-
tional utility among young African American females
than among white females.

  A previous Surgeon General's report indica-
ted that parental concern about whether an adoles-
cent smoked appeared to decrease the risk of that

Patterns of Tobacco Use  39


Surgeon Gerzeml `s Report

Table 11. Cumulative percentages of recalled age at which a respondent first tried a cigarette and began
    smoking daily, among African American, Hispanic, and white men and women aged 30-39,
    National Household Surveys on Drug Abuse, United States, 1994-1995

All men*

Age
(years)

    First tried a cigarette          Began smoking daily

African                     African
American   Hispanic     White    American   Hispanic     White

<12                 7.0       9.2       14.9        1.4        1.4       1.3
<14                  17.1       20.6       32.2        3.7        4.6       4.6
<16                  34.8       39.0       51.0       10.9       11.2       11.8
48                 55.1       54.7       68.7      20.3       19.6      26.4
<19                 59.9       62.7       74.0       25.5       26.3      34.3
<20                  64.6       65.5       76.1       28.6       28.4       38.5
<25                  71.5       72.9       80.9       40.5       37.2      47.4
<30                 74.3       76.4       81.7       44.6       42.5      48.8
539                 75.1       76.7       82.5       45.1       43.4       49.9
Mean age               NA       NA        NA       NA       NA       NA

All women+

Age
(years)

<12
<14
<16
418
<19
<20
<25
<30
139
Mean age

   First tried a cigarette          Began smoking daily

African                      African
American   Hispanic     White    American   Hispanic     White


  4.6        3.5        7.8        0.6        0.2       0.8
  13.3       11.3       27.7        2.5        2.0       5.3
  25.7      22.5       49.4       5.9        5.6       15.8
  43.9       33.9       67.5       15.9        9.5      30.0
  52.3       40.7       73.2       21.7       14.3       38.6
  55.8       43.0       75.7       24.0       15.5       41.6
  66.1       51.4       80.3       33.7       21.8      49.2
68.3       55.8       81.4       37.0       25.7      51.0
69.3       57.4       82.0       38.1       26.7      51.4
  NA       NA        NA       NA       NA       NA

*N = 3,536
+N = 5,143
NA = data not available.

adolescent becoming a cigarette smoker (USDHHS
1994). In a study conducted in Los Angeles and San
Diego in 1986, African American parents placed a
higher value than white parents on becoming involved
in preventing their children from beginning to smoke
(Flay et al. 1988; Koepke et al. 1990). Data from two
surveys conducted in eight U.S. communities in 1988
and 1989 indicate that African American adults were
more likely than white adults to perceive cigarette

smoking as a very serious health problem in their com-
munity, to favor eliminating vending machines from
places where teenagers gather, and to prohibit smok-
ing in their car (Royce et al. 1993).

  More recent findings from focus groups con-
ducted at several U.S. sites suggest that African Ameri-
can parents may be more likely than white parents to
express clear antismoking messages (McIntosh 1995;
Mermelstein et al. 1996). Findings from these focus

40 Chapter 2

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

Men who had ever smoked dailv

   First tried a cigarette          Began smoking daily

African                     African
American   Hispanic     White    American   Hispanic    White

8.9
22.7
45.7
73.7
81.1
87.0
96.1
99.9
100.0
15.9

13.6
29.7
55.4
74.1
83.4
86.9
97.0
99.6
100.0
15.3

15.7       3.0        3.2       2.7
36.7       8.3       10.6       9.2
61.0       24.2       25.7      23.7
83.9       45.0       45.1       52.9
90.5       56.4       60.7      68.8
93.0       63.5       65.4       77.1
98.4       89.7       85.7      95.1
98.9       98.9       97.9       97.7
100.0      100.0       100.0      100.0
14.6       18.4       18.6       17.6

Women who had ever smoked daily

   First tried a cigarette          Began smoking daily

African                      African
American   Hispanic     White    American   Hispanic    White

5.9       6.9        8.9        1.6        0.7       1.6
20.1       25.4       37.8        6.7        7.6       10.3
38.6       48.7       66.1       15.5       21.1       30.7
66.8       68.6       85.9       41.8       35.4       58.3
77.2       78.2       92.0       57.0       53.4       75.0
81.4       80.8       94.4       62.9       58.0      80.8
96.0      94.5       99.2       88.4       81.8      95.6
99.6      99.2       99.9       97.2       96.4       99.2
100.0      100.0       100.0      100.0      100.0      100.0
16.6       16.2        14.6       18.9       19.5       17.1

Source: Substance Abuse and Mental Health Services Administration, public use
data tapes, 1994-1995.

groups also suggest that smoking by African Ameri-
can adolescents may be a sign of disrespect toward
parents (USDHHS 1994). Additionally, African Ameri-
can adolescent females appear to perceive that absti-
nence from smoking enhances their image, whereas
white girls are more likely to perceive that smoking
empowers them (perhaps because of themes expressed
in cigarette advertising) (Mermelstein et al. 1996). The
responses of African American community leaders,

including that of former USDHHS Secretary Louis
Sullivan, against cigarette marketing campaigns that
appear to target African Americans may have influ-
enced young people's attitudes and behaviors about
smoking (McIntosh 1995).

   Further research is needed to better under-
stand the large decreases in smoking prevalence
that occurred among African American youth in
the 1970s and 1980s. Research is also needed to better

Patterns of Tobacco USC  42


Surgrun General's Report

Table 12. Percentage of African American and white high school seniors who reported previous-month and
    heavy* smoking, by selected variables, Monitoring the Future surveys, United States, 1976-1994

Previous-month smoking (%)

Characteristic

  1976-1979        1980-1984        1985-1989        1990-1994

African        African        African         African
Americans Whites Americans Whites Americans Whites Americans Whites

Parental education
Less than high school
High school
Some college
College
Some postgraduate
study

Personal income+
Low
Medium
High
Very high

School performance
Far above average
Slightly above average
Average
Below average

Importance of religion
Very important
Important
Not/somewhat
important

Region
Northeast
North Central
South
West

34.0     42.0     23.2     36.8     13.9     37.6     11.8     37.6
35.3     39.5     21.2     34.1     14.1     34.8     10.7     34.8
30.9     35.0     20.7     29.2     16.0     31.3      9.4     32.5
29.4     32.4     18.3     26.7     13.3     29.1      9.3     32.4
30.1     31.2     21.9     23.7     14.7     28.3      9.8     31.7

NA     NA     16.4     24.5     12.6     24.6      7.5     24.6
NA     NA     19.4     30.5     14.9     28.8      9.4     29.7
NA     NA     22.8     33.3     14.1     34.5      9.8     35.5
NA     NA     23.4     37.8     16.5     39.8     12.4     41.3

25.9     25.8     16.2     21.0     11.4     23.0      8.0     24.6
31.2     35.8     20.2     29.6     12.7     30.7      8.4     32.2
34.4     45.3     22.5     38.5     15.3     38.9     10.6     39.4
40.0     52.4     28.0     44.1     20.5     46.7     17.6     48.3

29.3     25.0     19.1     21.9     11.4     21.9      8.2     22.1
34.1     38.9     23.4     32.4     16.7     32.0     11.5     33.7
40.0     43.0     23.5     35.2     18.3     36.8     12.4     38.5

37.1     40.4     25.7     33.5     18.1     34.9     10.9     34.9
34.8     38.9     20.3     32.8     16.0     34.6     10.1     35.5
32.6     37.7     20.6     31.7     12.7     31.1     10.1     33.6
29.1     25.8     20.2     21.3     17.8     26.0      8.0     26.6

Locale in which respondent
grew up
Farm               33.6
Country            35.5
Small city           28.5
Medium-sized city      31.5
Suburb of medium-     34.5
sized city
Large or very large city   36.2
Suburb of large or      34.1
very large city

37.9     24.9     31.6     26.7     33.0     22.3     31.9
38.3     23.3     30.7     14.6     33.1     12.2     32.2
37.4     20.0     30.1     14.1     31.1     12.1     32.6
37.4     20.1     31.2     14.5     32.3      8.7     34.7
36.9     18.5     32.0     16.5     32.0     6.8     34.7

38.5     22.3     32.0     13.9     33.4      8.5     33.6
32.7     20.0     29.1     14.0     30.2     9.0     33.8

*Heavy cigarette smoking is 10 or more cigarettes smoked per day reported at time of survey.
`Personal income is the sum of income from employment, allowance, and other sources. Trend data are available
for 1982-1994 only.
NA = data not available.

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

Heavy cigarette smoking (%I

  1976-1979        1980-1984        1985-1989        1990-1994

African         African         African         African
Americans Whites Americans Whites Americans Whites Americans Whites

9.3     24.0      6.2     21.5      3.0     21.3      2.7     19.1
10.8     21.6      4.6     17.4      2.4     15.7      1.6     15.9
9.1     17.4      4.8     13.1      3.3     12.3      1.4     12.6
7.2     14.9      3.5     10.3      2.4      9.5      1.6     11.6
9.1     14.8     5.3      9.0      4.1      8.3      1.2      9.8

NA     NA      3.1     10.1      2.2      8.7      1.1      8.0
NA     NA      3.4     12.5      3.0      9.2      1.7      9.1
NA      NA      6.1     16.3      2.4     14.2      1.2     13.5
NA     NA      6.9     20.7      3.3     19.8      2.3     20.1

7.6     10.6      3.7      8.1      3.0      7.1      1.5      7.1
8.4     17.7      4.1     12.8      2.0     11.2      1.2     11.3
10.2     25.9      5.2     20.2      2.7     17.5      1.5     17.3
11.7     33.5      7.2     26.1      5.1     25.4      4.4     26.0

8.5     10.4      4.0      8.7      2.1      7.3      1.2      7.5
9.4     19.1      5.7     14.5      3.1     12.0      1.9     11.9
12.8     25.0      6.0     18.6      3.9     16.3      2.4     16.5

12.2     23.2      6.3     17.4      4.7     16.6      2.1     14.4
11.1     19.3      5.3     16.0      3.0     13.8      1.9     13.9
9.2     19.5      4.7     14.8      2.1     12.4      1.6     13.8
7.4     12.5      4.2      7.9      3.3      8.4      1.1      8.8

9.9     16.4      5.4     12.3      8.1     12.2      5.1     12.2
10.0     20.2      5.1     14.9      2.9     13.7      1.5     13.1
8.7     19.0      4.5     13.7      2.7     12.2      2.8     12.5
9.4     20.2      4.9     15.4      2.2     13.1      1.3     13.4
9.0     20.6      4.0     15.2      2.8     12.6      1.1     12.7

10.8     22.9      5.4     16.5      2.3     14.9      1.2     14.0
9.3     16.4      3.8     14.0      3.7     11.0      1.2     12.2

Source: Institute for Social Research, University of Michigan, public use data tapes, 1976-1994.

Patterm of Tobacco Use  43


Surgeon Gerzeral's Reyort

understand the reasons for the increase in prevalence
that occurred in the early 1990s (Figures 2 and 3) (CDC
1996).

  Other risk behaviors. The Surgeon General's re-
port Preventing Tobacco Use Among Young Peo,vle
(USDHHS 1994) has concluded that "Tobacco use
in adolescence is associated with a range of health-
compromising behaviors, including being involved in
fights, carrying weapons, engaging in higher-risk
sexual behavior, and using alcohol and other drugs"
(p. 9). Escobedo and colleagues (1997) have observed
these associations for African American adolescent
males and females. Using data from the YRBS supple-
ment of the 1992 NHIS, the researchers found that af-
ter their analysis controlled statistically for age,
ethnicity, sex, parental educational level, region of the
country, and other risk behaviors, marijuana use, binge
drinking, and physical fighting were significantly as-
sociated with cigarette smoking among African Ameri-
can adolescent males and females. Focus group data
suggest that African American youths are more likely
than white youths to pair cigarette smoking with mari-
juana use as a way to maintain and enhance the drug
effects of each (Mermelstein et al. 1996).

Smokeless Tobacco Use

  The prevalence of smokeless tobacco use among
African American adolescents has remained fairly
constant in recent years. According to the MTF sur-
veys, previous-month smokeless tobacco use (based
on two-year rolling averages) was reported by 1.8
percent of eighth-grade African American students in
1992 and 2.2 percent in 1996; among tenth-grade
students, the prevalence was 2.9 percent in 1992 and
2.5 percent in 1996; and among high school seniors,
the prevalence was 2.1 percent in 1987 and 2.7 per-
cent in 1996 (Johnston et al. 1996; Institute for Social
Research, University of Michigan, unpublished data
from the 1996 MTF surveys). Similarly, the YRBS data
indicate that 2.1 percent of African American high
school students were current smokeless tobacco us-
ers in 1991 (USDHHS 1994), and 2.2 percent were so
in 1995 (CDC 1996).

   African American adolescent males are substan-
tially less likely than white adolescent males to use
smokeless tobacco. Among male high school students
participating in the 1995 YRBS, for example, 3.5 percent
of African Americans and 25.1 percent of whites reported
that they had used smokeless tobacco in the previous
month (CDC 1996). Among females, 1.1 percent of Afri-
can Americans and 2.5 percent of whites reported they
had used smokeless tobacco in the previous month.

American Indians and Alaska Natives

  Data assessing long-term trends in tobacco use
among American Indians and Alaska Natives have
been unavailable, for the most part, because national
surveys and databases have only recently begun to
identify persons of American Indian or Alaska Native
ancestry. Studies using data from regional surveys or
data on specific American Indian tribes have, however,
provided useful information about tobacco use among
members of these groups. Because the geographic
location of American Indian and Alaska Native people
reflects unique cultural and historical experiences,
researchers should consider these differences when
interpreting region-specific data about smoking preva-
lence. Data from regional studies also may provide
information that is useful in developing culturally
appropriate tobacco control efforts.

  National surveys provide limited capability to
assess the level of tobacco use and the effectiveness of
tobacco control efforts among American Indians and
Alaska Natives. The NHIS, for example, did not be-
gin identifying American Indian and Alaska Native
respondents until 1978. Because American Indians and
Alaska Natives make up a small proportion of the U.S.
population, data must be aggregated from several
years to provide meaningful estimates.

  Also noteworthy is that the data on tobacco use
among American Indians and Alaska Natives include
some ceremonial use (e.g., in pipes) in addition to daily
addictive behavior (see Chapter 4). Anecdotal infor-
mation also suggests that standard definitions and
classifications of smoking may not accurately reflect
smoking habits among American Indians, some of
whom may smoke no more than one or two cigarettes
per day (Nathaniel Cobb, personal communication,
1994; Roscoe et al. 1995). Yet American Indians who
smoke a few cigarettes every day are classified in the
<15-cigarettes-per-day category, which may imply a
higher overall consumption than actually exists. Such
differences in amounts of daily smoking may have
important implications for the design of culturally ap-
propriate smoking cessation interventions targeting
American Indians.

Prevalence of Cigarette Smoking

  Among American Indian and Alaska Native men
and women, rates of smoking have been substantially
higher than smoking rates in any other U.S. subgroup.
In the 1987 Survey of American Indians and Alaska
Natives (SAIAN) of the National Medical Expenditure
Survey, 32.8 percent of respondents reported being

44 Chapter 2


current smokers (Lefkowitz and Underwood 1991).
This survey-the only nationally representative
sample designed to assess the health practices of
people of American Indian and Alaska Native ances-
try-targets people who live on or near reservations
and who are eligible for services provided by the In-
dian Health Service (IHS). The NHIS rate of smoking
among American Indians and Alaska Natives for 1987
and 1988 (39.2 percent) was greater than the SAIAN
estimate, perhaps because of different modes of
administration and sampling (tribally enrolled benefi-
ciaries in the SAIAN and the general population of
American Indians and Alaska Natives in the NHIS).

  In a more recent survey<onducted on reserva-
tions between 1989 and 1992 and involving 4,549 Ameri-
can Indians 45-74 years old in 13 tribes in Arizona, North
Dakota, South Dakota, and southeastern Oklahoma-the
prevalence of cigarette smoking was higher in nearly all
American Indian groups (40.5 percent for men and 29.3
percent for women) than in the general U.S. population,
but wide variation was notable (Welty et al. 1995). ln
this study, known as the Strong Heart Study, the smok-
ing prevalence was highest in North Dakota and South
Dakota (53.1 percent for men and 45.3 percent for women)
and lowest in Arizona (29.7 percent for men and 12.9
percent for women).

  According to the NHIS data, the overall preva-
lence of cigarette smoking among American Indians
and Alaska Natives was 48.2 percent in 1978-1980 and
39.2 percent in 1994-1995. Although the data are im-
precise, they suggest a substantial drop in prevalence
for men from 1978-1980 to 1983-1985 (Table 13)
(NCHS, public use data tapes, 1978-1995). However,
no progress for men was observed from 1983-1985 to
1994-1995 and, for women, no progress was observed
from 1978-1980 to 1994-1995.

   Another major source of data on smoking pat-
terns among American Indians and Alaska Natives is the
BRFSS, which, for these analyses, included data collected
in 47 states and the District of Columbia (CDC 1992a).
The BRFSS data for 1987-1991 show that among Ameri-
can Indians and Alaska Natives, 33.4 percent of men and
26.6 percent of women reported that they were current
smokers. The 95 percent confidence intervals associated
with smoking rates overlap between American Indian
and Alaska Native women and men in both surveys,
Even though data were aggregated for several years, the
small sample sizes of American Indians and Alaska Na-
tives in both surveys produced imprecise estimates that
make it impossible to determine whether the prevalence
of smoking actually differed between men and women.

The prevalence of smoking among American
Indian and Alaska Native women in the NHIS (35.2

percent in 1987-1988 and 37.2 percent in 1990-1991)
differed substantially from the prevalence found in the
1987-1991 BRFSS (26.6 percent). Similarly, the preva-
lence of smoking among American Indian and Alaska
Native men in the NHIS (43.5 percent in 1987-1988 and
32.9 percent in 1990-1991) differed appreciably from
the prevalence found for men in the 1987-1991 BRFSS
(33.4 percent). Methodological differences between the
surveys may explain these differences. Household,
face-to-face interviews were conducted for the NHIS,
whereas telephone interviews were performed for the
BRFSS (Goldberg et al. 1991; Sugarman et al. 1992;
Leonard et al. 1993). Because telephone coverage in
the areas where American Indians and Alaska Natives
live tends to be lower than in areas where other ethnic
groups live (Goldberg et al. 1991; Sugarman et al. 19921,
sometimes as low as 60.4 percent of households (U.S.
Bureau of the Census 19941, American Indians and
Alaska Natives probably were less likely than others
to have been included in the BRFSS surveys. More-
over, because telephone service requires financial abil-
ity to pay, persons of higher socioeconomic status may
ha\Te been more likely than other persons to be in-
cluded in the BRFSS surveys (Thornberry and Massey
1988). Thus, the BRFSS may have yielded lower smok-
ing rates than the NHIS because the BRFSS surveys
selected more affluent respondents, who were less
likely than others to smoke.

  Estimated rates and trends in cigarette smoking
were not significantly related to educational attain-
ment, according to NHIS (Table 13) and SAIAN data.
However, both surveys suffered from imprecision be-
cause of small sample sizes.

Number of Cigarettes Smoked Daily

   NHIS data for 1978-1995 show few variations
over time in the number of cigarettes smoked per day
among American Indian and Alaska Native smokers
(Table 14) (NCHS, public use data tapes, 1978-1995).
In the years 1978-1980, 39.9 percent of American In-
dian and Alaska Native smokers reported smoking
fewer than 15 cigarettes per day, and 25.2 percent re-
ported smoking 25 or more cigarettes per day. By 1994-
1995, the proportion of American Indian and Alaska
Native smokers who smoked fewer than 15 cigarettes
per day was 49.9 percent, whereas the proportion who
smoked 25 or more cigarettes per day was 17.0 per-
cent. Data from the Strong Heart Study showed that
American Indian smokers reported smoking fewer
cigarettes per day (range of 6.1 among women in Ari-
zona to 15.0 among men in North Dakota and South
Dakota) than the national average (Welty et al. 1995).

Pattrrlls of Tobacco Use  45


Surgeon General's Report

Table 13.  Percentage of American Indian and Alaska Native adults who reported being current cigarette
     smokers,* overall and by gender, age, and education, National Health Interview Surveys, United
     States, 1978-1995 aggregate data

1978-1980) 1983-1985+ 1987-1988+ 199&1991+ 1992-1993+ 1994-1995+

Characteristic


Total

Gender
Men
Women

Age (years)
18-34
35-54
255
Educations
Less than high school
High school graduate/
any college

%  fCI$ %   fC1 %   fC1 %   KI %   +c1 %   fC1


48.2 5.8 35.6 8.0   39.2 5.9 35.0 6.9   39.1 5.1 39.2 7.3



63.0 11.0 41.4 12.9   43.5 9.3 32.9 7.1   37.5 9.3 45.4 13.1
34.1 10.1 32.3 8.8   35.2 6.2 37.2 9.1   40.3 8.6 34.2 8.7



53.3 9.2 39.9 13.6   38.1 7.1 36.1 9.3   41.3 8.7 48.0 11.1
53.5 11.0 36.7 12.1   47.4 8.0 40.2 7.0   45.1 8.4 42.9 11.3
33.4 15.1 24.7 11.3   29.2 10.7 23.4 14.9   22.3 9.3 10.5 8.9



49.9 8.8 28.7 11.3   42.5 8.3 33.4 8.9   42.6 12.3 44.1 14.2
35.0 11.5 36.7 10.2   35.7 6.7 35.4 7.9   37.9 7.4 33.5 7.8

*Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978-1991,
current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who
reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons
who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they
currently smoked every day or on some days.
`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
$95% confidence interval.
SIndudes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

In the years 1978-1980, American Indian and Alaska
Native men were more likely than women to smoke
25 or more cigarettes per day (Table 14). Since 1980,
however, the proportion of men smoking 25 or more
cigarettes per day has decIined.

  Cigarette consumption data from the BRFSS and
the NHIS cannot be compared directly because the
BRFSS data are for the mean number of cigarettes
smoked daily (CDC 1992a). However, both sources of
data indicate that the number of cigarettes smoked is
slightly greater among older than among younger
American Indians and Alaska Natives.

Quitting Behavior

  State and regional surveys also indicate that the
prevalence of smoking cessation remains relatively low
among American Indian and Alaska Native smokers
compared with smokers in other racial/ethnic groups

(Goldberg et al. 1991; Lando et al. 1992). In the past 17
years, the percentage of American Indians and Alaska
Natives who have ever smoked 100 cigarettes and have
quit smoking has changed only slightly overall; NHIS
data indicate that the prevalence of cessation was 31.6
percent in 1978-1980 and 32.9 percent in 1994-1995
(Table 15) (NCHS, public use data tapes, 1978-1993).
During this period, the prevalence of smoking cessa-
tion fluctuated substantially for both genders, with
similar estimates reported for 1978-1980 and 199P
1995. The prevalence of smoking cessation among
American Indians and Alaska Natives has increased
with increasing age: those aged 18-34 years have had
the lowest prevalence of cessation, those aged 35-54
years have had intermediate proportions, and those
aged 55 years and older have had the highest preva-
lence of cessation. The prevalence of cessation in-
creased among older American Indians and Alaska
Natives; however, no progress occurred among those

46 Chapter 2


Tobacco USP Among U.S. Rncinl/Efhnic Minority Groups

Table 14.  Percentage of adult American Indian and Alaska Native 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  ICP %   +c1 %   fC1 %   +a %   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
< 15 cigarettes
  15-24 cigarettes
225 cigarettes
35-54
< 15 cigarettes
  15-24 cigarettes
225 cigarettes

255
< 15 cigarettes
  15-24 cigarettes
225 cigarettes
Education_
Less than high school
< 15 cigarettes
  15-24 cigarettes
225 cigarettes
High school/any college
< 15 cigarettes
  15-24 cigarettes
225 cigarettes

39.9 10.2   38.2 12.5   33.7 7.5   46.3 7.3   50.0 11.9   49.9 14.6
34.9 9.5   48.5 12.5   45.8 7.6   34.7 8.2   32.6 9.3   33.0 12.7
25.2 9.2   13.3 9.6   20.6 5.3   19.1 6.7   17.4 8.8   17.0 8.3

35.8 12.7   22.7 15.2   20.9 10.4   35.5 10.2   38.7 15.9   36.2 28.1
31.8 12.7   63.6 17.8   53.8 11.6   44.9 14.9   39.8 15.6   42.1 23.1
32.3 14.8   13.7 12.1    25.4 8.7   19.7 10.6   21.5 12.0   21.7 15.7

47.1 16.9   48.9 14.6   48.3 11.2   56.2 9.5   58.9 14.7   64.9 12.3
40.3 17.4   38.1 12.7   36.6 12.2   25.3 7.3   27.0 11.0   23.1 11.2
12.7 11.2   13.0 12.2   15.1 5.6   18.5 7.8   14.1 11.8   12.0 6.4

42.0 15.7   45.0 18.7   51.8 15.1   59.5 12.7   49.9 16.7   57.6 18.9
41.0 11.7   49.1 18.1   40.8 13.3   29.7 11.7   35.0 14.3   29.7 17.0
17.0 11.2    5.9 7.1    7.4 5.7   10.8 5.3   15.1 14.4   12.6 10.4

26.9 15.7   26.6 17.2   21.3 9.9   37.3 10.2   46.1 19.1   43.3 17.2
34.3 15.2   52.1 21.2   40.4 12.9   39.6 10.8   31.1 15.7   32.3 16.1
38.8 19.5   21.3 19.1   38.3 14.9   23.2 10.9   22.9 12.4   24.3 14.6

60.5 23.6   41.3 29.4   20.9 19.3   30.8 12.9   66.1 24.3   14.6 22.4
19.7 19.6   38.3 31.2   70.0 22.8   35.7 22.9   29.4 24.0   75.5 30.2
19.8 19.9   20.4 33.3    9.2 9.8   33.5 30.2    4.4 6.3    9.9 19.8

38.0 13.7   30.2 18.1   19.8 12.7   33.2 14.8   45.0 23.9   37.4 21.7
38.6 13.9   52.7 20.6   51.1 14.1   39.4 18.6   30.9 17.5   40.1 21.1
23.4 13.1   17.1 20.3   29.1 10.5   27.4 14.1   24.1 22.0   22.5 17.2

37.8 17.7   36.9 16.4   31.3 11.6   45.6 9.1   47.5 13.5   57.0 16.3
27.8 18.9   48.5 17.4   47.9 11.7   33.4 9.7   33.7 12.2   25.8 13.4
34.4 19.1   14.6 13.4   20.8 8.8   21.0 8.7   18.8 9.7   17.2 11.9

*Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978-1991,
current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who
reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons
who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they
currently smoked every day or on some days.

`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.
$95R confidence intervai.
%zludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.


Table 15.  Percentage of adult American Indian and Alaska Native ever smokers who have quit,* overall and
    by gender, age, and education, National Health Interview Surveys, United States, 1978-1995
     aggregate data

1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 199~1995+

Characteristic             %  +c1$ %  fC1    % +c1 %  fC1 %   XI %   KI

Total                  31.6 7.9   37.7 9.3   36.1 7.5   38.2 8.2   34.6 9.1   32.9 9.6

Gender
Men
Women

Age (years)
18-34
35-54
255

Education_
Less than high school
High school/any college

28.5 11.8   38.2 12.9   37.5 9.5   44.0 9.7   43.8 15.3   28.3 13.9
36.5 11.8   37.4 12.8   34.3 8.4   31.7 9.8   25.2 7.7   37.2 13.0

29.5 12.0   30.2 15.1   28.0 8.2   28.3 10.1   20.7 13.4   16.3 13.3
25.4 12.1   38.0 15.2   34.7 9.5   33.0 8.6   34.8 10.5   29.1 13.4
44.8 18.4   54.1 17.5   50.9 17.3   63.5 19.5   61.7 15.4   81.7 14.8

28.4 11.3   43.8 15.7   29.8 12.4   49.4 11.7   37.4 13.1   39.3 15.1
47.3 15.6   39.1 13.3   43.1 9.1   36.0 10.3   36.2 12.3   36.5 11.0

*Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. The prevalence
of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who
reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were
not smoking, and ever smokers include current and former smokers.
`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.

aged 18-54 years. Interviews with patients at urban
IHS clinics in Milwaukee, Minneapolis, Seattle, and
Spokane also showed a low prevalence of cessation
(29.7 percent) (Land0 et al. 19921, compared with 45
percent reported for the total U.S. population during
the same time.

  Data from the NC1 Supplement of the 1992-1993
CPS indicate that among American Indians and Alaska
Natives aged 18 years and older who were daily smok-
ers one year before being surveyed, 62.8 percent re-
ported that they were still smoking daily and that they
had not tried quitting for at least one day during the
previous year (Table 4). Another 28.9 percent had tried
quitting for at least one day, 3.7 percent were occasional
smokers (i.e., smoked only on some days), 1.8 percent
had not smoked for the past l-90 days, and 2.8 per-
cent had not smoked for the past 91-364 days. This
distribution was similar to that among whites.

Women of Reproductive Age

  Since 1978, rates of smoking have remained strik-
ingly high among American Indian and Alaska
Native women of reproductive age (1844 years) par-
ticipating in the NHIS (Table 16) (NCHS, public use
data tapes, 1978-1995). Between 1978 and 1995, the
prevalence of cigarette smoking among reproductive-
aged American Indian and Alaska Native women
changed little overall, and the data are not precise
enough to allow meaningful comparisons according
to educational attainment.

  A recent study by Davis and colleagues (1992)
confirms that the prevalence of smoking is higher
among American Indian women of reproductive
age than among their counterparts in other racial/
ethnic groups. The investigators analyzed birth certifi-
cates issued in Washington state between January 1,


Table 16.  Percentage of American Indian and Alaska Native women of reproductive age who reported
    being current cigarette smokers,* overall and by education, National Health Interview Surveys,
     United States, 1978-1995 aggregate data

197%1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic             7c  iCIS 7%   FCI 7c   _+a 7r  KI %   _+CI %   _+CI

Total                 40.2 12.8 35.9 11.3   39.2 8.9 43.3 11.1   39.7 9.4   44.3 12.0

Educations
Less than high school      60.4 23.7 47.6 24.9   53.1 18.9 61.3 14.5   82.1 18.6   62.4 30.0
High school/any college    17.2 13.1 27.6 11.7   30.5 9.3 42.9 14.4   32.7 11.2   45.6 14.4

*Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978-1991,
current cigarette smokers include women aged 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 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 d;lta \vere combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
$95% confidence interval.
SIncludes persons aged 25 years and older.

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

1984, and December 31,1988, and found that the preva-
lence of smoking among American Indian mothers, ad-
justed for maternal age and marital status, was 1.3 times
higher than the prevalence among white mothers.

  Data from the 1988 NMIHS indicate that 35 per-
cent of American Indian mothers sampled reported
smoking cigarettes in the 12 months before delivery
(Sugarman et al. 1994). Recent birth certificate data
from U.S. final natality statistics show that 20.9 per-
cent of American Indian and Alaska Native mothers
smoked during pregnancy (Ventura et al. 1997), a slight
decline from 23.0 percent in 1989 (Table 6). The preva-
lence of smoking among American Indian mothers was
higher than all groups in 1989-1995 (Table 6).

Young People

Cigarette Smoking

One of the few studies focusing on tobacco use

whites (Table 7). The prevalence of previous-month
cigarette smoking during 1990-1994 was 39.4 percent
among American Indian and Alaska Native females
and 41.1 percent among males. During 1985-1989,
rates of daily smoking and of smoking one-half pack
or more per day were higher among American Indian
and Alaska Native youths than among youths of other
racial/ethnic groups (Bachman et al. 1991a).

   Data from a revised version of the Adolescent
Health Survey showed that for every grade level after
the seventh, American Indian and Alaska Native fe-
males were somewhat more likely to be daily cigarette
smokers than were American Indian males. The preva-
lence of daily cigarette smoking among females in-
creased from 8.9 percent in junior high school to 17.8
percent in high school, whereas among males the
prevalence of daily cigarette smoking increased from
8.1 percent in junior high school to 15.0 percent in high
school (Blum et al. 1992).

among American Indian and Alaska-Native youths is
the MTF, which includes a series of surveys of high
school seniors. Between 1976 and 1994, American In-
dian and Alaska Native high school seniors had higher
rates of cigarette smoking than all of their counterparts,
although the rate of decline was more rapid than for

Smokeless Tobacco Use
  The use of smokeless tobacco is also high among
American Indian and Alaska Native youths. Bruerd
(1990) reviewed nine studies of schoolchildren's
use of smokeless tobacco in South Dakota, Montana,


Nebraska, Washington, Arizona, New Mexico, and
Alaska and found that the prevalence of regular
smokeless tobacco use ranged from 18 percent among
students in kindergarten through the sixth grade to
55.9 percent among students in the ninth and tenth
grades. The percentage of schoolchildren who re-
ported ever using or experimenting with smokeless
tobacco ranged from 29 to 82 percent. In general, the
findings suggested a young age at onset of smokeless
tobacco use, similar prevalence of use among adoles-
cent boys and girls, and higher overall prevalence of
use among American Indian and Alaska Native school-
children than among students in other populations. A
1987-1988 survey of 650 American Indian and Alaska
Native youths at three IHS sites (Alaska; the Billings
region, which encompasses Montana and Wyoming;
and the Navajo region, which encompasses portions
of Arizona, Colorado, New Mexico, and Utah) indi-
cated that these youths were experimenting with and
regularly using smokeless tobacco at higher rates than
white youths (Backinger et al. 1993).

Regional and Tribal Tobacco Use

Cigarette Smoking

  Although a high rate of smoking has been esti-
mated nationally for American Indians and Alaska
Natives, regional and state differences in tobacco-use
patterns are evident when 1988-1992 aggregate data
from the BRFSS are considered.. High smoking
prevalences were found in Alaska (45.1 percent), the
Northern Plains (Montana, Nebraska, North Dakota,
and South Dakota) (44.2 percent), and the Northern
Woodlands (Iowa, Michigan, Minnesota, and Wiscon-
sin) (35.6 percent), whereas much lower overall smok-
ing prevalences were found in California (25.4 percent)
and the Southwest (Arizona, Colorado, New Mexico,
and Utah) (17.0 percent) (Table 17) (CDC, public use
data tapes, 1988-1992). The prevalence of current ciga-
rette smoking varied by geographic region more than
twofold for men and nearly threefold for women. For
example, 21.3 percent of men and 13.5 percent of
women in the Southwest reported that they currently

Table 17.  Percentage of American Indian and Alaska Native adults who reported being current cigarette
     smokers,* overall and by region/state, gender, age, and education, Behavioral Risk Factor
     Surveillance System, 1988-1992 aggregate data

Characteristic

Alaska        California

7c   XI*        7c    kc1

Northern
Plains+

7c    kc1

Northern
Woodlands+

70    KI

Total


Gender
Men
Women

Age (years)
18-34
35-54
255

Education_
Less than high school
High school/any college

45.1   5.9        25.4    7.0       44.2



48.4   8.7        27.9   10.5       49.1
41.7   8.0        22.7    8.9       38.4




48.5   9.0        20.9    8.7       51.2
41.5   8.6        34.4   13.4       47.2
41.3  14.6       24.0   20.6       27.3



43.1   11.2        25.8   15.3       44.5
44.9   7.3       32.5   9.7       40.1

7.8       35.6   4.8

11.3       33.0 7.6
9.9       37.6   6.2

12.4       33.4   6.7
12.4       45.4   9.0
15.1       27.0   9.1

14.8       40.6 11.0
9.8       35.3   5.7

*Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in
their lives and who reported at the time of survey that they currently smoked.
`The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern
Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes
Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah;
and "other" includes all remaining states not specified above that participated in the Behavioral Risk Factor
Surveillance System during this period.


Tobacco Use Amng U.S. Racial/Ethnic Minorify Groups

smoked, compared with 49.1 percent of men and 38.4
percent of women in the Northern Plains (Table 17).

  The majority of American Indians and Alaska
Natives (83.3 percent) responding to the BRFSS
smoked 15 or fewer cigarettes per day; this finding was
consistent across all states and regions (Table 18) (CDC,
public use data tapes, 1988-1992). Overall, female
American Indians and Alaska Natives smoked fewer
cigarettes than their male counterparts-a finding
that was consistent across all states and regions.
American Indian smokers in the Northern Plains (13.5
percent) were the most likely to smoke 25 or more ciga-
rettes per day. American Indian smokers in the South-
west (51.2 percent) and the Pacific Northwest (46.8
percent) had the highest prevalence of cessation,
whereas American Indians in the Northern Plains (31.8
percent) and Alaska Natives (37.0 percent) had the low-
est prevalence of cessation (Table 19) (CDC, public use
data tapes, 1988-1992).

   In similar analyses of the BRFSS data ag-
gregated for 1985-1988, the prevalence of smoking

varied markedly by gender and geographic region
(Sugarman et al. 1992). For American Indian men, the
prevalence of smoking was highest among those liv-
ing in the Plains region (Iowa, Minnesota, Montana,
Nebraska, North Dakota, South Dakota, and Wiscon-
sin) (48.4 percent), followed by those in the West Coast
region (California, Idaho, and Washington) (25.2 per-
cent) and the Southwest (Arizona, New Mexico, and
Utah) (18.1 percent). Similarly, for American Indian
women, the prevalence of smoking was highest among
those living in the Plains region (57.3 percent), followed
by those in the West Coast region (31.6 percent) and
the Southwest (14.7 percent).

  Regional and tribal data on cigarette smoking are
also available from a probability sample of American
Indians living on or near the northern Montana
Blackfeet Reservation and those served by the Native
American Center in Great Falls, Montana, in 1987
(Goldberg et al. 1991). Among Blackfeet Indians, 34
percent of men and 50 percent of women reported that
they smoked cigarettes. Among American Indians in

Oklahoma

Pacific
Northwest+

Southwest+       Other+          Total

%    KI        %


30.4    7.3       33.1



36.2   12.7       35.4
26.0 8.9       31.2



33.5   12.6       37.6
35.0   12.8       30.3
21.7   10.6       26.2



25.1   14.4       42.5
31.2   8.7       33.9

6.0        17.0



9.2        21.3
7.9       13.5



9.6       13.3
8.4        18.9
14.7       29.8



15.4       29.7
7.3       15.1

4.6       28.9 4.2       29.2   2.5

8.2       36.5    6.4       34.4   4.0
5.0       21.3 5.2       24.2   3.1

5.6       30.2 6.8       28.9   3.8
8.8       33.6 7.1       33.8   4.4
14.2       18.6    6.6        22.5   5.3

12.3       34.0    9.4       33.4   5.6
5.9       29.4   5.0       30.5   3.2

t9570 confidence interval.
_Includes persons aged 25 years and older.
Source: Centers for Disease Control, public use data tapes, 1988-l 992.

Patterns of Tubacca Usf  51


Table 18.  Percentage of adult American Indian and Alaska Native smokers* who reported smoking ~15,
     15-24, or 225 cigarettes per day, overall and by region/state, gender, age, and education,
     Behavioral Risk Factor Surveillance System, 1988-1992 aggregate data

Characteristic

Total
  <15 cigarettes
  15-24 cigarettes
  2 25 cigarettes

Gender
Men
  <15 cigarettes
  15-24 cigarettes
  2 25 cigarettes

Women
<15 cigarettes
15-24 cigarettes
2 25 cigarettes

Age (years)
18-34
  <15 cigarettes
  15-24 cigarettes
  2 25 cigarettes

35-54
<15 cigarettes
15-24 cigarettes
2 25 cigarettes

255
<15 cigarettes
  15-24 cigarettes
2 25 cigarettes

Educations
Less than high school
  <15 cigarettes
  15-24 cigarettes
  2 25 cigarettes

High school/any coliege
<15 cigarettes
15-24 cigarettes
2 25 cigarettes

Alaska

c/c   ?cIS
    -

83.7   4.1        88.0    5.0       70.9    7.5       84.6   3.6
12.2   3.7        8.5    4.4       15.7   5.5       12.3   3.3
4.1   2.2        3.5   2.7       13.5   6.5        3.1   1.6

79.3   7.0       87.7    7.4       66.8   11.4       83.9   5.5
15.2   6.1        8.3    6.4       14.3    7.8       11.7   5.0
5.5   4.0        4.0    4.1       19.0   10.4        4.4   2.6

88.2   4.2       88.2    6.8       75.8    8.8       85.2   4.6
9.0   3.9        8.8   5.9       17.3    7.7       12.7   4.3
2.7   1.9        3.0   3.5        6.9   5.4        2.1   2.0

87.7   5.1        90.8    5.8       68.1   12.4       87.4   4.5
8.7   3.8         5.4    4.4       18.8    9.5       10.9   4.2
3.6   3.7        3.8    4.0       13.0   10.6        1.7   1.6

78.5   7.4        82.1   11.0       65.6   12.0       79.5   7.4
15.6   6.9        16.2   10.8       16.3   8.7       14.9   6.7
6.0   3.5        1.7    2.5       18.1   10.6        5.6   4.0

80.7   12.3        89.1   12.8       83.5   13.7       84.9   7.4
16.8   12.2        5.1    9.9        8.9    9.8       12.1   6.8
2.6   2.1        5.8    8.4        7.6   10.9        3.0   3.1

85.0   7.7        90.6    9.9       66.3   14.8       81.7   7.3
12.0   7.6        5.1    5.8       13.3   10.5       14.9   6.7
3.0   2.0         4.4    8.3       20.4   13.5        3.4   3.1

78.2   6.2        83.1    7.7       74.1    8.9       84.2   4.6
15.8   5.3        13.2    7.2       16.3    7.4       12.0   4.1
6.1   4.0        3.7    3.2        9.6    6.3        3.9   2.4

California

%    ASI

Northern
Plains+

Q   %I

Northern
Woodlands+

%   %I

-

*Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in
their lives and who reported at the time of survey that they currently smoked.
`The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern
Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes
Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah;
and "other" includes all remaining states not specified above that participated in the Behavioral Risk Factor
Surveillance System during this period.


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


Long-Term Trends in Cigarette-Smoking
Initiation

  Another type of birth cohort analysis was con-
ducted to determine long-term trends in smoking among
young adults (2G29 years of age) by gender and educa-
tional attainment. Information on smoking history was
determined during the years that each person was 2G29
years of age. For each year, the prevalence of smoking
was determined by dividing the number of smokers aged
20-29 years by the total number of persons aged 2C-29
years in that year. Unlike the birth cohort analysis de-
scribed in the preceding section of this chapter, in this
analysis the group for which prevalences are computed
changes from year to year because new respondents en-
ter the group when they are 20 years old and leave it
when they become 30 years old.

   The information for African Americans was ob-
tained from NHIS data collected in 1978, 1979, 1980,
1987, and 1988, whereas the information for Hispan-
ics was obtained from HHANES data collected in
1982-l 984.

Figure 11.

BO-

70-

60-

  5O-
!+
2 40-
8
z
o 30-


  20-


  lo-

African Americans

  Up until the early 197Os, African American men
had substantially higher rates of smoking initiation
than African American women (Figure 11). Within
each gender group, significant education-related
differences were not observed until the 195Os, when
rates of smoking initiation among male high school
graduates began to decline sharply and rates among
females with less than a high school education began
to increase. Rates among less educated females surged
drama tically between 1970 and 1980. After 1980, rates
of smoking have consistently declined among each of
these subgroups of African Americans except males
with less than a high school education.

Hispanics

  Significant education-related differences in
rates of smoking initiation have been evident only
among Hispanic males. Around 1940, Hispanic males
who graduated from high school began showing

Reconstructed prevalence of smoking among African American adults aged 20-29 years, by
gender and education, National Health Interview Surveys, United States, 1910-1988

Men with less
E%% 3~ation

Men with a high
school education

Women with less
ZXZ %kation

Women with a
high school
education

0 ;        I        I        I        I        I        I        I        I
1910    1920    1930    1940    1950    1960    1970    1980    1990

                          Year

Source: National Center for Health Statistics, public use data tapes, 1978,1979,1980,1987, and 1988 combined.


Tobacco Use Among U.S. Racinl/Efhic Minority Groups

appreciably lower smoking rates than Hispanic males
with less than a high school education (Figure 12).
These differences increased in the 1960s and even more
rapidly in the mid-1970s.  No consistent differences
in smoking rates by education were observed among
Hispanic females.

Cigarette Brand Preferences

  Knowing what influences cigarette brand.prefer-
ence among smokers is belie\red to be important be-
cause this information can be used to develop
counteradvertising strategies. In the late 1970s and the
198Os, the 12 most commonly used brands of ciga-
rettes-Marlboro, Winston, Salem, Kool, Pall Mall, Kent,
Benson & Hedges, Camel, Merit, Vantage, Virginia
Slims, and Newport-were used by at least 76 percent
of all current U.S. smokers, according to data from the
1986Adult Use of Tobacco Survey (AUTS) and the 1978-
1980 and 1987 NHISs (Table 32). Brand use varied some-
what by race/ethnicity. For example, the top brands

preferred by African Americans were Kool, Newport,
Salem, and Winston, whereas whites preferred
Marlboro, Winston, Salem, and Benson & Hedges.

  These differences in part reflect the greater use
of mentholated cigarettes by African Americans
(Cummings et al. 1987; USDHHS 1989). Fifty-five
percent of all African American smokers reported us-
ing one of three brands that were available only in
mentholated form (Newport, Kool, and Salem). Simi-
lar patterns and percentages of brand preferences were
observed in the 1987 NHIS (Table 32).

  Hymowitz and colleagues (1995) recently stud-
ied menthol cigarette smoking among adults who par-
ticipated in a stop-smoking study. Among African
Americans who smoked menthol cigarettes (n = 1741,
the top reasons given for smoking menthols were as
follows: 83 percent said that menthol cigarettes tasted
better than nonmenthol cigarettes, 63 percent said that
they had always smoked menthol cigarettes, 52 per-
cent said that menthol cigarettes were less harsh to the
throat than nonmenthol cigarettes, 48 percent found
inhalation to be easier with menthol cigarettes, and 33

Figure 12.  Reconstructed prevalence of smoking among Hispanic adults aged 20-29 years, by gender
     and education, Hispanic Health and Nutrition Examination Surveys, 1920-1984

    Men with less
- ZnOOa !Z&ation

   Men with a high
11-v.  school education


    Women with less
  %Z," ZEation

    Women with a
- high school
    education

I          I                   I
1950     1960   ld70     1980  1490

   Year

Source: National Center for Health Statistics, public use data tapes, 1982-1984.

Pafferm of Tobacco Use  79


Table 32.  Percentage of self-reported cigarette brand use among adult current cigarette smokers, overall
    and by race/ethnicity and gender, National Health Interview Surveys (NHIS) 1978-1980 com-
      bined, Adult Use of Tobacco Survev (AUTS) 1986, and NHIS 1987

Survey

Sample
Size*

Benson &
Hedges     Camel      Kent      Kool     Marlboro

% KIS    % XI     %X1 %   %I    % &CI

NHIS 1978-1980
African Americans
   Total
   Men
   Women

1,540      6.0 1.6    1.3 0.7    1.6 0.6    28.0 4.0    3.8 1.3
750       4.0 1.7    2.3 1.2    1.1 0.8    31.3 4.7    4.2 1.7
790       8.1 2.4    0.3 0.4    2.2 0.8   24.4 4.5    3.3 1.6

Whites
Total
Men
Women

AUTS 1986
African Americans
   Total
   Men
   Women

Whites
Total
Men
Women

NHIS 1987
African Americans
   Total
   Men
   Women

Whites
Total
Men
Women

13,228       4.2 0.6    4.4 0.5    4.8 0.5    6.3 0.6    17.5 1.1
6,675      2.7 0.5    6.9 0.7    4.0 0.6    6.8 0.8    20.3 1.5
6,553       5.8 0.8    1.7 0.4    5.7 0.6    5.8 0.7    14.4 1.2

388      9.2 3.5    0.9 1.2    0.6 0.6    19.9 4.9    6.7 3.1
176       4.6 3.8    1.2 2.0    0.5 0.5    19.6 7.2    10.2 5.5
212      13.8 5.7    0.5 1.2    0.7 0.7   20.3 6.7    3.2 2.9

3,693       4.1 03    4.9 0.9    2.7 2.7    4.2 0.8   28.3 1.8
1,883       2.9 0.9    7.9 1.5    2.3 2.3    4.7 1.2    32.4 2.6
1,810      5.5 1.3    1.5 0.7    3.2 3.2    3.5 1.0    23.7 2.4

428       6.3 2.7    2.6 2.0    2.5 2.3    24.8 5.4    2.7 1.5
174       2.2 1.8    3.4 3.3    2.1 2.8    30.3 8.6    3.1 2.2
254      11.2 5.1     1.7 2.2    3.0 3.7    18.4 5.5    2.3 1.9

1,860       5.8 1.2    3.8 1.1     3.1 0.9    3.7 1.0    31.1 2.6
934      3.8 1.4    5.7 1.6    2.1 1.0    3.6 1.3   38.8 3.5
926       8.1 2.1     1.6 1.7    4.3 1.6    3.7 1.4    22.0 3.1

*Unweighted sample size.

`In the NHIS, "other" includes other brands, no particular brand, and roll-your-own cigarettes; in the AUTS,
"other" includes other brands.

percent said that they could inhale menthol cigarettes   always smoked menthol cigarettes, and 21 percent found
more deeply. Among a small sample (n = 39) of whites   inhalation to be easier with menthol cigarettes.
who smoked menthol cigarettes, 74 percent said that     Evaluating changes in young smokers' brand
menthol cigarettes tasted better than nonmenthol ciga-   preferences is especially important because it can
rettes, 51 percent said that menthol cigarettes were more   help identify factors that influence their choices and
soothing to the throat, 39 percent said that they had   may suggest ways to discourage them from starting


Totmcco Use Ammo U.S. RacidjEthnic Minority Groups

Merit    Newport

Yc   kc1 %   kc1

Pall                 Virginia
Mall      Salem    Vantage     Slims    Winston    Other+

% kc1 7r   kc1 x   kc1 Yc   kc1 Yc   kc1 7%   XI

1.4   0.6    5.2 2.3    6.9   1.5   15.9   2.0    0.9 0.5    2.6 0.9   11.9 2.1   14.5 2.0
1.3   0.9    5.6 2.7    9.6 2.5   12.7 2.8    0.7 0.2    0.2 0.3   13.4 3.3   13.6   2.5
1.4 0.9    4.7 2.8    4.0 1.3   19.4   2.7    1.1   0.8    5.2   1.9   10.3 2.1   15.6 3.2

4.3   0.4    1.2 0.4    5.4 0.4    9.0 0.7    3.5 0.4    2.2 0.3   13.3 0.9   23.9 1.1
4.0 0.6    1.2 0.4    6.4 0.6    7.9   0.8    3.5 0.6    0.2 0.1   15.5 1.2   20.6 1.4
4.7 0.6    1.2 0.4    4.2 0.5   10.3   1.0    3.5   0.5 4.4   0.5   10.8   1.0   27.5 1.4

0.1   0.4   23.4 3.2    2.3 1.8
0.0 0.0   26.2 8.0    2.8   3.0
0.1   0.5   20.5   6.7    1.8   2.2




4.9 0.9    2.4 0.6    3.5 0.7
4.6 1.2    2.7 0.9    3.9   1.1
5.3 1.3    2.1   0.8    2.9 0.9

17.4   3.6    0.4
15.2   6.5    0.5
19.7 6.4    0.4

8.2 1.1    3.6
6.4 1.4    3.5
10.4   1.7    3.8

1.3   1.1   19.6 5.7    2.2   1.2   12.7 3.8    0.5
0.8 1.2   21.9 9.1    2.1   1.6   11.9 5.4    0.0
1.9 2.0   16.9 5.3    2.3 1.7   13.5   4.7    1.0

4.5 1.0    2.8 0.9    2.5 0.8    7.0 1.4    2.6
4.1 1.4    2.5 1.2    3.2 1.2    5.4 1.9    2.8
4.9   1.3    3.2 1.3    1.5 0.8    8.9 2.1    2.4

0.8    3.4 2.2    6.5 3.0    9.4 3.6
1.3    0.3   1.0    8.8 5.1   10.2   5.5
1.0    6.4 4.0    4.2 3.3    8.5 4.6

0.7    3.0   0.7   11.0 1.2   19.2 1.6
1.0    0.4 0.4   13.0 1.9   15.4 2.0
1.1    6.0   1.3    8.8   1.6   23.6 2.4

0.5    1.9 1.2   11.7 4.0   11.2 3.5
0.0    0.5 0.8   12.9 6.3    8.8 4.4
1.2    3.4 2.4   10.3 4.8   14.1   5.0

0.8    3.8 0.9   12.3   1.9   17.0 1.9
1.0    0.1   0.2   13.6 2.7   14.3 2.5
1.1    8.2 2.0   10.7 2.6   20.5 2.8

$9570 confidence interval.
Sources: National Center for Health Statistics, public use data tapes, 1978-1980 and 1987; Centers for Disease
Control, public use data tapes, 1986.

to smoke (Hunter et al. 1986; Pierce et al. 1991a). Data   (10.9 percent), and Salem (9.7 percent) were preferred
from the 1989 TAPS show that among adolescents who   by African Americans (Table 33) (CDC 1992d). In the
usually bought their own cigarettes (61.9 percent),   1993 TAPS, the most popular brands were still
Marlboro was the most popular brand among whites   Marlboro among whites (63.5 percent) and Hispanics
(71.4 percent) and Hispanics (60.9 percent), and the   (45.4 percent) and Newport among African Americans
mentholated brands of Newport (61.3 percent), Kool   (70.4 percent) (Table 33).


Table 33.  Percentage of self-reported cigarette brand use among adolescent current cigarette smokers,* by
     race/ethnicity, Teenage Attitudes and Practices Surveys (TAP%), 1989 and 1993

Benson &

Sample  Hedges     Camel      Kool     Marlboro     Merit   Newport

Survey

Size+  R &CIS    % ?CI

% XI %   ?CI    % ?CI

TAPS 1989
Race
African American
White

41   3.3 6.4     3.1   6.2   10.9 9.1    8.7 9.7
807   1.3   1.2    8.4 2.2    0.6 0.5    71.4 3.4

46   3.7 4.9    7.6 8.6    5.8 6.1    60.9 15.0
817   1.3   1.2    8.1 2.1    0.8 0.6   69.1 3.5

41   1.7 3.3    0.0 0.0   11.9 10.9    8.5 8.5
646   0.2   0.4    14.4   3.1    0.5 0.8   63.5 4.3

50   0.0 0.0    10.1   7.7    4.5 8.6    45.4 14.9
647   0.3 0.4    13.6   3.1    0.9 0.8    60.9 4.3

      Salem
Sample
Size+ 7r   &CI

Vantage

Virginia
Slims

Winston

0.0   0.0
0.5   0.5



0.0   0.0
0.5   0.5

61.3 15.7
5.6 1.6

12.8 9.5
8.0 1.9

$     ?    70.4 14.1
NA NA    8.7 2.4

NA NA   34.0 15.1
NA NA   11.0 2.5

Other

Ethnicity
Hispanic
Non-Hispanic

TAPS-II 1993
Race
African American
White

Ethnicity
Hispanic
Non-Hispanic

Survey

%   KI

7c   kc1

TAPS 1989
Race
African American   41    9.7   7.2    0.0   0.0    NA  NA    0.0   0.0    2.9   5.8
White         807   1.0   0.7    0.1   0.2    NA  NA    3.4   1.3    7.6   2.0

Ethnicity
Hispanic
Non-Hispanic

46   2.8   5.4    0.0   0.0   NA  NA    0.0   0.0    6.5   7.6
817   1.5   0.8    0.1   0.2    NA  NA    3.3   1.3    7.3   1.9

TAPS-II 1993
Race
African American   41    1.4   2.7    NA  NA    0.5   1.0    0.0   0.0    5.5   6.0
White          646    1.0   0.8    NA  NA    1.0   1.0     1.2   0.1    9.4   2.8

Ethnicity
Hispanic
Non-Hispanic

50   0.0   0.0   NA  NA    0.0   0.0    6.0   8.1    0.0   0.0
647   1.1   0.8   NA  NA    1.1   1.0    0.8   0.7   10.4   2.9

*Current smokers are adolescents aged 12-18 years who reported smoking cigarettes on 1 or more of the 30 days
preceding the survey.
+Unweighted sample size.
t95% confidence interval.
"Numbers are too small for meaningful analysis; this brand is included in the "other" category.
NA = data not available.
Sources: National Center for Health Statistics, public use data tapes, 1989; Centers for Disease Control and
Prevention, public use data tapes, 1993.


Tdmso USC Avmr~ U.S. Rncial/Ethnic Minority Groups

  A notable change in brand preferences occurred
between 1989 and 1993, however. The percentage of
adolescents purchasing Marlboro cigarettes decreased
13 percent, whereas the percentage of those purchas-
ing Camel cigarettes increased 64 percent and the
percentage of those purchasing Newport cigarettes
increased 55 percent (CDC 1994a). The declining pref-
erence for Marlboro cigarettes was greatest among
Hispanics (CDC 1992d). Increases in brand preference
were greatest among white adolescents who preferred
Camel cigarettes and among Hispanic adolescents who
preferred Newport cigarettes. In 1993, the brands of
cigarettes most commonly smoked among a small

sample of Vietnamese middle and high school students
in Worcester, Massachusetts, were Marlboro (71 .O per-
cent) and Camel (9.7 percent) (Wiecha 1996).

   Data from the 1989 and 1993 TAPSs indicate that
brand preference is more concentrated among adoles-
cents than among adults. In both surveys, the three
most popular brands for each racial/ethnic group were
purchased by at least 80 percent of adolescent smok-
ers. Both surveys identified very small numbers of
smokers among African American adolescents (41 in
1989 and 45 in 1993) and Hispanic adolescents (46 in
1989 and 50 in 1993); thus, brand preference estimates
for these groups are imprecise.

Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior

  In this chapter, smoking prevalence has been
shown to vary by racial/ethnic minority group and
by educational attainment. Because educational at-
tainment varies among racial/ethnic groups and is
related to smoking prevalence, the question arises as
to whether racial/ethnic differences in smoking can
be explained by differences in educational attainment.

  A previous analysis of the 1985 NHIS data
showed that controlling for selected measures of so-
cioeconomic status, such as employment status and
poverty level, reduced differences in the smoking
prevalence between African Americans and whites
(Novotny et al. 1988).

  Although education, together with such variables
as income and occupation, is often used to create a
composite measure of socioeconomic status, many
researchers have used education as a single proxy in-
dicator of socioeconomic status because education is
often associated with many lifestyle characteristics
(Liberatos et al. 1988). In addition, education data are
usually more accurate and easier to collect than income
and occupation data (Liberatos et al. 1988).

  Findings in this report indicate that the
prevalences of cigarette smoking, smoking cessation,
and heavy smoking are all associated with race/
ethnicity and educational attainment. Because racial/
ethnic group and educational attainment are often in-
terrelated, multivariable models were used in this
analysis to distinguish how each variable influences
smoking behavior. Data were derived from the NHISs

for 1987,1988,1990, and 1991 (Table 34) (NCHS, pub-
lic use data tapes, 1987, 1988, 1990, and 1991). The
multivariable logistic regression technique was used
to assess the odds ratios of smoking behaviors for
African Americans, American Indians and Alaska
Natives, Asian Americans and Pacific Islanders, and
Hispanics compared with whites, before and after ad-
justing for the effects of educational attainment.' Four
separate logistic regression models were constructed
for different measures of smoking behavior: current
smoking, ever smoking, heavy smoking (among cur-
rent smokers), and smoking cessation (among ever
smokers). Four design variables were created to rep-
resent the racial/ethnic groups (African Americans,
American Indians and Alaska Natives, Asian Ameri-
cans and Pacific Islanders, and Hispanics), with whites
serving as the reference group. Similarly, two design

' Let p,,, = logistic regression coefficient for the ith ethnicity
group h~$rr education was included, and p,, = logistic regression
coefficient for the ith ethnicity group after education was
included. Then p,,, - p,, measures education's confounding effect
on the relationship between smoking and ethnicity. The variance
of p,,, - p,, can be approximated as var(p,,,) + var(p,,); and the
standard error, SE(P,,, p,,), is the square root of the variance. In
terms of the more commonly used measure, odds ratio (OR), the
following relationship exists: ORI,,/OR,, = exp(!3,, - p,,). The 95
percent confidence interval for OR,,,/OR,, can then be computed
as exp[@,$, - p,,) + 1.96 X SE@,, o,,)]. Education's confounding
effect on the relationship between smoking and ethnicity is
determined to be statisticalIy significant if the 95 percent
confidence interval for OR,,,/OR,, does not include 1.0.

Pattcms of Tobacco Use  83


Table 34.  Relationship between smoking status and race/ethnicity among adults,* before and after
    controlling for education,+ National Health Interview Surveys, United States, 1987,1988,1990, and
     1991 aggregate data

Race/ethnicity

Not controlling
for education

ORoS   CIS

Controlling
for education

0%     CI

  Effect of
educationt

OR,,/ORl CI

CurrenP

Former1

Heavy**

Ever'+

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

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

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

African Americans
Hispanics
Asian Americans and Pacific Islanders
American Indians and Alaska Natilres
Whites

1.11  1.06,1.16
0.74  0.70, 0.79
0.51  0.45, 0.58
1.46  1.16, 1.85
1.0    referent

0.65  0.61, 0.70
0.97  0.90, 1.05
0.95  0.80,1.13
0.66  0.47,0.92
1.0    referent

0.19  0.16,0.21
0.25  0.21,0.30
0.17  0.11,0.26
0.74  0.58, 0.95
1.0    referent

0.82  0.79,0.86
0.63  0.60, 0.67
0.39  0.35, 0.43
1.21  1.05, 1.40
1.0    referent

0.96  0.91, 1.00    1.16  1.08, 1.24
0.58  0.54, 0.62    1.29  1.18, 1.42
0.54  0.47, 0.62    0.94  0.78, 1.14
1.20  0.95, 1.51    1.22  0.88, 1.70
1.0    referent    1.0   referent

0.74  0.69, 0.78
1.16  1.07, 1.26
0.88  0.74, 1.05
0.74  0.53, 1.02
1.0    referent

0.89  0.81,0.97
0.84  0.75,0.94
1.08  0.85, 1.38
0.89  0.56, 1.41
1.0    referent

0.18  0.16, 0.20
0.23  0.20,0.28
0.17  0.11,0.27
0.70  0.55,0.90
1.0    referent

1.04  0.87, 1.25
1.08  0.84, 1.38
0.97  0.52,1.83
1.05  0.74,1.49
1.0    referent

0.76  0.72, 0.79
0.55  0.52, 0.58
0.40  0.36, 0.44
1.09  0.93, 1.27
1.0    referent

1.09  1.02, 1.16
1.15  1.06, 1.24
0.97  0.83, 1.13
1.11  0.90, 1.38
1.0    referent

*Includes persons aged 25 years and older.
`Education was evaluated at three levels: less than high school education, high school education, and at least
some college.
SO& = odds ratio not controlling for education; OR, = odds ratio controlling for education. Odds ratios were
calculated as follows: OR JOR,, = exp@,,, - pi,), where p,,, is the logistic regression coefficient for the ith ethnic
group before controlling for education, and pII is the coefficient after controlling for education. Other variables
in the logistic models include age, gender, marital status, geographic region, and year of survey.
595% confidence interval.
`Current cigarette smokers are persons who reported smoking at least 100 cigarettes in their lives and who
reported at the time of survey that they currently smoked. The association presented is for current smoking
compared with former and never smoking.
_Former smokers are those who reported smoking at least 100 cigarettes in their lives and who reported at the
time of survey that they were not smoking cigarettes. The association presented is for former smoking
compared with current smoking.

**Heavy smokers include current smokers who reported at the time of survey that they were smoking 25 or more
cigarettes per day. The association presented is for heavy smoking compared with current smoking of l-24
cigarettes per day.

"Ever smokers are those who reported at the time of survey that they had smoked at least 100 cigarettes in their
lives, regardless of their current smoking status. The association presented is for ever smoking compared with
never smoking.

Sources: National Center for Health Statistics, public use data tapes, 1987,1988,1990, and 1991; Escobedo
et al. 1995.


Tobacco Use Amo~~g U.S. Rncid/Ethnic Minority Groups

variables were created to represent persons with and
without a high school education, with persons having
at least some college education serving as the refer-
ence group. In addition to including race/ethnicity
and education, the logistic regression models included
the year of the survey, age, gender, marital status, and
geographic region.

   Education was first omitted from and then en-
tered in these models. The difference in estimated co-
efficients before and after the inclusion of education
was computed for each of the four design lrariables
representing the different racial/ethnic groups. The
variance of this difference was estimated to be the sum
of the variances of the two coefficients. The 95 per-
cent confidence interval of the difference was com-
puted by using this variance estimate. The difference
in coefficients was translated into the ratio of the odds
ratios before and after adjusting for education (Table
34) (Escobedo et al. 1995).

Current Smoking

  Before adjustment for education, the data indi-
cated that African Americans as well as American
Indians and Alaska Natives were more likely than
whites to be current smokers (Table 34). Hispanics as
well as Asian Americans and Pacific Islanders were
substantially less likely than whites to be current smok-
ers. After adjustment for the confounding effects of
education, the odds ratios for current smoking among
African Americans and Hispanics decreased signifi-
cantly (Table 34).

  Thus, when the data were adjusted for educa-
tion, current smoking among African Americans
did not differ from whites-an indication that
the differences in the unadjusted rates were probably
attributable to factors related to differences in educa-
tional attainment. For Hispanics, current smoking
was lower than for whites, and adjustment for the
confounding effects of education further accentuated
these differences.

Smoking Cessation

   African Americans as well as American Indians
and Alaska Natives who had ever smoked were sub-
stantially less likely than whites to have quit smoking
(Table 34). When education was included in these
models, the odds ratio for smoking cessation increased,
suggesting that lack of education accounts for some
but not all of the low rates of quitting in these two
groups. Before adjustment for education, the data
showed that Hispanics were as likely as whites to quit

smoking. However, after adjustment for education,
the data showed that Hispanics were more likely than
whites to quit smoking. Thus, the unadjusted smok-
ing cessation rate was lower among both African
Americans and Hispanics than among whites partially
because of confounding by educational attainment. A
similar magnitude of change was observed among
American Indians and Alaska Natives, but this differ-
ence was not statistically significant. Educational at-
tainment does not explain why African Americans are
less likely than whites to quit smoking.

Heavy Smoking

  Members of all four racial/ethnic groups were
less likely than whites to be heavy smokers, before and
after the data were adjusted for the effects of educa-
tion (Table 34). These differences were greatest
between whites and Asian Americans and Pacific Is-
landers and were smallest between whites and Ameri-
can Indians and Alaska Natives. Because the odds ratio
of heavy smoking changed little after adjustment for
education, the differences in heavy smoking between
racial/ethnic groups appear to be independent of
factors associated with educational attainment.

Ever Smoking

  Before the data were adjusted for the effects
of education, all racial/ethnic groups except Ameri-
can Indians and Alaska Natives were substantially less
likely than whites to have ever smoked (Table 34).
After adjustment for education, the odds ratios for ever
smoking among African Americans and Hispanics de-
clined even further, and these declines were statisti-
cally significant. This finding suggests that if African
Americans and Hispanics had socioeconomic status
more comparable with that of whites, they would be
even less likely ever to smoke than whites.

  Differences in current smoking, quitting, and ever
smoking between whites and Asian Americans and
Pacific Islanders also were found. Asian Americans
and Pacific Islanders were less likely than whites to be
current smokers, substantially less likely to be ever
smokers, but also slightly less likely to have quit smok-
ing. After adjustment for education, the odds ratios
associated with these smoking behaviors changed little
(Table 34). Thus, the lower smoking prevalences
among Asian Americans and Pacific Islanders may be
related to factors other than education-presumably
cultural factors associated with being an Asian Ameri-
can or a Pacific Islander in the United States.

Pnttrrm of Tobncco Use  85


Occasional Smoking

  In addition to smoking more cigarettes each day
whites who currently smoke are generally more likely
than members of other racial/ethnic groups to smoke
on a daily basis. According to the 1993,1994, and 1995
combined NHISs, 15.2 percent of whites who smoked
were occasional (i.e., nondaily) smokers, compared
with 26.0 percent of African Americans, 22.2 percent
of American Indians and Alaska Natives, 33.1 percent
of Asian Americans and Pacific Islanders, and 35.5 per-
cent of Hispanics. Only the estimate for American In-
dians and Alaska Natives did not differ significantly
from that for whites (data not shown) (NCHS, public
use data tapes, 1993, 1994, 1995). Husten and

Exposure to Environmental Tobacco Smoke

colleagues (1998) used data from the 1991 NHIS to
study persons who had ever smoked 100 lifetime ciga-
rettes but who had never smoked on a daily basis.
Among the ever smokers, African Americans (12.0
percent), American Indians and Alaska Natives (15.0
percent), Asian Americans and Pacific Islanders (12.1
percent), and Hispanics (16.8 percent) were all signifi-
cantly more likely than whites (6.2 percent1 never to
have smoked daily. In gender-specific multivariate
analyses that controlled for income, age, and educa-
tion, African Americans, Hispanics, and others (Ameri-
can Indians and Alaska Natives combined with Asian
Americans and Pacific Islanders) were significantly
more likely never to have smoked daily.

  Data on exposure to environmental tobacco
smoke (ETS) among members of U.S. racial/ethnic
minority groups are extremely limited. In the 1991-
1993 NHIS, nearly one-third of all respondents indi-
cated exposure to ETS at home three or more days per
week (Table 35) (NCHS, public use data tapes, 1991-
1993). African Americans (37.6 percent) and Ameri-
can Indians and Alaska Natives (36.9 percent) were
more likely than other groups to report such levels of
exposure to ETS at home. These findings are consis-
tent with smoking prevalence data presented earlier
in this chapter. Similar patterns exist among nonsmok-
ers, although the occurrence of higher levels of expo-
sure (three or more days) is reduced by 40 to 60 per-
cent among nonsmokers compared with the total
population. Among Asian American, Pacific Islander,
American Indian, and Alaska Native nonsmokers,
women had substantially more prolonged exposure
than men.

  Using 1988-1991 NHANES III data on persons
aged 17 years and older who did not use tobacco, Pirkle
and colleagues (1996) found that 36.9 percent of Afri-
can Americans, 35.1 percent of Mexican Americans,
and 37.4 percent of whites reported that they were
exposed to ETS either at home or at work. Wagen-
knecht and colleagues (1993) analyzed data collected
in 1985 and 1986 from 3,300 persons aged 18-30 years
who were recruited in four urban centers (Birming-
ham, Chicago, Minneapolis, and Oakland). African
Americans were more likely than whites to report
home exposure to ETS and to report that they spent
time mostly with smokers. Using 1988 NHIS data on

the number of smokers in the home, Overpeck and Moss
(1991) estimated that 42.4 percent of US. children aged
five years and younger were living in a household with
a smoker. In 1988, African American children were more
likely to be living with a smoker (51.3 percent) than were
white children (41.6 percent), and non-Hispanic chil-
dren (43.2 percent) were more likely to be doing so than
were Hispanic children (35.8 percent).

  In recent years, small-scale studies have reported
on potential exposure to ETS among young people in
U.S. racial/ethnic groups. For example, in two rural
Alaska villages, an analysis of saliva samples from chil-
dren in the Alaska Native Head Start program showed
that 44 percent of the children (3-6 years of age) had
cotinine concentrations indicative of exposure to ETS
(Etzel et al. 19921. Recent research has compared levels
of cotinine (a metabolite of nicotine) in biological flu-
ids and hair of children, young adults, and adults
Pattishall et al. 1985; Wagenknecht et al. 1993; Crawford
et al. 1994; Knight et al. 1996; Pirkle et al. 1996). Most
of these investigations (Pattishall et al. 1985; Crawford
et al. 1994; Knight et al. 1996; Pirkle et al. 1996) reported
that African Americans who did not use tobacco had
higher cotinine levels than whites, even after ETS
exposure and other factors were taken into account.
Further factors, including possible racial differences in
nicotine absorption and metabolism (Pattishall et al.
1985; Benowitz et al. 1995; Clark et al. 1996; Knight et
al. 1996) and measurement issues, need to be consid-
ered (see Racial/Ethnic Differences in Nicotine Metabo-
lites in Chapter 3 for further discussion of this topic).


Table 35.  Percentage of all adults and nonsmokers who reported levels of exposure to environmental
     tobacco smoke in the home, by racejethnicity and gender, National Health Interview Surveys,
     United States, 1991-1993 aggregate data

Home
exposure*

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

7c  ,c1+      7%   +CI        7c   +CI      %   +CI   % +CI Total(%)*

All adults
O-2 days
   Tootal
   Men
   Women

>3 days
  Total
  Men
  Women

Nonsmokers
O-2 days
   Total
   Men
   Women

>3 days
  Total
  Men
  Women

60.8 1.3      78.5   2.8       60.9   4.5     74.4   1.7   66.9 0.6   67.1
57.3   2.0      76.7   3.7       67.3   6.4     72.4 2.3   66.1 0.7   66.1
63.5   1.5      80.4   3.9       54.9   5.6     76.0 2.1   67.5 0.7   68.0

37.6 0.7      20.5   2.9       36.9   4.4     24.5   1.6   31.9 0.6   31.7
41.1   2.0      21.9   3.7       30.8   6.1     26.3 2.2   32.7 0.7   32.7
34.8   1.5      19.0   3.8       42.7   5.9     22.7 2.1   31.3 0.7    30.8

80.4   1.3      87.6   L.3 3'        83.6   1.5     86.6   1.4   85.7 0.5    85.3
80.1   2.1      92.0   2.8       90.0   4.9     87.2 2.0   85.2 0.7   85.1
80.6   1.5      84.0   3.7       78.8   7.0     86.1   1.9   86.2 0.6   85.4

18.3   1.2      11.7   2.5        13.5   4.3     12.6 1.4   13.5 0.5    13.9
18.6 2.0       7.0   2.7        9.5   4.8     12.0   1.9   14.0 0.7   14.0
15.1   1.5      15.5   3.6       17.8   6.4     13.0 2.0   13.1 0.6    13.8

*Home exposure was the average number of days per week that anyone was inside the home, as reported by
respondents answering "yes" to the question, "Does anyone smoke cigarettes, cigars, or pipes anywhere inside
this home?" However, these percentages include persons who indicated no exposure. Percentages exclude
"don't know" and "not ascertained" responses regarding the number of days; therefore, the sum may not
total 100%.
`95% confidence interval.
tTotal includes persons of other, unknown, or multiple ethnicities and unknown Hispanic origin.
Source: National Center for Health Statistics, public use data tapes, 1991-1993.

Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use

Cigarette Smoking

   The most recent data from the 1994 and 1995 com-
bined NHISs show that the age-adjusted prevalence
of current cigarette smoking was highest among
American Indians and Alaska Natives (36.0 percent),
intermediate among African Americans (26.5 percent)
and whites (26.4 percent), and lowest among Hispan-
ics (18.0 percent) and Asian Americans and Pacific Is-
landers (14.2 percent) (Table 36) (NCHS, public use

data tapes, 1994-1995). Among all racial/ethnic groups
except American Indians and Alaska Natives, men had
significantly higher rates of cigarette smoking than
women. Using data from the NC1 Supplement of the
1992-1993 CPS, Shopland and colleagues (1996) re-
ported patterns similar to those seen in the NHIS for
African Americans, Asian Americans and Pacific Is-
landers, Hispanics, and whites (data on American In-
dians and Alaska Natives were not included in their
report). From 1978 through 1995, the age-adjusted


prevalence of smoking declined for African Americans,
Asian Americans and Pacific Islanders, and Hispanics-
overall and for both men and women (Figures 13-15)
(NCHS, public use data tapes, 1978-1995). A differ-
ent picture emerges for American Indians and
Alaska Natives. Although a fairly substantial decline

in prevalence was observed, particularly among men,
for American Indians and Alaska Natives from 1978-
1980 to 1983-1985, prevalence did not change overall
or for men from 1983-1985 to 1994-1995 or for women
from 1978-1980 to 1994-1995.

Table 36.  Age-adjusted prevalence of current cigarette smoking" among adults, overall and by race/
    ethnicity and gender, National Health Interview Surveys, United States, 1994 and 1995
     aggregate data

             African     American Indians/
            Americans     Alaska Natives

Characteristic %   %I+       %    XI

Asian Americans/
Pacific Islanders

%      ?CI

Hispanics

%   XI

Whites

%    %I

Total         26.5   1.7      36.0    6.0       14.2     2.7     18.0   1.5    26.4   0.7

Men         31.4   2.6      39.3    9.5      23.8     5.1     21.7   2.3    28.1   1.0

Women        22.2   1.8      32.9    8.0       5.4     2.1     14.6   1.8    25.0   0.9
*Current cigarette smokers are 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. Data were age-adjusted
to the 1990 U.S. census population.
`95% confidence interval.
Source: National Center for Health Statistics, public use data tapes, 1994-1995.

Figure 13.  Trends in the age-adjusted prevalence of current cigarette smoking among African American,
     American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white
     adults, National Health Interview Surveys, United States, 1978-1995 aggregate data

70

60

    African
- Americans

American
Indians and
Alaska Natives

Asian
Americans
and Pacific
Islanders

10-

----- Hispanics

    Whites

0    I  I   I  I  I  I  II  1 II  I  I   I  I   I 11  11  11 11   11 11  II 1
1978-80           1983-85       1987-88     1990-91  1992-93  1994-95

                         Year

Note: Data were age-adjusted to Ihe 1990 U.S. census population.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.


Figure 14. Trends in the age-adjusted prevalence of current cigarette smoking among African American,
    American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and
    white men, National Health Interview Surveys, United States, 1978-1995 aggregate data

70-

      .
  60- `%, o ? ?? o ? ??
  50-            *, o ? o ?
5  40-
`=:
6
;  30
c

20-

10 -I

   African
- Americans

    American
- n - I. Indians and
   Alaska Natives

Asian
Americans
and Pacific
Islanders

De-D Hispanics

- Whites

O,,,l,l,l l,l,,/l/ll/llIlIIIII IllI
1978-80           1983-85       1987-88     1990-91 1992-93 1994-95

                         Year

Note: Data were age-adjusted to the 1990 U.S. census population.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

Figure 15. Trends in the age-adjusted prevalence of current cigarette smoking among African American,
    American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and
    white women, National Health Interview Surveys, United States, 1978-1995 aggregate data

    African
- Americans

   American
1111. Indians and
   Alaska Natives

                                                        Americans
                                                        and Pacific
t                                                      Islanders
20                                   -. ---D Hispanics

- Whites

0fl,ll,ll,,,l,l,l,ll,llllllllllll
1978-80           1983-85       1987-88     1990-91  1992-93  1994-95

                         Year

Note: Data were age-adjusted to the 1990 U.S. census population.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

Patferns of Tobacco Use  89


Table 37.  Cigarette smoking status *+ and number of cigarettes smoked per dayt among adults, overall
    and by race/ethnicity and gender, National Health Interview Surveys, United States, 1987,
    1988,1990, and 1991 aggregate data

Characteristic

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

Total
Never smokers
Former smokers
Current smokers
Cigarettes smoked per day
   <15 cigarettes
   15-24 cigarettes
   225 cigarettes

54.4              41.1              70.6
15.4               21.9               13.4
30.1               37.1               16.0

59.6              39.7              58.1
32.4              40.4              35.3
8.0               19.9               6.5

Men
Never smokers
Former smokers
Current smokers
Cigarettes smoked per day
   <15 cigarettes
   15-24 cigarettes
   225 cigarettes

44.6              36.1              56.8
19.6              26.0              19.6
35.9              38.0              23.6


54.1               27.5              56.1
36.3              49.7              37.8
9.6              22.8               6.1

Women
Never smokers                   62.6              46.0              85.3
Former smokers                   12.0               17.9               6.9
Current smokers                   25.4               36.2                7.8
Cigarettes smoked per day
   <15 cigarettes                 65.8              52.3              64.6
   15-24 cigarettes                27.9               30.9              27.6
   225 cigarettes                   6.3               16.8                7.9
Note: For racial/ethnic-specific data on cigars, pipes, chelving tobacco, snuff, or any form of tobacco, see Table 38.
*Never smokers are those who reported that they had never smoked at least 100 cigarettes; former smokers are
those who reported smoking at least 100 cigarettes in their lives but ~.ho reported at the time of survey that
they did not currently smoke; and current smokers are persons who reported smoking at least 100 cigarettes in
their lives and who reported at the time of survey that they currently smoked.
`95% confidence intervals for cigarette smoking status do not exceed 10.6% for whites, +1.4% for African
Americans, *3.1% for Asian Americans and Pacific Islanders, f6.6'k for American Indians and Alaska Natives,
i-0.5% for all non-Hispanics, ?1.7% for all Hispanics, *2.3% for Mexican Americans, k5.2R for Puerto Ricans,
+6.5% for Cuban Americans, ?3.3% for other Hispanics, and +0.5% for the total population.

  Analyses of aggregated NHIS data from the 1987,   Pacific Islanders (16.0 percent). The prevalence of
1988,1990, and 1991 surveys indicate differing patterns   never smoking cigarettes was highest among Asian
in the prevalence of current smoking, never smoking,   Americans and Pacific Islanders (70.6 percent) and
former smoking, and cigarette consumption among   lowest among American Indians and Alaska Natives
members of the four racial/ethnic groups (Table 37)   (41 .l percent). Rates of former cigarette smoking were
(NCHS, public use data tapes, 1987, 1988, 1990, and   highest among whites (26.0 percent) and lowest among
1991). The prevalence of current cigarette smoking was   Asian Americans and Pacific Islanders (13.4 percent).
highest among American Indians and Alaska Natives   Overall, men were more likely than women to be cur-
(37.1 percent) and lowest among Asian Americans and   rent or former smokers, whereas women were more


Hispanics

  All
Hispanics

Cuban
Americans

Puerto
Ricans

Mexican
Americans

Other
Hispanics

Whites

Total5

60.3           61.9        58.7        61.0          59.3        46.7       49.2
17.2           17.5        16.3        16.8          18.4        26.0       23.8
22.5          20.7        25.0        22.2          22.4        27.3       27.0

61.4          43.3        52.2        68.4          57.9        26.8       33.4
30.0          40.1        36.7       25.7          44.8        32.0       42.3
8.6           16.6         11.1         5.9           10.1         28.3       24.3

49.8           49.6        52.4        38.9          50.6         38.9       40.7
21.6           24.1         19.4        22.1          20.8        32.1       29.6
28.6           26.3        28.3        29.0          28.6        29.1       29.6

58.8           38.5        52.1        65.9          52.4        21.7       29.1
30.9           39.9        31.7        27.2          35.7        42.9       41.2
10.3           21.6        16.2         6.9           11.9        35.4       29.7

69.5           71.1        63.3        72.7          66.5        53.9       56.8
13.4           12.5        14.0        11.7           16.3         20.4       18.6
17.0           16.4        22.7        15.5          17.2        21.7       24.6

65.2           49.2        52.3        72.8          65.9        32.1       38.1
28.8           40.4         41.1        23.2          26.6         46.9       43.5
6.0           10.5         6.6         4.0          17.5        21.1       18.4

t95% confidence intervals for the number of cigarettes smoked dailv do not exceed +0.8% for whites, +2.2% for
African Americans, f9.7% for Asian Americans and Pacific Islanders, *10.4% for American Indians and Alaska
Natives, +0.9%' for all non-Hispanics, f3.4% for all Hispanics, *4.7% for Mexican Americans, f8.6% for Puerto
-Ricans, f12.4% for Cuban Americans, f6.8% for other Hispanics, and +O.S% for the total population.
"Includes persons of other, unknown, or multiple ethnicities and of unknown Hispanic origin.
Source: Centers for Disease Control and Prevention 1994~.

likely than men never to have smoked. Among Afri-
can Americans, Asian Americans and Pacific Island-
ers, and all Hispanics except Cuban Americans, the
majority of current smokers reported smoking fewer
than 15 cigarettes per day, whereas whites, American
Indians and Alaska Natives, and Cuban Americans
were more likely than others to report smoking 25 or
more cigarettes per day. For all groups except Puerto
Ricans, women were much more likely than men to
report smoking fewer than 15 cigarettes per day.

Pipe and Cigar Use

  The prevalence of current pipe or cigar use has
been higher among American Indians and Alaska Na-
tives than among other racial/ethnic groups, accord-
ing to aggregated data from the 1987 and 1991 NHISs
(Table 38) (NCHS, public use data tapes, 1987 and
1991). Current pipe or cigar use occurred primarily
among men; use was negligible among women of all
racial/ethnic groups. The prevalence of cigar or pipe

Patftws of Tobacco Use  91


Table 38.  Percentage of adults
     tobacco, overall and

         who reported using cigars, pipes, chewing tobacco, snuff, or any form of
         by race/ethnicity and gender, National Health Interview Surveys, United
States, 1987 and 1991 aggregate data*

Characteristic

African        American Indians/
Americans        Alaska Natives

Asian Americans/
Pacific Islanders

Cigar smoking+
Total
Men
Women
Pipe smoking*
Total
Men
Women

Cigar or pipe smoking+t
Total
Men
Women
Any tobacco smoking'
Total
Men
Women
Use of chewing tobacco1
Total
Men
Women

Use of snuff**
Total
Men
Women

Use of chewing tobacco or snuffl*'
Total
Men

Women
Use of any tobacco product++
Total
Men

Women

1.8               2.7                1.1
3.9               5.3                2.2
0.1               0.2               0.1

1.1               3.5
2.4               6.9
0.0               0.0

2.5               4.9               1.7
5.6               9.8               3.3
0.1               0.2               0.1

32.6              36.4              16.0
40.2              37.3              24.0
26.5              35.6               7.8

2.0               3.1               0.2
2.7               5.3               0.4
1.5                0.8                0.0

1.4               1.8              0.5
0.9               3.2               0.9
1.9                0.4               0.0

3.0               4.5               0.6
3.1               7.8                1.2
2.9               1.2               0.0

35.2              40.2              16.8
42.4               43.9              25.6
29.3              36.6               7.9

1.2
5:;

Note: For racial/ethnic-specific data on cigarette smoking, see Table 37.
*95% confidence intervals do not exceed +0.7% for whites, *2.1% for African Americans, f4.0% for Asian
Americans and Pacific Islanders, f9.6% for American Indians and Alaska Natives, f0.7% for all non-
Hispanics, f2.27~ for all Hispanics, &2.9% for Mexican Americans, +_7.0% for Puerto Ricans, f8.0% for
Cuban Americans, +3.9% for other Hispanics, and +0.7% for the total population.
`Includes persons who reported they had smoked at least 50 cigars in their lives and who reported at the time
of survey that they currently smoked a cigar.

tlncludes persons who reported they had smoked a pipe at least 50 times in their lives and who reported at the
time of survey that they currently smoked a pipe.
gIndicates a value of >O and ~0.05.

smoking among men was highest among American
Indians and Alaska Natives (9.8 percent) and lowest
among Puerto Ricans (1.5 percent). Unfortunately, the
1987 and 1991 NHISs did not distinguish between

ceremonial and addictive daily pipe smoking, and this
factor may partially account for the high prevalence
of pipe smoking among American Indian and Alaska
Native men.


Tobrrcco USC Alnong U.S. Racinl/Ethnic Minority Groups

Hispanics

  All         Cuban
Hispanics      Americans

Puerto
Ricans

Mexican
Americans

Other
Hispanics

Whites

Total

1.1            1.0         0.7         0.6           1.9         2.3        2.1
2.1                       1.3         1.5           3.8         4.8        4.4
0.1                     0.1         0.0           0.2         0.1        0.1

0.5            1.1         0.1         0.7           0.8         1.4        1.3
1.0           2.6         0.2         1.5           1.7         2.9        2.7
0.0           0.0         0.0        0.0          0.0         0.1       o.os

::;     2.1 5.1    0.8 1.5    2.7 1.2     4.3 2.1    3.3 6.7    3.0 6.2
0.1           0.0         0.1         0.0           0.2         0.1        0.1

22.7          22.5        22.1        26.8          21.7        29.6       29.1
29.3           30.8         29.4        31.9          27.2        33.2       33.4
16.8           16.9         14.8        23.1          16.9        26.3       25.2

0.4           0.0         0.4         0.1           0.5         2.0
0.7           0.0         0.8         0.3           1.1         4.1
0.1            0.0         0.1         0.0           0.1         0.1        0.3

0.5           0.1         0.6         0.3           0.8         1.9        1.7
1.0           0.3         1.0         0.6           1.6         3.8
0.1           0.0         0.2         0.0           0.0         0.3    Z:i

0.8           0.1         0.9        0.3           1.1         3.4        3.1
1.5           0.3         1.5         0.6           2.3         6.8        5.9
0.1           0.0         0.3         0.0           0.1         0.3        0.6

23.4           22.7        22.9        27.4          22.4        32.2       31.5
30.4           31.2        30.7        32.8          28.4        38.0       37.6
17.0           17.0        15.1        23.3          17.1         26.8       26.0

-\Includes current users of cigarettes, cigars, or pipes.
_Includes persons who reported thev had used chewing tobacco at least 20 times in their lives and who reported
at the time of survey that they currently chewed tobacco.
**Includes persons who reported they had used snuff at least 20 times in their lives and who reported at the
time of survey that they currently used snuff.
`+Includes users of cigarettes, cigars, pipes, chewing tobacco, or snuff.
Source: Centers for Disease Control and Prevention 1994~.

  A 1996 survey of U.S. students aged 14-19 years
found that white (28.9 percent) and Hispanic (26.2 per-
cent) students were slightly more likely than African
American students (19.3 percent) to report having
smoked at least one cigar during the previous year. In

each racial/ethnic group, males were significantly
more likely than females to have smoked at least one
cigar during the previous year. Use among females
ranged from 13.4 percent in African Americans to 20.0
percent among Hispanics. The prevalence of more

Pattcrm of Tobncco USC  93


frequent cigar use did not differ by racejethnicity; 3.6
percent of African Americans, 2.5 percent of Hispanics,
and 2.3 percent of whites reported that they had smoked
at least 50 cigars during the previous year (CDC 1997b).

Use of Smokeless Tobacco

   American Indians and Alaska Natives were the
most likely (4.5 percent) to use chewing tobacco or snuff,
according to aggregated data from the 1987 and 1991
NHISs, whereas Asian Americans and Pacific Island-
ers (0.6 percent) as well as Hispanics (0.8 percent) were
the least likely to use smokeless tobacco (Table 38).

Conclusions

Among all racial/ethnic groups except African Ameri-
cans, men were much more likely than women to use
chewing tobacco or snuff. Among African American
women, the use of smokeless tobacco has been high-
est among those aged 65 years and older (CDC 1994~).
These findings are consistent with those in published
studies (Bauman et al. 1989; Novotny et al. 1989; Rouse
1989), although they differ somewhat from the 1985
CPS estimates for males aged 16 years and older; these
estimates showed rates of reported snuff use among
African Americans (0.7 percent) and whites (2.2 per-
cent) that were significantly lower than the NHIS-
based rates reported here (Marcus et al. 1989).

1.

2.

3.

4.

5.

6.

In 1978-1995, the prevalence of cigarette smoking
declined among African American, Asian Ameri-
can and Pacific Islander, and Hispanic adults.
However, among American Indians and Alaska
Natives, current smoking prevalence did not
change for men from 1983 to 1995 or for women
from 1978 to 1995.

Tobacco use varies within and among racial/
ethnic groups; among adults, American Indians
and Alaska Natives have the highest prevalence
of tobacco use; African American and Southeast
Asian men also have a high prevalence of smok-
ing. Asian American and Hispanic women have
the lowest prevalence.

In all racial/ethnic groups discussed in this report
except American Indians and Alaska Natives, men
have a higher prevalence of cigarette smoking than
women.

In all racial/ethnic groups except African Ameri-
cans, men are more likely than women to use
smokeless tobacco.

Cigarette smoking prevalence increased in the
1990s among African American and Hispanic ado-
lescents after several years of substantial decline
among adolescents of all four racial /ethnic minor-
ity groups. This increase is particularly striking
among African American youths, who had the
greatest decline of the four groups during the 1970s
and 1980s.

Since 1978, the prevalence of cigarette smoking has
remained strikingly high among American Indian

7.









8.









9.









10.

and Alaska Native women of reproductive age and
has not declined as it has among African Ameri-
can, Asian American and Pacific Islander, and
Hispanic women of reproductive age.

Declines in smoking prevalence were greater
among African American, Hispanic, and white
men who were high school graduates than they
were among those with less formal education.
Among women in these three groups, education-
related declines in cigarette smoking were less
pronounced.

Educational attainment accounts for only some of
the differences in smoking behaviors (current
smoking, heavy smoking, ever smoking, and
smoking cessation) between whites and the racial/
ethnic minority groups discussed in this report.
Other biological, social, and cultural factors are
likely to further account for these differences.
Compared with whites who smoke, smokers in
each of the four racial/ethnic minority groups
smoke fewer cigarettes each day. Among smok-
ers, African Americans, Asian Americans and Pa-
cific Islanders, and Hispanics are more likely than
whites to smoke occasionally (less than daily).
The data in general suggest that acculturation in-
fluences smoking patterns in that individuals tend
to adopt the smoking behavior of the current
broader community; however, the exact effects of
acculturation on smoking behavior are difficult to
quantify because of limitations on most available
measures of this cultural learning process.


Appendix 1. Sources of Data

  Most of the data reported in this chapter were
collected through a number of large-scale sur\reys
conducted by the federal go\`ernment or private
researchers. When data from one period were insuffi-
cient (e.g., because of small sample size) for estimat-
ing the prevalence of a risk factor or a behaI,ior, thev
were combined with similar data for several periods,
provided the prevalence under consideration had not
changed rapidly over the periods being aggregated.
This process, used in some of the NHIS and BRFSS
analyses, increased the reliabilitlr and stabilitv of preva-
lence estimates (CDC lY92e).

  The data reported in this chapter are limited
in several ways. For example, because some racial/
ethnic groups were underrepresented in the data
sources, the small number of responses ma\' not be
representativre of the group as a whole. Moreo\.er,
most surveys haire been conducted in English only,
thus limiting the validitv of the responses of indi\pidu-
als with limited proficiency in English, particularly
among Asian Americans, Pacific Islanders, and His-
panics. In addition, some surveys ha\,e used tele-
phone surveys (excluding persons who lack telephone
service) or school surveys (excluding youths who
dropped out of school or who were frequently absent
from class); these survreys have thus excluded a num-
ber of respondents who may be at increased risk for
cigarette smoking. Despite these limitations, the pat-
terns described in this chapter are the first and largest
effort to present a comprehensive perspective on ciga-
rette use among members of racial/ethnic minority
groups in the United States.

National Health Interview Survey (NHIS)

  Since 1965, the CDC's NCHS has collected data
on tobacco use through the NHIS, which uses a prob-
ability sample of noninstitutionalized adult civilians
in the United States (NCHS 1975,1985a, 1989). Some
NHISs have excluded adults 18 and 19 years of age;
however, this report uses data from surveys that have
included respondents who were aged 18 years and
older (i.e., 1978,1979,1980,1983,1985,1987,1988,1990,
1991,1992,1993,1994, and 19951. Most interviews were
conducted in the home; when respondents could not
be interviewed in person, telephone interviews
were conducted. The overall NHIS response rate for

surveys on smoking has remained at least 85 percent
(NCHS 1985a). Overall, sample sizes have ranged from
10,342 in 1980 to 86,332 in 1966. In this report, data
have been adjusted for nonresponse and have been
weighted to provide national estimates. Confidence
intervals have been calculated by using standard er-
rors generated by the Professional Software for
Survey Data Analysis (SUDAAN) (Shah et al. 1991).
Responses from various administrations of the NHIS
have been aggregated to produce more stable results
for Hispanics, Asian Americans and Pacific Islanders,
and American Indians and Alaska Natives.

Hispanic Health and Nutrition
Examination Survey (HHANES)

   The NCHS conducted the HHANES from 1982
through 1984 to assess the health and nutritional
status and needs of Cuban Americans, MexicanAmeri-
cans, and mainland Puerto Ricans. No other equiva-
lent source of recent data is available for Hispanics.
This survey sampled Mexican Americans from Ari-
zona, California, Colorado, New Mexico, and Texas;
Cuban Americans from Dade County, Florida (Miami);
and Puerto Ricans from New York, New Jersey, and
Connecticut. Demographic and cigarette smoking in-
formation were collected from Hispanics aged 20-74
vears. All interviews were conducted in the home or
i
in a mobile examination center. NCHS estimates that
the HHANES data represent approximately 76 percent
of the 1980 Hispanic-origin population. All data in
this report have been adjusted and weighted for the
complex sample design, nonresponse bias, potential
noncoverage bias, and regional nature of the sample
(NCHS 1985b).

Behavioral Risk Factor Surveillance
System (BRFSS)

   The CDC's National Center for Chronic Disease
Prevention and Health Promotion coordinates the state
surveillance of behavioral risk factors through the
BRFSS, initiated in 1981 (Gentry et al. 1985; Remington
et al. 1988). Each state that participates in the BRFSS
provides estimates of numerous risk behaviors for the
state's population of persons aged 18 years and older.

Paftcnls of rolJncc0 Use  95


States collect data through random digit-dialed
telephone interviews. BRFSS sample sizes have ranged
from 476 in Indiana in 1984 to 3,988 in California in
1992. Since 1991, at least 1,178 persons have been
sampled in each state. In this report, the data have
been weighted to reflect the age, race/ethnicity, and
gender distribution of each participating state. Ninety-
five percent confidence intervals have been calculated
by using the Standard Errors Program for Computing
of Standardized Rates from Sample Survey Data
(SESUDAAN) (Shah 1981).

Adult Use of Tobacco Survey (AUTS)

  Since 1964, the AUTS has been conducted peri-
odically to determine rates of tobacco use as well as
descriptive information on smoking patterns among
representative samples of the U.S. population. Infor-
mation gathered has included a history of individual
use of any tobacco product as well as attitudes and
beliefs about smoking-related issues. The AUTS was
conducted in 1964, 1966, 1970, and 1975 by the
USDHEW's National Clearinghouse for Smoking and
Health, and the most recent survey was conducted in
1986 by the CDC's Office on Smoking and Health. In
the 1986 AUTS, a computer-assisted telephone inter-
view protocol (random-digit dialing) was used to sur-
vey 13,031 noninstitutionalized civilian U.S. adults
(217 years of age). Population estimates were obtained
by weighting the sample according to smoking status,
age, race/ethnicity, gender, education, and geographic
region (USDHHS 1990b).

Monitoring the Future (MTF) Surveys

  Each spring since 1975, the University of
Michigan's Institute for Social Research, with grants
from NIDA, has surveyed nationally representative
samples of high school seniors as part of the MTE
Sample sizes have ranged from 15,850 to 18,448. The
data in this report have been weighted to provide na-
tional estimates. Analyses were conducted on data
collected for 1976-1994. Data from subsequent years
were obtained from published reports (e.g., Johnston
et al. 1996) and from the University of Michigan's In-
stitute for Social Research. Since 1991, data have been
collected for eighth- and tenth-grade students. Some
data from these surveys are cited in this report
(Johnston et al. 1993b, 1995a, 19961.

Youth Risk Behavior Survey (YRBS)

  The CDC developed the Youth Risk Behavior Sur-
veillance System to measure six categories of priority
health-risk behaviors, including tobacco use, among
adolescents. Data were collected through national,
state, and local school-based surveys of high school stu-
dents, conducted during the spring of odd-numbered
years, and a national household-based survey of youths
aged 12-21 years, conducted during 1992 (Kolbe 1990;
Kolbe et al. 1993; CDC 1996). Data from the 1991 and
1995 national school-based surveys and the 1992 na-
tional household survey are cited in this report
(USDHHS 1994; CDC 1996; Lowry et al. 1996).

   The national school-based YRBSs each used a
three-stage cluster sample design to draw a nationally
representative sample of ninth- to twelfth-grade stu-
dents in public and private schools in all 50 states and
the District of Columbia. Schools having a substantial
proportion of African American and Hispanic students
were oversampled. The questionnaire was adminis-
tered in the classroom by trained data collectors. The
data were weighted to provide national estimates.

  The 1992 YRBS was a follow-back survey to the
1992 NHIS. The sample of young people aged 12-21
years was drawn from families who were interviewed
for the 1992 NHIS. Participants responded in person.
Respondents listened through a headset to an audio-
cassette containing previously recorded questions.
Respondents recorded their responses on answer
sheets, which were returned to the interviewers in
sealed envelopes. The data were weighted to provide
national estimates.

Teenage Attitudes and Practices Survey
(TAPS)

  In 1989 and 1993, the U.S. Public Health Service
conducted the TAPS to collect data on knowledge, at-
titudes, and practices regarding tobacco use from a
national household sample of adolescents (aged 12-18
years) through telephone interviews. The 1993 TAPS
included a longitudinal component (TAPS-II) in which
7,960 (87.1 percent) of the 9,135 respondents to the 1989
TAPS were reinterviewed; these respondents were 15-
22 years of age during TAPS-II. TAPS-II also included
4,992 persons from a new probability sample. In this
report, data on 9,135 TAPS respondents and 7,311 TAPS-
II respondents have been analyzed. Data have been
weighted to provide national estimates, and confidence
intervals have been calculated by using the standard
errors generated by the SUDAAN (Shah et al. 1991).


Tobacco Use Among U.S. Racinl/Efhnic Mi~orify Grcmps

Appendix 2. Measures of Tobacco Use

  Several measures of tobacco use among members
of racial/ethnic groups can be derived from state and
national surveys and other data sources. The most
common measures include cigarette smoking and ces-
sation; the number of cigarettes smoked daily; and the
use of cigars, pipes, and smokeless tobacco.

Cigarette Smoking and Cessation

  The NHIS gathers information on a range of ciga-
rette smoking behaviors, using some of the following
terms and measurements:

For 197881991, ci~~~zt srr~okcrs are defined as those
who have smoked 100 or more cigarettes in their
lifetime and who report at the time of survey that
they currently smoke.  For 1992-1995, current
smokers are defined as those who have smoked at
least 100 cigarettes in their lives and who report at
the time of survey that they currently smoke ev
ery day or on some days.

Former smokers are those who have smoked 100 or
more cigarettes in their lifetime and who do not
currently smoke.

Netler smokers are those who have smoked fewer
than 100 cigarettes in their lifetime.
Ezler smokers consist of current smokers and former
smokers.

The prevalence ofcessafi~ (or quit ratio) is defined
as the percentage of ever smokers who are former
smokers (Fiore et al. 1989; USDHHS 1989,199Oa).

  NHIS data on age at initiation of regular smok-
ing and on duration of abstinence for former smokers
have been used to reconstruct the prevalence of ciga-
rette smoking for the decades in this century before
systematic surveillance of cigarette smoking was
conducted (NC1 1991). Information such as the
respondent's date of birth, age at initiation of smok-
ing, and age at cessation for former smokers can be
used to assess the smoking status of a respondent for
any given year. Similar analyses have been reported
in previous Surgeon General's reports (USDHHS 1980,
1985) and in the literature (Harris 1983; Escobedo and
Remington 1989; Pierce et al. 1991b).

  The BRFSS has routinely reported estimates of
"regular" cigarette smoking. Current regular smok-
ers are defined as those (1) who report that they have

smoked 2100 cigarettes and that they currently smoke
and (2) who do not respond that they are occasional
smokers when asked to report the average number of
cigarettes they smoke daily. The use of a measure of
current regular smoking generally results in median
prevalence estimates that are about 0.7 to 1.0 percent-
age points lower than those estimates that include
current occasional smokers (CDC 1994~). The BRFSS
defines and calculates the prevalence of smoking ces-
sation in the same manner as is done in the NHIS.

  In the MTF surveys, current cigarette use patterns
are defined as any use of cigarettes within the 30 days
preceding the survey. This same definition was used
for current alcohol, marijuana, cocaine, and any other
illicit drug use.

Number of Cigarettes Smoked Daily

  Cigarette consumption traditionally has been
reported in three categories: (1) smoking fewer than
15 cigarettes per day, (2) smoking between 15 and 24
cigarettes per day, and (3) smoking 25 or more ciga-
rettes per day. In the NHISs and the BRFSS surveys,
respondents were asked to report the actual number
of cigarettes smoked per day.

  In the 1978-1991 NHISs, cigarette consumption
was defined as the average number of cigarettes that
current smokers reported smoking each day. Starting
in 1992, however, current smokers who reported that
they smoked only on some days were asked to report
the number of days out of the past 30 days that they
smoked any cigarettes and the average number of ciga-
rettes they smoked on the days that they smoked.

  The MTF survey asks respondents how fre-
quently they have smoked during the previous 30
days. Possible responses are "not at all," "less than
one cigarette per day, " "one to five cigarettes per day,"
"about one-half pack per day," "about one pack per
day," " about one and one-half packs per day," and
"two packs or more per day."

Use of Cigars, Pipes, and Smokeless Tobacco
  The 1987 and 1991 NHISs defined current cigar
smokers as those who had smoked 50 or more cigars
in their lifetime and who were current cigar smokers,
and they defined current pipe smokers as those who
had smoked 50 or more pipes full of tobacco and who


were current pipe smokers. Current snuff users were
defined as those who had used snuff 20 or more times
and were currently snuff users. The same logic was
used to classify chewing tobacco users.

  In the BRFSS surveys, smokeless tobacco users
were defined as those who said that they had ever used
smokeless tobacco (such as chewing tobacco or snuff)
and who were current users of any smokeless tobacco
products.

Appendix 3. Patterns of Cigarette Use Among Whites

Table 39. Percentage of white adults who reported being current cigarette smokers,* overall and by gender,
    age, and education, National Health Interview Surveys, United States, 1965-1995

                              1965          1966          1970          1974

Characteristic                 7c   kC1t      %    XI      %    IfrcI      %    %I

Total                      42.1    0.6     42.4    0.5     37.0    0.7     36.4 0.8

Gender
Men
Women

51.1    0.8     51.8    0.8     43.2    0.8     41.9 1.0
34.0    0.7     33.9    0.7     31.6    1.0     31.7    1.1

Age (years)
18-34
35-54
255

48.6    1.0     48.3    0.9
48.5 0.9     48.7    0.9
26.3 0.9     27.4    0.9

41.3
42.8
25.1    0.9

40.7 1.6
41.9    1.1
24.9    1.1

Education5
Less than high school
High school
Some college
College

4?%   NA
     0.7
NA NA
40.4-'   1.3

41.3    0.9     37.1    1.0     36.9 1.3
44.3 1.0     39.0    0.9     38.1 1.3
44.4 1.8     38.5 1.4     37.9 2.0
35.2    1.8     28.6    1.5     28.2    1.7

1985          1987          1988          1990

Characteristic                  YC    kC1      5%    !CCI      7c    KI      YC    XI

Total                      29.9    0.7     29.0    0.7     28.2    0.6     25.9    0.6

Gender
Men
Women

31.8    1.0     30.6    0.9     30.3    0.9     27.8    0.9
28.2    0.9     27.5    0.8     26.3    0.7     24.1 0.8

Agleg!y;rs)
35-54

33.6    1.2     32.2 1.1     31.9 1.1     29.7 1.0
33.7    1.2     33.7    1.0     32.1    1.0     29.9    1.0
21.5    1.0     20.2    0.9     19.7    0.8     16.8    0.8

255
Education_
Less than high school
High school
Some college
College

33.7 1.6     34.8 1.6     33.7 1.3     32.0 1.5
33.1    1.2     32.6    1.1     32.6 1.0     30.0 1.0
30.3 1.6     28.5 1.3     27.8 1.3     24.9 1.2
18.3 1.2     16.9 1.0     16.2    1.0     13.7 0.9

*Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites;
these data exclude those whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette
smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the
time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported
smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked
every day or on some days.


1976+        1977+          1978          1979          1980           1983

35.0   0.7      34.0 1.2      33.4 0.8      33.0 1.1      32.3   0.7

39.0   1.0      37.3   1.9       36.6   1.0      36.5   1.6      34.6   1.1
31.8   1.1      31.1   1.3      30.6 1.0      29.8   1.5      30.2   0.9

38.9   1.5      37.0 1.8      37.3 1.3      35.2   1.8      36.0   1.2
41.1    1.1      40.5 2.0       38.4   1.3      38.8 2.0      37.4   1.3
25.1   1.1      23.6  1.7      23.6 0.9      24.3 1.6      22.5   1.1

35.7   1.3      35.6 2.2      35.1   1.5      35.5   2.0      35.3   1.6
37.8   1.4      37.0 1.9      35.3 1.3      34.9   2.0      34.8   1.3
37.0   1.8      34.1 3.1       35.7   1.8      33.9   3.1      32.8   1.9
25.9   1.7      23.8 2.6       23.2 1.6      24.4   2.3      20.1   1.5

35.9

40.7
31.9

40.0
41.2
25.0

36.6
37.6
37.6
27.2

0.7


1.1
1.0


1.2
1.4
1.1


1.5
1.4
2.1
1.7

1991

1992          1993          1994          1995

YC   XI       YC   %I       Yc   KI       5%   XI

YC   ASI

26.0   0.6


27.5   0.9
24.6   0.7


29.8 1.0
30.0   1.0
17.3   0.8


33.3   1.5
30.6 0.9
24.9   1.2
13.8 0.9

27.2   0.8      25.4 0.8      25.5 0.7      25.6   1.0

28.6   1.2      27.0 1.2      28.2 1.1      27.1   1.5
25.9   1.1      24.0 1.0      23.1 0.9      24.1   1.3

32.8   1.5      30.1 1.4      29.3 1.4      29.7   1.8
30.1   1.3      29.3 1.4      28.9 1.2      28.3   1.6
17.5   1.2      15.8 1.1       16.2 1.1      17.8 1.3

32.0 2.0      31.8 2.6      31.9 1.8      33.3 2.6
31.9   1.4      29.1 1.3      29.8 1.3      30.2   1.7
25.9   1.7      24.9 1.7      25.7 1.7      24.1 1.9
14.8 1.3      13.5 1.3      12.3 1.1      14.0 1.6

`The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
were statistically adjusted to produce estimates for the total population, males, and females that approximate
those for whites aged 18 years and older. Estimates for ersons in the 18-34 year old age category were statisti-
               i$
cally adjusted to produce estimates that approximate thos
t95'% confidence interval.                for whites aged 18-34 years.
51ncludes persons aged 25 years and older.
`Levels presented for 1965 are for persons who had a high school education or less and persons who attended
some college or were college graduates.
NA = data not available.
Source: National Center for Health Statistics, public use data tapes, 1965-1995.    Pnffer~ls of l-dm-co Use  99


Table 40.  Percentage of adult white smokers* who reported smoking <15,1>24, and 2 25 cigarettes per day,
    overall and by gender, age, and education, National Health Interview Surveys, United States,
       1965-1995

Characteristic

Total
  <15 cigarettes
  15-24 cigarettes
  2 25 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
  2 25 cigarettes
35-54
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
255
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
Educations
Less than high school
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
High school
  cl5 cigarettes
  15-24 cigarettes
  225 cigarettes
Some college
  <15 cigarettes
  15-24 cigarettes
225 cigarettes
College
  cl5 cigarettes
  15-24 cigarettes
225 cigarettes

1965            1966           1970            1974

YC

KI

33.1   1.1       31.7    0.8      29.7    0.9       27.7    1.2
45.3   0.8       45.9    0.9       45.0    0.9      44.7    1.2
21.6   0.7       22.4    0.7      25.4    0.9      27.6    1.1

26.6   1.0       25.8    1.0      24.4    1.2      21.5    1.6
46.7   1.1       47.2    1.2       45.2    1.2      44.5    1.9
26.7   0.9       27.0    1.0      30.4    1.2      34.1    1.7

41.8   1.3       39.5    1.2      35.9    1.1      34.5    1.7
43.4   1.3       44.3    1.3       44.7    1.1      45.0    1.6
14.8   0.9       16.2    1.0       19.4    0.9      20.5    1.2

34.7   1.4       33.9    1.3      31.6    1.2      30.9    1.8
47.4   1.5       48.2    1.3       46.9    1.2      46.3    1.8
17.9   1.1       17.9    1.0       21.6    1.2      22.8    1.6

29.0   1.1       26.7    1.1       24.7    1.1      21.4    1.6
45.1   1.2       45.5    1.3       44.2    1.2      42.9    1.8
28.0   1.2       27.8    1.1       31.1     1.1      35.7    1.7

40.1   1.9       38.8    1.9      36.3    1.6      32.7    2.4
41.5   1.9       42.2    1.9       42.7    1.4      44.7    2.4
18.4   1.5       18.8    1.5       21.1    1.5      22.7    2.3

NA   NA       30.7    1.3      28.6    1.5      25.7    2.0
NA   NA       45.8    1.3       44.3    1.2      45.1    2.1
NA   NA      23.5    1.2      27.0    1.4      29.2    1.8

31.1l   1.0       28.5    1.4       26.2    1.4      25.7    2.0
15.9l   1.1       46.9    1.7       47.3    1.4      44.7    2.3
23.0'   0.9       24.6    1.4      26.5    1.3      29.6    1.9

NA   NA       29.4    2.7       27.1    2.4      23.1    3.1
NA   NA      44.6    3.0       43.1    2.8      42.7    3.3
NA   NA      26.0    2.6       29.8    2.2      34.2    2.6

33.2A   2.0       35.0    3.1       31.7    2.1      27.9    3.9
42.3'   2.2       39.2    3.2       40.2    2.8      43.0    3.8
24.5'   2.0       25.9    2.8      28.1    3.1      29.1    3.4

*Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data
exclude those whites who indicated they were of Hispanic origin. For 1965-1991, 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.
NA = data not available.
Source: National Center for Health Statistics, public use data tapes, 1965-1995.


Tdacco Use Amot~g U.S. Racial/Ethnic Minority Groups

1976+

YC    %I

27.8    1.2     26.9    1.2     23.7    1.5     24.4
45.2    1.3     43.6    1.4     44.7    1.7     44.7
27.0    1.2     27.5    1.4     31.6    1.6     30.9

23.2    1.6     23.8    1.2
44.6    1.9     46.8    1.4
32.2    1.9     29.4    1.3

22.0
45.2
32.8

1.6
1 .6
1 .7

20.5    1.3     17.8    1.9     20.0
41.6    1.7     43.6    2.5     43.1
33.5    1.8     38.6    2.3     36.9

1.0
1.3
1.2



1.2

1 .7
1 .7


.6
.9
.5

17.7    2.2     17.8    1.5
44.3    2.7     45.1    2.0
38.0    2.7     37.1    1.6

34.0
45.1
21.0

.7
.8
5
.L

33.7    1.6     30.1    2.4     29.2
45.8    1.9     45.8    2.3     46.5
21.0    1.6     24.1    2.3     24.4

29.3    2.1     30.1    1.7
44.8    2.6     48.4    1.9
25.9    2.3     21.5    1.6

30.0
47.3
22.6

.8
.9
.9

29.9    1.7     25.2    2.2     26.5
45.9    1.9     47.8    2.6     47.4
21.9    2.1     27.0    2.7     26.1

.7     25.2    2.7     27.5    1.9
.8     48.0    2.9     49.9    2.0
.5     26.9    2.6     22.7    1.7

22.7    1.7     21.2    1.8     19.0    2.3     19.2    1.5     17.6    2.6     18.0    1.7
43.3    2.0     42.6    2.0     41.5    2.7     41.8    2.2     40.5    2.9     42.6    2.2
34.0    1.8     36.3    2.0     39.5    2.4     39.0    2.2     41.9    3.4     39.4    2.2

32.0    2.5     31.6    2.6     28.9    3.6     28.8    2.6     28.7    3.2     26.0    2.5
43.8    2.7     42.9    2.9     43.9    4.1     44.1    3.0     44.7    3.7     47.3    2.9
24.2    2.3     25.6    2.5     27.2    3.7     27.2    2.5     26.6    3.3     26.7    2.5

26.7    1.9     26.2    2.1     23.3    2.9     23.1    2.0     21.2    3.0     20.4    2.2
44.5    2.2     43.3    2.7     44.1    3.3     44.0    2.6     44.9    3.7     45.4    2.9
28.8    2.2     30.5    2.3     32.7    2.4     32.9    2.2     33.9    3.6     34.3    2.7

24.2    1.8     22.7    1.7     22.4    2.5     20.5    1.7     21.0    2.7     21.3    1.8
46.3    2.3     45.6    2.1     43.8    2.7     46.0    2.3     44.6    3.5     46.0    2.3
29.5    2.2     31.7    2.1     33.8    2.9     33.5    2.1     34.4    3.4     32.7    2.2

26.2    3.6     27.8    3.2     18.9    3.2     22.0    3.0     18.0    4.2     21.2    2.9
41.8    3.4     41.4    3.6     44.2    5.7     42.1    3.2     45.9    5.5     46.3    3.6
32.0    3.4     30.8    3.1     37.0    5.5     35.9    3.0     36.0    4.7     32.5    3.4

30.4    3.7     30.4    3.1     25.8    5.2     29.6    3.7     27.7    5.0     28.4    3.8
41.2    4.4     40.2    3.8     41.1    5.9     37.2    3.9     35.2    5.4     40.9    4.2
28.4    3.3     29.4    3.7     33.2    4.7     33.2    3.6     37.1    5.7     30.7    4.2

1977+          1978          1979          1980          1983

YC    ASI      5%    ASI      YC    ?CI      YC    KI      70    KI

+The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
were statistically adjusted to produce estimates for the total population, males, and females that approximate
those for whites aged 18 years and older. Estimates for persons in the 18-34 year old age category were statisti-
cally adjusted to produce estimates that approximate those for whites aged 18-34 years.
195% confidence interval.
SIncludes persons aged 25 years and older.
`Levels presented for 1965 are for persons who had a high school education or less and persons who
attended some college or were college graduates.

Patterns of Tobacco Use  101


Surgem Gerzeral'.s Xcport

Table 40.  Continued

Characteristic

1985             1987             1988           1990

%   KIS        %    3.3        %    WI       %    %I

26.1   1.1       25.4    1.0       24.7    1.0      27.9    1.1
43.6   1.3       43.7    1.1       45.7    1.1      45.2    1.2
30.3   1.2       30.9    1.1       29.6    1.0      26.9    1.2

20.1   1.6       20.6    1.4       20.4    1.3      21.7    1.4
42.6   1.9       40.6    1.6       43.9    1.6      43.9    1.8
37.3   1.8       38.8    1.6       35.7    1.6      34.5    1.9

32.1   1.6       30.3    1.5       29.3    1.5      34.5    1.6
44.7   1.7       46.9    1.6       47.5    1.6      46.6    1.6
23.2   1.4       22.8    1.4       23.3    1.2      19.0    1.4

31.1   1.9       29.8    1.7       29.3    1.7       34.9    1.9
45.2   2.0       45.6    1.8       47.7    1.8       47.3    1.9
23.8   1.7       24.6    1.5       22.9    1.5      17.8    1.6

19.0   1.7       20.1    1.6       18.1    1.5      20.4    1.6
41.1   2.1       41.3    1.8       43.7    1.8      43.4    2.0
39.9   2.1       38.6    1.5       38.3    1.8      36.2    2.0

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)
IS-34
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
35-54
  cl5 cigarettes
   15-24 cigarettes
  225 cigarettes
  255
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
Educations
Less than high school
  cl5 cigarettes
   15-24 cigarettes
  225 cigarettes
High school
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
Some college
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
College
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
x95% confidence interval.
$Includes persons aged 25 years and older.

27.7   2.4       26.3    1.6       27.7    2.0       29.1    2.5
44.7   2.6       44.6    1.8       45.0    2.2      44.5    2.5
27.6   2.3       29.2    1.9       27.2    2.1      26.4    2.3

19.5   2.2       19.9    2.1       19.1    1.8      19.5    2.2
44.3   2.7       44.2    2.4       44.5    2.4       48.6    2.9
36.2   2.7       35.8    2.4       36.5    2.4      31.9    2.7

23.1   1.8       22.8    1.5       20.5    1.4      24.5    1.7
44.5   2.1       43.4    1.8       47.7    1.8      45.8    1.9
32.4   1.9       33.8    1.8       31.8    1.6      29.6    1.8

26.3   2.8       24.9    2.3       25.6    2.3      27.8    2.6
42.0   3.1       43.0    2.8       43.2    2.7      43.5    3.1
31.7   2.9       32.2    2.7       32.2    2.4      28.7    2.8

30.5   3.4       31.0    3.1       32.4    2.9      35.1    3.3
37.9   3.7       39.9    3.4       39.5    3.2      39.6    3.4
31.6   3.6       29.2    3.0       28.1    2.9      25.3    3.3


Tobrrcco USE Among U.S. Racial/Ethic Minority Groups

1991           1992          1993          1994          1995

7c    KI      R    kc1      c    kC1      5%    %I      70    XI

29.8    1.2     31.7    1.5     32.5    1.7     35.6    1.8     35.0    2.0
45.0    1.3     43.3    1.6     44.9    1.7     44.4    1.9     41.8    2.1
25.2    1.2     25.0    1.4     22.6    1.4     20.0    1.4     23.2    1.8

24.6    1.6     25.8    1.9     27.5    2.4     30.5    2.5     28.0    2.6
43.4    1.7     41.8    2.4     43.0    2.5     44.3    2.7     41.6    3.0
31.9    1.8     32.4    2.2     29.5    2.3     25.1    2.2     30.4    2.8

35.0    1.6     37.7    2.3     37.6    2.3     40.8    2.5     42.3    2.8
46.6    1.7     44.9    2.2     46.8    2.4     44.5    2.4     41.9    2.8
18.4    1.3     17.4    1.6     15.6    1.8     14.6    1.9     15.8    2.0

36.5    2.0     37.4    2.6     39.5    3.0     42.5    3.0     44.3    3.4
46.1    2.1     43.9    2.5     45.6    2.8     45.4    3.1     41.1    3.4
17.5    1.7     18.6    2.2     15.0    2.0     12.1    1.7     14.6    2.9

23.9    1.6     26.8    2.3     27.6    2.6     29.6    2.6     31.0    3.0
43.4    1.9     42.3    2.8     44.1    2.5     42.9    2.6     41.6    3.0
32.7    1.9     30.9    2.4     28.3    2.4     27.6    2.5     27.4    2.6

29.1    2.1     29.9    3.2     30.0    3.4     34.6    3.6     27.0    3.4
46.2    2.4     44.2    3.6     45.2    4.1     45.9    4.1     43.2    4.2
24.7    2.2     25.9    2.9     24.8    3.1     19.5    3.2     29.8    4.2

21.4    2.2     24.6    3.2     25.3    3.5     25.6    3.5     19.9    3.7
43.8    2.6     41.5    3.7     45.9    4.0     44.5    4.5     45.4    4.8
34.8    2.7     33.9    3.7     28.8    3.7     29.9    4.1     34.7    4.6

25.7    1.6     26.7    2.3     28.2    2.5     30.5    2.7     29.2    2.8
47.7    1.9     46.3    2.8     46.2    2.7     46.8    2.9     45.0    3.1
26.6    1.9     27.0    2.4     25.6    2.4     22.7    2.3     25.8    3.0

33.0    2.7     33.7    3.7     34.0    3.7     36.8
43.6    2.9     42.0    3.6     44.3    4.3     44.0
23.4    2.4     24.3    3.5     21.8    3.4     19.2

4.4
4.0
3.3


5.4
5.3
3.7

40.2    4.6
39.2    4.6
20.6    3.8

35.3    3.4     43.2    4.5     42.1    5.4     48.7
42.9    3.4     37.6    4.6     37.7    5.0     36.9
21.8    2.9     19.2    4.1     20.2    3.8     14.4

50.6    5.6
34.0    5.5
15.4    3.8

-

Patterns of Tobacco Use  103


Surgeon Gmt~ral `s Report

Table 41.  Percentage of adult white ever smokers who have quit,* overall and by gender, age, and
     education, National Health Interview Surveys, United States, 1965-1995

                            1965          1966          1970          1974

Characteristic                 %   ?-cIS     %    XI      %    kc1      %    kc1

Total                    25.2    0.6     25.3 0.6     34.3 0.8     36.1 0.9

Gender
Men
Women

28.9    0.8     28.9    0.8     39.0    1.0     41.0    1.1
19.6    0.9     19.6    0.9     27.8    0.9     29.6    1.4

Age (years)
18-34
35-54
255

17.6    0.9     16.9    0.9     25.9    1.1     26.2    1.7
24.5    1.0     25.0    0.9     33.5    1.1     35.2    1.2
38.3    1.6     38.2    1.5     47.5    1.3     51.0    1.8

Education5
Less than high school          NA    NA     26.4    1.0     34.6    1.2     36.2    1.6
High school             25.4'   0.8     25.1    1.2     34.5    1.0     36.3    1.5
Some college               NA    NA     28.4    2.2     37.1    1.6     39.5    2.5
College                33.2+    1.6     38.5    2.3     49.7    2.3     50.6    2.4

Characteristic

1985          1987          1988          1990

%    ASI      7c    kc1      %    KI      70    KI

Total                       46.6    1.0     46.2    0.9     47.7    0.9     50.9 1.0

Gender
Men
Women

51.0    1.3     50.5    1.2     51.1    1.2     54.2    1.3
41.0    1.3     40.9    1.3     43.5    1.1     47.0    1.2

Age (years)
18-34
35-54
255

32.4    1.5     31.4    1.4     32.3    1.5     35.1    1.6
46.2    1.6     44.6    1.5     45.9    1.4     48.6    1.5
62.2    1.6     63.1    1.5     65.0    1.3     68.9    1.3

Education5
Less than high school         46.5    2.1     44.3    1.9     45.7    1.7     47.8    2.0
High school               44.5    1.6     44.8    1.4     45.0    1.4     48.2    1.5
Some college               48.7    2.3     48.9    1.9     50.7    1.9     54.0    1.9
College                  63.7    2.2     63.0    2.1     64.6    1.8     68.7    1.9

*Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites;
these data exclude those whites 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.

`The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
were statistically adjusted to produce estimates for the total population, males, and females that approximate
those for whites aged 18 years and older. Estimates for persons in the 18-34 year old age category were statisti-
cally adjusted to produce estimates that approximate those for whites aged 18-34 years.


Tohncco Use Amolzg U.S. XaciallEthnic Mhorify Groups

1976+        1977+         1978          1979          1980          1983

36.5

41.3
30.4

25.3
36.5
51.6

37.1
36.6
39.7
49.4

1.0      36.3



1.3      41.4
1.5      30.0



1.3      26.8
1.7      35.2
1.9      50.7



1.9      36.8
1.7      36.1
2.8      39.4
2.7      50.2

1.0      39.5 1.7      40.5 1.2      40.8

1.1      44.7 2.1       45.3   1.3      45.2
1.5      32.8 2.0       34.3 1.7      35.0

1.8      29.1 2.3      29.4 1.5      30.5
1.5      36.7 2.6      39.7 1.8      39.8
1.9      56.0 2.7       55.5 1.6      54.5

1.7      39.1 2.7       41.2 1.9      39.7
1.9      39.0 2.3       40.2 1.8      40.7
2.2      44.9 3.9       41.7 2.4      43.5
2.8      54.5 3.9       55.6   2.7      54.2

1.7      42.0



2.1      46.6
2.4      36.2



2.3      29.1
2.6      40.3
2.9      59.0



3.0      41.5
2.7      41.9
4.3      44.6
3.9      57.9

1.4
1.4

1.5
1.7
1.8

2.1
1.7
2.6
2.7

1991          1992          1993          1994          1995

7c   KI       R   %I       7c   2321       7c   XI       %   321


50.5   0.9      48.5   1.3      51.6 1.3       51.0 1.3      50.5 1.6

54.2   1.2      52.0   1.7      54.6 1.7       53.7 1.7      52.9 2.2
46.2   1.3      44.4   1.8      48.1 1.7       47.8 1.9      47.6 2.1

31.9   1.5      27.4   2.0      31.4 2.0      29.0 2.2      31.5 2.6
48.7   1.4      48.0   1.9      48.6 2.0       49.3 1.9      48.6 2.4
68.8   1.3      68.1   2.0      71.8 1.8       72.1 1.8      68.0 2.2

  46.0   2.0      49.1   2.7      49.2 3.4      47.1 2.8      46.5 3.3
  48.0   1.4      45.6   2.0      49.8 1.9       48.5 2.1      47.2 2.4
  54.9   1.9      53.6   2.7      55.1 2.6      54.7 2.8      55.7 3.0
  67.8   1.8      64.2   2.6      68.1 2.6      70.8 2.6      66.1 3.4
t95% confidence interval.
kcludes persons aged 25 years and older.
`Levels presented for 1965 are for persons who had a high school education or less and persons who
attended some college or were college graduates.
NA = data not available.
Source: National Center for Health Statistics, public use data tapes, 1965-1995.

Paftcms of Tobacco Use  105


Surgeolr Genernl's Report

Table 42.  Percentage of white women of reproductive age who reported being current cigarette smokers,*
     overall and by education, National Health Interview Surveys, United States, 1965-1995

                          1965       1966       1970       1974    1976+

Characteristic                  %   +CIS %   +CI    %   +CI YO   +CI %   +CI

Total                      42.2 1.1   41.5 1.1   36.8 1.2   37.3 1.7   36.4 1.5
Educations
Less than high school           NA NA   48.0 2.2   46.7 2.0   50.5 3.1   49.4 4.4
High school                44.2 1.4   41.3 1.8   36.6 1.8   38.2 2.5   38.0 2.5
Some college                NA NA   43.8 3.8   37.5 3.2   35.2 4.3   34.8 4.4
College                   41.3 2.9   34.6 4.4   27.2 2.6   25.5 3.3   25.0 3.4
               1977+       1978       1979       1980       1983

                        R   +CI %   *CI %   +CI %   +CI %   +CI

Total                      36.8 1.5   35.6 2.1    36.0 1.4   33.2 1.9   35.5   1.3
Educations
Less than high school          47.6 3.9   56.1 5.9   52.0 3.9   53.9 7.0   53.6   4.6
High school                37.3 2.5   38.4 3.2   37.3 2.4   33.4 3.6   39.4   2.4
Some college                 35.3 3.6   31.8 5.8   36.3 4.3   32.2 5.3   30.8   3.2
College                   24.7 3.6   20.1 4.3   21.9 2.7   22.8 4.4   17.8   2.5

                           1985       1987       1988       1990       1991

                         %   +CI %   +CI %   +a Yo   +CI 70   +CI

Total                    32.5 1.3   31.1 1.1   30.3 1.0   27.9 1.1   28.7   1.1
Educations
Less than high school          55.1 4.4   60.6 3.7   57.9 3.9   58.4 4.3   59.6   3.8
High school                 37.1 2.1   36.5 1.8   35.7 1.8   34.4 1.8   36.5   2.0
Some college                28.8 2.7   29.2 2.2   29.2 2.3   24.5 2.1   25.1   2.0
College                   14.9 2.2   15.1 1.7   14.2 1.6   10.9 1.5   11.8   1.5

                           1992       1993        1994       1995

                          x   +CI w   +CI    %   +CI    %   +CI

Total                     30.7   1.6   29.1   1.4   30.6   1.6   28.2   1.8
Educations
Less than high school          55.5   6.0   60.1   6.2   56.1   7.2   51.7   7.8
High school                38.3   2.8   38.6   2.7   40.2   2.9   37.0   3.4
Some college               28.3   2.9   23.4   2.8   27.2   3.2   26.0   3.6
College                   14.3   2.2   11.5   2.0   11.6   2.3   15.3   2.9

*Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites;
these data exclude those whites who indicated they were of Hispanic origin. For 1965-1991, 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.
`The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
were statisticallv adjusted to produce estimates that approximate those for white women aged 18-44 years.
$95% confidence'interval.
SIncludes persons aged 25 years and older.
NA = data not available.
Source: National Center for Health Statistics, public use data tapes, 1965-1995.

1 Oh  Chapter 2

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

Table 43.  Percentage of white adults who reported being current cigarette smokers," overall and by gender,
     age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data
                1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+

Characteristic              %  fCIS Yc   KI %   +c1 70   +c1 Yo   +c1 Yo   +c1

Total                  33.5 0.7   30.9 0.6   28.6 0.5   25.9 0.5

Gender
Men
Women

Age (years)
18-34
35-54
255

Education_
Less than high school
High school
Some college
College

36.8 1.0   32.9 0.8   30.5 0.7   27.6 0.7
30.5 0.8   29.0 0.7   26.9 0.6   24.4 0.6

36.7 1.1   34.6 0.9   32.0 0.8   29.8 0.8
39.0 1.0   35.1 1.0   32.9 0.7   30.0 0.7
23.7 0.8   21.9 0.7   19.9 0.7   17.1 0.6

35.3 1.2   34.4 1.3   34.2 1.1   32.6 1.1
35.6 1.1   33.8 0.9   32.6 0.8   30.3 0.7
34.8 1.3   31.2 1.3   28.2 1.0   24.9 0.9
23.6 1.2   19.0 1.0   16.5 0.7   13.8 0.7

26.4 0.6   25.9 0.7



27.8 0.8   27.6 0.9
25.0 0.8   24.4 0.8



31.6 1.1   31.3 1.2
29.7 1.0   28.7 1.1
16.7 0.8   16.8 0.9



31.9 1.6   33.8 1.7
30.6 1.0   30.3 1.1
25.4 1.2   24.7 1.3
14.2 0.9   13.3 1.0

*These data exclude whites who indicated thev were of Hispanic origin. For 1978-1991, current cigarette
smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the
time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported
smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently
smoked every day or on some days.

`1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
were combined.
$95% confidence interval.
51ncludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

Pafterns of Tobacco Use  107


Surgeon General's Report

Table 44. Percentage of adult white 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             %  *cc Yo   fC1 R  +c1    % +c1 %   fC1 %   fC1

Total
  Cl5 cigarettes
  15-24 cigarettes
225 cigarettes
Gender
Men
  Cl5 cigarettes
  15-24 cigarettes
  225 cigarettes

Women
  Cl5 cigarettes
  15-24 cigarettes
225 cigarettes
Age (years)
18-34
  Cl 5 cigarettes
  15-24 cigarettes
  225 cigarettes

35-54
Cl5 cigarettes
15-24 cigarettes
225 cigarettes

255
Cl5 cigarettes
15-24 cigarettes
225 cigarettes

24.0 0.7   25.1 0.8   25.0 0.7   28.9 0.8   32.1 1.1   35.3 1.3
44.7 0.9   44.9 0.9   44.7 0.8   45.1 0.9   44.0 1.2   43.1 1.4
31.4 0.9   30.0 0.9   30.3 0.8   26.1 0.9   23.9 1.1   21.6 1.1

18.9 0.9   19.1 1.2   20.5 1.0   23.2 1.1   26.6 1.6   29.3 1.8
43.5 1.3   43.7 1.3   42.3 1.1   43.6 1.3   42.3 1.8   43.0 2.0
37.6 1.3   37.2 1.4   37.3 1.2   33.2 1.3   31.1 1.6   27.7 1.8

29.4 1.1
45.9 1.3
24.7 1.1

25.9 1.3
47.6 1.2
26.5 1.3

18.8 1.0   18.6 1.4   19.1 1.1    22.2 1.1   27.2 1.7   30.3 2.0
41.4 1.6   41.7 1.7   42.5 1.3   43.4 1.5   43.1 1.8   42.2 2.0
39.8 1.5   39.7 1.7   38.4 1.3    34.4 1.5   29.7 1.6   27.5 1.8

28.8 1.7   27.0 1.7   27.0 1.4   29.1 1.6   29.9 2.5   30.5 2.5
44.2 2.0   45.8 1.8   44.8 1.6   45.4 1.7   44.7 2.7   44.4 2.9
27.1 1.7   27.2 1.7   28.2 1.5   25.5 1.6   25.4 2.2   25.0 2.7

46.2  1
22.5  1

29.6  1
47.1  1

23.3 1.2

29.8 1.0
47.2 1.1
23.0 0.9

29.6 1.2
46.7 1.3
23.8 1.1

46.6  1
18.7  1

35.7  1
46.7  1

17.6 1.2

37.7 1.6   41.6 1.9
45.7 1.6   43.2 1.8
16.6 1.2   15.2 1.4

38.3 2.0   43.3 2.2
44.6 1.9   43.4 2.3
17.1 1.5   13.3 1.6

*These data exclude those whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette
smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the
time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported
smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked
every day or on some days.

308 Chapter 2


7%mxn Use Allzollg U.S. Racial/Ethnic Miuority Croup

Table 44. Continued

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

Characteristic

- R  fCIS %   KI %   XI %   +c1 %   fC1 x   +c1

Education5
Less than high school
  <15 cigarettes
  15-24 cigarettes
  225 cigarettes
High school
  <15 cigarettes
  15-24 cigarettes
125 cigarettes

Some college
<15 cigarettes
15-i-24 cigarettes
225 cigarettes
College
<15 cigarettes
15-24 cigarettes
225 cigarettes

22.7 1.4   19.9 1.6   19.5 1.4   20.5 1.6   24.9 2.3   22.8 2.6
44.2 1.9   44.8 2.0   44.3 1.7   46.1 1.9   43.5 2.8   45.0 3.3
33.1 1.6   35.4 1.9   36.1 1.7   33.4 1.9   31.6 2.7   32.2 3.1

21.1 1.2
45.1 1.9
33.8 1.7

20.4 1.9   24.3 2.3   25.3 1.6   30.5 1.9   33.8 2.7   38.5 3.2
43.5 2.1   43.7 2.5   43.1 2.0   43.5 2.2   43.1 2.8   41.7 3.1
36.2 2.4   32.0 2.4   31.7 1.7   26.0 1.8   23.1 2.3   19.9 2.5

28.2 2.8   29.6 2.7   31.7 2.3   35.2 2.4   42.7 3.4   49.7 3.9
37.6 2.9   39.2 2.7   39.7 2.3   41.3 2.3   37.6 3.3   35.3 3.8
34.2 2.5   31.2 2.6   28.6 2.1   23.5 2.2   19.6 2.7   15.0 2.6

22.4 1.3   21.6 1.0   25.1 1.2   27.4 1.6   29.9 2.0
45.1 1.5   45.6 1.3   46.8 1.4   46.2 1.9   45.9 2.1
32.5 1.5   32.8 1.2   28.1 1.4   26.4 1.7   24.2 1.9

`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.
%cludes persons aged 25 years and older.
Source: National Center for Health Statistics, public use data tapes, 1978-1995.

Patterns of Tobacco Use  109


Table 45.  Percentage of adult white 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             %  KIT 7r   fC1 %   +c1 %   fC1 %   KI %   KI


Total                  40.3  1.1   44.7  0.8   46.9  0.7   50.7  0.7   50.0  0.9   50.7  1.0

Gender
Men
Women

45.1  1.2   49.3  1.0   50.8  0.9   54.2  0.9   53.2  1.2   53.3  1.4
34.1   1.4   39.1   1.0   42.2  0.9   46.6  0.9   46.1   1.3   47.7  1.4

Age (years)
18-34
35-54
255

29.6  1.3   31.1   1.1   31.8  1.1   33.5  1.1   29.2  1.5   30.2  1.7
39.0  1.3   43.9  1.3   45.3  1.1   48.6  1.1   48.3  1.3   49.0  1.5
55.4  1.4   60.9  1.2   64.1  1.0   68.9  0.9   69.9  1.3   70.1  1.4

Education5
Less than high school      40.3  1.4   44.5  1.8   45.0  1.4   46.9  1.5   49.1  2.1   46.8  2.2
High school            40.0  1.5   43.5  1.1   44.9  1.1   48.1  1.0   47.6  1.5   47.9  1.6
Some college           42.9  1.8   47.1  1.8   49.8  1.4   54.5  1.3   54.3  1.8   55.2  2.0
College               55.0  2.2   61.6  1.7   63.8  1.4   68.2  1.4   66.1  1.9   68.4  2.2

*These data exclude those whites 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 current smokers,
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.


Table 46.  Percentage of white 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  fCIS %   KI %   KI 7c   fC1 %   fC1 %   fC1

Total                  35.3 1.2   33.7 1.0   30.7 0.8   28.3 0.8   30.0 1.2   29.4 1.2

Education
Less than high school      53.4  3.0   54.5  3.4   59.2  2.7   59.0  3.0   57.5  4.2   53.9  5.2
High school            36.6  1.8   38.0  1.7   36.1  1.4   35.5  1.3   38.5  2.1   38.6  2.3
Some college            34.2  2.8   29.6  2.1   29.2  1.7   24.8  1.5   26.0  2.1   26.6  2.4
College               21.7  1.9   16.0  1.6   14.6  1.2    11.4  1.0   13.0  1.4   13.5  1.8

*These data exclude whites 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 currentIy 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.

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


Appendix 4. Patterns of Cigarette Use Among Among African Americans

Table 47.  Percentage of adult African Americans who reported being current cigarette smokers,* overall and
     by gender, age, and education, National Health Interview Surveys, United States, 1965-1995

Characteristic

1965          1966          1970          1974

%   XI*      %    KI      %    KI      %    ASI

Total                     45.8    1.5

45.9    1.7     41.4 1.8     44.0    2.2

Gender
Men
Women

Age (years)
18-34
35-54
255

Educations
Less than high school
High school
Some college
College

60.4    2.8     60.1 2.5     52.9 2.0     54.4    3.9
33.7    2.3     34.2 2.3     32.2    2.5     36.4 2.6

53.2    2.8     52.4    2.9     46.0    2.8     46.2    3.5
50.3 3.0     52.6    2.9     47.0 2.2     53.3    3.8
27.0    3.2     24.8    3.1     25.1 2.3     28.0 3.8

44.6 2.4     41.0    2.1     43.3    3.2
51.9 4.6     45.4    3.8     49.1    4.3
52.9 7.8     43.0    6.0     37.3    8.6
39.6    8.5     34.2    6.4     44.9 9.1

44.6A   2.0

37.5A   5.8

1985          1987          1988         1990

Characteristic                  %   KIS      R    KI      %    kc1      %    XI

Total                     35.0    1.8     32.9    1.6     31.7 1.6     26.2 1.5

Gender
-Men
Women

39.9 3.0     38.7    2.8     36.6 2.5     32.6 2.4
31.2    2.2     28.2    1.8     27.8    1.9     21.2    1.6

Age (years)
18-34
35-54
255

34.0    2.8     32.6    2.4     31.5 2.4     25.0 2.2
42.3    3.4     38.6    2.8     36.0    2.6     32.6 2.7
27.7    3.0     25.9    2.9     26.4    2.7     19.2    2.4

Educations
Less than high school
High school
Some college
College

39.6    3.0     37.7    2.9     35.0 2.5     30.6 2.8
39.1    3.4     38.7    2.9     38.8 2.9     31.9 2.5
35.0    4.9     34.2    4.0     31.9    3.7     25.7    3.8
28.4    6.1     18.3    3.9     20.9    4.6     17.5 3.8

`Data collected before 1978 do not distinguish between blacks of Hispanic origin and non-Hispanic blacks;
these data exclude those African Americans who indicated they were of Hispanic origin. For 197&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.
`The 1976 and 1977 survevs collected data only for persons aged 20 years and older. The data for 1976 and
1977 were statistically adjusted to produce e&mates for the total population, males, and females that
approximate those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year
old age category were statistically adjusted to produce estimates that approximate those for African
Americans aged 18-34 years old.


Tobacco Use Among U.S. Racial/Ethic Minority Gruuys

1976+        1977+         1978          1979         1980           1983

70   KI       7c   kc1       %   kc1       %   KI       %   KI       %   AXI

2.1      40.7



3.3      47.3
3.1      35.9



3.1      44.4
3.7      46.9
3.3      29.9


2.8      40.2
4.7      48.2
7.5      41.8
10.3      37.1

2.5      37.5 3.7      37.3   2.4      37.1   3.3      35.8   2.2

4.0
3.1


3.9
4.2
4.3

46.1 5.5      44.5 3.7      44.9 4.4      40.8   3.5
31.1 4.5       31.6 2.5      31.0   4.3      31.8   2.6

39.1 5.8      38.0 3.2      39.9   4.5      35.8   3.2
46.0 6.1      44.4 3.9      40.5   6.9      42.1   4.1
24.4 5.2       27.0 4.0      27.5   6.6      27.9   4.2

3.9      36.7 4.8       37.3 3.6      33.7   6.5      37.4   3.9
4.9      40.6 5.1      40.5 4.8      47.6   7.2      39.4   4.3
7.4      46.0 9.9       35.5 6.4      30.8   8.7      34.4   6.3
8.4      37.3 13.5      36.3 7.5      29.4 8.8      28.4   7.3

40.8

49.3
34.6

44.2
46.9
27.5

38.9
44.5
49.4
36.3

  1991          1992          1993         1994          1995

%   kc1       5%   kc1       %   KI       7%   KI       7e   kc1

29.4   1.6      27.8   2.0      26.0 2.0       27.2 2.3      25.8   2.6

35.5   2.7      32.3   3.5      32.4 3.4      33.9 4.0      28.8 3.7
24.5   1.9      24.1   2.2      21.0 2.2       21.8 2.2      23.5 3.1

27.0 2.4      22.4 3.0      21.6 3.3       22.0 3.4      19.9   3.4
38.3   2.7      38.0 3.7      33.6 3.6      34.7 3.9      33.6 4.6
20.7 2.7      22.4 3.5      22.3 4.1      24.0 4.0      23.0 3.8

35.4 3.0      34.4   4.5      33.9 4.5       35.3 4.5      34.1   5.0
34.9   2.6      32.3   3.7      31.4 3.8      31.6 4.5      31.0 5.0
31.8   3.8      28.4   4.8      26.6 4.4      27.6 5.4      25.2 5.1
18.0 4.2      22.4   6.6      13.9 4.6       15.7 5.2      17.6   5.4

t95% confidence interval.
SIncludes persons aged 25 years and older.
`Levels presented for 1965 are for persons who had a high school education or less and persons who attended
some college or were college graduates.
Source: National Center for Health Statistics, public use data tapes, 1965-1995.

Pa ttems of Tobacco Use  113


Table 48.  Percentage of adult African American smokers* who reported smoking <15,15-24, or 125 cigarettes
     per day, overall and by gender, age, and education, National Health Interview Surveys, United States,
       1965-1995

Characteristic

1965            1966            1970            1974

%   ?a*       %    KI       %    KI       %    321

Total
  cl5 cigarettes
   15-24 cigarettes
  225 cigarettes
Gender
Men
  cl5 cigarettes
   15-24 cigarettes
  225 cigarettes
Women
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes

  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
35-54
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
255
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
Educations
Less than high school
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
High school
  <15 cigarettes
   15-24 cigarettes
   225 ci B arettes
Some co1 ege
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
Colle e
  t
  <l cigarettes
   15-24 cigarettes
  225 cigarettes

56.9    2.7      55.8    2.5       55.5    2.5       58.3
35.5    2.5       36.2    2.5       36.0    2.4       33.0
7.6    1.4       8.0    1.3        8.6    1.4       8.7

:::
1.8

49.1    3.3      48.3    3.2       49.6    3.2      52.9    5.0
42.0    3.3      41.8    3.1       40.7    3.1      36.5    4.9
9.0    1.9       9.9    1.9        9.7    1.7       10.6    2.9

68.0    3.7      66.1    3.8       62.8    2.8      64.3    4.0
26.3    3.5      28.5    3.5       30.0    2.5       29.1    3.8
5.7    1.9       5.5    1.7        7.2    1.7       6.6    2.3

59.7    4.0       57.3    3.9       58.5    3.2      64.0    3.9
33.0    3.7      35.0    4.0       34.0    3.2      27.8    4.0
7.4    2.1        7.7    2.1        7.4    2.0       8.2    2.4

51.4    3.9      52.0    3.9       50.7
39.9    3.8       39.1    3.7       38.7
8.7    2.2       8.9    2.3       10.6

3.2
2:

49.3    6.2
39.4    5.7
11.3    3.5

65.2    6.4      63.3    6.9       59.3    5.9      65.3
29.8    6.4       30.6    7.2       34.3    5.6      31.4
5.1    3.0       6.1    3.5        6.5    2.1        3.4

a2
2:6

El2  K
NA   NA

55.3    3.5       52.5    3.9      55.8    5.5
36.0    3.3       38.0    3.7      35.8    5.3
8.7    2.0        9.5    2.1       8.4    2.6

55.8'   3.1      50.6    5.7       52.7    4.3      52.9    8.0
35.9J   3.0       40.4    7.9       37.9    4.4      37.4    6.6
8.33   1.8       9.1    3.2        9.4    2.8       9.8    4.1

NA
E

K
NA

59.0   10.4       49.9   10.1       56.4   12.5
32.1    9.4       37.1    8.9      29.5   11.0
9.0    3.8       13.0    6.5       14.1   10.5

54.6-'   9.1       60.9   10.1       69.0   11.1       64.8   15.1
36.1'   8.5      32.3   10.1       23.4    9.7      30.2   14.3
9.3>   5.3       6.8    5.3        7.6    7.3       5.1    7.1

*Data collected before 1978 do not distin uish between African Americans of His
           %
African Americans; these data exclude t ose African Americans who indicated t R anic origin and non-Hispanic
                                   ey were of Hispanic origin.

For 1965-1991, 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 fl ersons who reported smoking at least 100 cigarettes in their lives and who reported at the time of
survey t at they currently smoked every day or on some days.
+The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
were statistically adjusted to produce estimates for the total population, males, and females that approximate
those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year old a
were statistically adjusted to produce estimates that approximate those for African Amerrcans age B e category
                                                              18-34

years old.


Tobacco Use AVZOJZ~ U.S. Racial/Efhnic Mimrify Groups

197ci+         1977+          1978          1979          1980          1983

7c    kc1      R    kC1      9%    %I      c    &CT      7c    XI      %   kC1

52.4    3.9     54.7    4.8     57.0    5.1     55.9    3.2     55.2    5.7     54.9    3.9
39.0    3.7     35.7    4.4     34.0    4.6     33.3    3.1     33.8    4.8     35.6    3.7
8.6    2.1      9.8    2.1      9.1    2.8     10.8    1.6     11.0    3.3      9.5    2.4

44.7    4.7     48.4    5.9     49.5    7.3     51.5    4.9     48.8
44.2    4.4     35.3    5.2     37.3    6.3     36.3    4.7     38.7
11.2    3.0     12.6    3.9     13.2    5.1     12.2    2.6     12.5

9.2
Ei

51.4
36.5
12.1

Z:i;
4.1

60.3    5.8     61.2    6.2     65.0    7.0     60.8    4.4     62.1    6.8     58.5    5.1
33.8    5.9     36.1    5.6     30.4    6.4     30.0    3.8     28.5    6.3     34.6    5.0
6.0    2.2      6.9    2.3      4.6    3.0      9.2    2.6      9.4    3.2      6.9    2.5

56.5    5.5     59.4    5.8     60.3    7.9     60.5    5.2     57.8
35.9    5.3     34.8    6.3     31.5    7.0     31.1    4.3     33.1
7.6    2.6      8.0    3.4      8.2    4.2      8.4    2.5      9.1

6.0
!:i

57.7
33.0
9.4

5.7
E

44.8
44.0
11.3

ii:;
3.4

51.6    7.3     53.0    8.4     48.4    5.1     56.1   10.5     47.6    6.4
33.4    6.2     37.2    7.5     36.2    4.5     32.1    9.2     40.6    6.1
13.0    3.6      9.8    4.8     15.4    4.3     11.8    7.1     11.9    4.4

57.4    6.4     51.1    8.6     56.1    12.6     59.1    8.7     46.5   11.9     61.7    8.8
36.9    6.8     40.2    7.5     33.9   12.5     33.3    8.6     38.9   10.6     32.9    8.6
5.8    3.7      8.7    4.5     10.0    7.2      7.6    4.1     14.7   10.4      5.4    4.0

50.4    5.8     54.1    7.0     53.4    9.2     52.8    5.7     53.9
41.2    5.1     35.2    5.6     35.4    8.3     32.9    5.2     32.6
8.3    3.3     10.7    3.2     11.3    5.4     14.3    4.2     13.6

E
7:3

52.8
34.0
13.2

2::
5.1

48.4    6.9     53.9
44.3    6.2     34.0
7.3    3.1     12.1

7.9
2:

60.4    9.5     53.5    5.6     48.9
31.1    9.1     36.1    6.3     35.8
8.5    5.5     10.4    4.4     15.3

i. :
5:6

52.6    7.0
42.1    6.9
5.4    3.1

54.7
29.2
16.1

44.9
38.8
16.3

11.7
9.9
7.9

14.9
13.9
13.0

49.5   12.0     41.5   17.6     57.0   11.5     44.7   18.2     50.2   12.1
42.8   12.7     46.1   16.8     30.1    9.2     42.7   18.5     37.1    11.7
7.7    6.0     12.5    9.0     13.0    6.8     12.5   11.0     12.7    7.9

48.1   15.6     71.9   17.1     47.5   13.2     65.7   18.7     51.6   15.3
37.9   15.6     22.6   12.5     40.1   11.5     31.1   18.3     36.7   14.8
14.0    9.6      5.5    9.8     12.5    9.2      3.3    6.4     11.7   10.9

$95X confidence interval.

Vncludes persons aged 25 years and older.
"Levels presented for 1965 are for
some college or were college gra 1 ersons who had a high school education or less and persons who attended
                         uates.
NA = data not available.
Source: National Center for Health Statistics, public use data tapes, 1965-1995.


Table 48. Continued

Characteristic

  1985            1987           1988            1990


70   kCIS       5%    KI       %    KI       %    kC1

Total
  cl5 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
  cl5 cigarettes
   15-24 cigarettes
  225 cigarettes
255
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
Educations
Less than high school
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
High school
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
Some college
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes
College
  <15 cigarettes
   15-24 cigarettes
  225 cigarettes

55.8    3.2       61.2    2.9       56.4    2.7      59.9    3.2
35.0    2.9       31.0    2.8       34.6    2.5       34.2    3.2
9.3    1.9       7.8    1.6        9.0    1.6       6.0    1.5

52.8    5.2       55.3    4.2       51.0    4.1      52.6    4.7
36.2    4.3       35.8    4.4       38.2    3.8       40.1    4.7
11.0    3.2        8.9    2.4       10.8    2.5       7.3    2.3

58.7    3.9       67.9    3.5       62.2    3.9      68.8    3.6
33.7    3.8       25.7    3.2       30.7    3.6      26.9    3.4
7.6    2.0        6.5    1.8       7.2    2.0       4.3    1.7

56.4    5.4       66.2    4.5       62.1    4.0      67.5    4.9
35.4    4.8       27.6    4.0       29.4    3.7      25.8    4.6
8.2   3.0       6.2    2.3       8.5    2.4       6.7    2.5

53.1    4.8       54.9    4.6       49.2    4.3      51.9    4.9
35.9    4.6       34.9    4.6       40.5    4.4      42.2    4.7
11.0    3.0       10.1    2.4       10.3    2.5       5.9    2.2

59.6    6.5       61.5    7.1       56.8    7.3      60.8    6.9
31.8    6.6       31.8    6.9       35.3    6.7      34.9    6.8
8.6    4.1        6.7    3.8        7.9    3.4       4.3    2.7

57.9    5.0       62.8    4.3       51.4    4.5       54.1    5.8
31.8    4.8       27.7    4.5       38.0    4.5      39.2    5.7
10.3    3.2        9.5    2.9       10.6    3.0       6.7    2.6

52.4    5.5       57.6    5.2       58.9    4.7      60.6    5.1
39.8    5.4       34.2    4.9       32.3    4.6      34.0    5.0
7.9    2.8        8.2    2.9       8.9    2.5       5.4    2.1

47.6    8.9       57.7    7.0       55.0    7.2      57.1    7.8
37.6    8.3       35.3    6.7       34.0    6.8      37.6    7.8
14.8    6.6       7.0    3.9       11.0    4.9       5.4    3.7

50.5   12.6       56.8   12.1       54.0   13.5      67.9   11.6
35.0   11.6       34.7   11.7       40.8   13.5      28.1    11.1
14.5   12.8       8.5    5.8       5.2    4.0       4.0    4.0

f95% confidence interval.
%ncludes persons aged 25 years and older.

216 Chptu 2


73baccn Use Amorlg U.S. Xllcial/Ethnic Minority Grmps

  1991          1992          1993          1994         1995


%    XI      7%    KI      R    ASI      %    KI      %   XI

-

61.2    3.0     61.4    4.3     65.6    4.2     65.3    4.8     62.5    5.2
30.0    2.8     33.3    3.9     28.5    4.1     27.2    4.3     29.7    4.8
8.7    1.8      5.3    1.7      6.0    2.1      7.5    3.2      7.8    2.7

57.5    4.4     55.7    6.8     63.3    6.2     64.1    7.0     57.6    7.4
31.7    4.0     39.0    6.3     29.2    5.9     25.2    5.8     32.5    7.2
10.8    2.8      5.3    2.4      7.4    3.4     10.7    5.6      9.9    4.5

65.7    3.5     67.5    4.9     68.4    5.8     66.7    5.5     69.7    9.7
28.0    3.4     27.3    4.5     27.5    5.7     29.8    5.5     22.1    8.2
6.2    1.9     5.2    2.0     4.1    2.2      3.5    1.7      8.2    6.0

66.9    4.6     68.5    6.6     70.6    7.9     71.5    7.3     68.3    8.5
27.3    4.4     27.7    6.5     22.8    7.0     22.3    7.0     24.4    8.1
5.7    2.5      3.8    2.1      6.6    3.8      6.2    3.1      7.2    4.4

56.7    4.4     59.0    6.0     62.2    6.0     60.6    7.3     57.2    7.3
32.7    4.0     34.9    5.7     31.2    6.1     31.1    6.4     33.5    7.0
10.7    2.8      6.1    2.7      6.6    3.2      8.4    5.8      9.4    4.2

60.0    6.8     54.3    8.8     64.6   10.3     66.2    9.6     67.1    9.1
29.3    6.5     39.8    8.5     32.0   10.4     26.2    8.4     28.4    8.5
10.7    4.3     5.9    3.9     3.4    3.6      7.6    6.6      4.5    3.7

60.0    5.2     56.2    8.2     59.4    8.1     59.3    8.7     52.3    8.6
28.7    4.8     36.6    8.0     30.9    8.2     32.0    7.9     33.0    8.4
11.3    3.5      7.2    3.4      9.7    5.0      8.6    6.1     14.8    6.8

57.6    4.9     61.3    6.1     64.6    6.9     63.9    8.3     64.1    7.9
35.5    4.8     34.4    5.8     32.1    6.7     28.8    7.2     29.5    7.2
6.9    2.2      4.3    2.4     3.3    2.7      7.2    6.6      6.4    4.1

63.8    7.7     62.5    9.2     64.4   10.3     66.9   11.6     58.8   11.7
28.2    7.4     32.1    9.1     29.8    9.8     27.1    11.3     37.6   11.5
8.1    4.2      5.4    4.0      5.9    4.8      6.0    4.1     3.6    2.8

62.4   13.2     72.5   12.6     78.3   17.4     73.3   17.8     83.0   11.1
22.1   10.8     21.3   11.2     19.4   17.3     26.7   17.8     12.1    9.7
15.6   11.7      6.1    6.8      2.3    3.6     0.0    0.0      4.9    6.0

Patterns of Tobacco Use  117


Table 49.  Percentage of adult African American ever smokers who have quit,+ overall and by gender,
     age, and education, National Health Interview Surveys, United States, 1965-1995

Characteristic

1965          1966          1970          1974

%   KIS     %    KI      %    KI      %    WI

Total                      15.5    1.7     14.2 1.7     20.6    1.5     19.7 2.4

Gender
Men
Women

16.1 2.2     15.5    2.2     22.2 2.0     21.7    3.6
14.5 2.7     12.3 2.4     18.4 2.1     17.4 2.9

Age (years)
18-34
35-54
255

8.3    2.0      7.2 1.8     12.8    1.8     13.0    3.9
16.7    2.6     14.0    2.4     21.1    2.0     16.9    3.3
29.3    5.2     32.4 5.4     37.4    3.6     38.1 5.8

Education9
Less than high school
High school
Some college
College

NA NA     17.5    2.3     23.2    2.1     23.3    3.5
18.2'   2.1     11.2    3.5     19.4 3.7     17.4    4.7
NA    NA     12.8 6.5     24.2    6.8     33.2   11.8
13.2'   5.7     19.9 8.6     33.9    9.9     20.4    9.9

1985          1987          1988          1990

Characteristic                 %    KI      %    33      %    XI      %    %I

Total                       31.3    2.4     31.1    2.4     32.5    2.1     39.0    2.6

Gender
Men
Women

34.4 3.6     32.9    3.6     34.9    3.1     39.5    3.4
27.9    3.3     29.0 2.7     29.7    3.0     38.4 3.5

Age (years)
18-34
35-54
255

21.1    3.5     18.3 3.1     19.2    3.1     24.8    3.9
30.6    3.7     31.2    3.7     34.9 3.7     39.1    3.8
48.5    4.6     50.1    4.5     48.3    4.1     58.3    4.6

Education?
Less than high school
High school
Some college
College

32.8    3.6     34.2    3.7     35.8    3.4     40.4    4.4
30.8    4.4     27.0    3.7     27.6 3.5     35.7    3.9
36.6    6.6     35.8    5 5     37.3 5.8     43.8    6.5
37.4    8.7     49.9  ii2     50.4    8.3     51.4 8.2

*Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic
African Americans; these data exclude those African Americans who indicated they were of Hispanic origin.
The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are
those who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that
they were not smoking.
`The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
were statistically adjusted to produce estimates for the total population, males, and females that approximate
those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year old age category
were statistically adjusted to produce estimates that approximate those for African Americans aged 18-34
years old.

11 a  Cirtlpter 2


Tohncco Use A1710rzg U.S. Rncicll/Efhnic Minority Groups

1976+        1977+         1978          1979          1980          1983

7r   KI      %   kc1       `?r   ASI       7i   XI       %   ?CI       %   KI

24.3   2.5      22.7 2.5      26.2 4.1      26.7 2.7      27.5   3.4      28.0 2.9

26.7   3.4      26.4   4.4      28.L5 6.4      28.7 3.8      29.2   4.9      32.0 4.3
21.6   3.7      18.7   3.0      23.6 4.8      24.4 3.7      25.5   4.9      23.4 3.7

13.8 3.1      14.3   3.1      17.9 5.6      18.4 4.0      16.9   4.7      18.8   3.9
24.0   4.7      23.0   4.2      27.3 6.0      26.5 4.9      31.1 7.2      27.7 4.8
13.4   6.1      37.4   6.2      41.6 10.8      42.8 6.1      41.7 10.0      44.6   6.4

30.0   3.5      26.9   3.4      29.7  6.1       33.1   4.8      34.7   7.3      32.4 5.1
23.2   4.9      20.9   1.9      25.3 5.9       25.4  4.2      21.3   9.3      25.4   5.3
23.7   9.5      26.7   8.3      27.9 13.2      32.7 10.6      37.2 12.9      32.3 9.0
23.9 13.5      25.3 10.9      20.0 16.2      26.8 9.5      41.9 12.7      36.4 11.8

1991          1992          1993

1994          1995

%   kC1       7c   KI

%   KI

%   KI

33.4   2.6      36.4 3.3      37.8 3.4      34.7 3.5      36.1   3.9

34.2   3.6      40.1   5.2      37.9 4.8       34.1   5.3      35.9   5.3
32.4   3.2      31.9   4.0      37.6 4.8      35.3 4.3      36.4 5.3

17.2 3.6      23.9 7.2      23.3 5.8      16.7 5.6      22.7   6.2
31.8   3.3      31.3 4.5      35.5 5.1       34.1   5.3      32.1   5.9
56.4 5.2      57.4 5.4      56.0 6.7      53.8 6.2      55.6 6.1

35.8   4.5      38.9 5.6      41.2 6.1      34.5 5.6      39.3   5.9
29.4 3.4      33.5   5.8      33.3 5.4      32.3 6.2      30.8   6.3
33.0 5.5      37.7 7.6      40.3 7.7      37.6 8.7      37.0   9.2
51.2   9.1      43.9 11.8      55.1 12.2      50.3 13.0      51.7 11.3

t95% confidence interval.

*Includes persons aged 25 years and older.
`Levels presented for 1965 are for persons who had a high school education or less and persons who attended
some college or were college graduates.
NA = data not available.

Source: National Center for Health Statistics, public use data tapes, 1965-1995.


Table 50.  Percentage of African American women of reproductive age who reported being current
     cigarette smokers,* overall and by education, National Health Interview Surveys, United
      States, 1965-1995

Characteristic

1965          1966          1970          1974

o/c   -1%      77c    KI      %    KI      %    XI

Total                      42.9 2.9

Education_
Less than high school
High school
Some college
College

NA NA
45.0~ 4.0
NA NA
44.7"   9.6

1985

Characteristic

7%    &CI

42.6    2.9     38.6    3.1     41.1 3.5

48.1    4.7     45.4    4.6     47.1    7.7
45.9    6.7     38.9 5.4     45.4    6.4
49.6   11.7     36.6   10.4     25.6   12.6
42.9   10.9     41.2    9.2     52.7   13.3

1987          1988          1990

%    3X1      %    ?CI      YO    &CI

Total                     34.0 2.8     31.4 2.5     29.8    2.4     22.7    2.1

Educations
Less than high school          54.3    6.8
High school               36.9    4.9
Some college               34.0    7.1
College                   21.3    7.3

49.1    6.0     47.2    6.1     38.2 6.8
35.8    4.3     33.2 4.1     30.7    4.3
32.4    5.6     28.9 5.0     21.2 4.1
19.7    6.5     20.2 6.0     14.9    5.8

*Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic
African Americans; these data exclude those African Americans who indicated they were of Hispanic origin.
For 19651991, 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 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,


Yhbacco USC Awzo~g U.S. Racinl/Etknic Minority Groups

1976+       1977+         1978          1979          1980          1983

YO   AXI      %   kc1       %   KI       %   KI       %   KI       YO   KI


38.8 4.2      41.7 4.0      36.4  6.3      35.2 3.0      34.6   5.4      34.3   3.4

45.3 7.1      44.0   9.0      41.5 10.3       43.2 8.9      35.7 12.9      49.6   8.9
39.1 7.3      49.3 7.6      36.4 7.7       34.5 6.8      40.0 10.0      36.5 6.2
46.0   9.6      41.4 10.5      53.0 15.3       33.2 9.7      30.5 11.8      29.3 8.4
35.5 15.4      36.6 15.1      45.9 19.2      36.2 10.3      31.0 17.4      22.5 9.2

  1991          1992          1993          1994          1995

%  L-G      %   kC1       YC   XI       YC   ASI       %   AC1


28.1 2.4      24.5   2.9      23.1 2.9      22.9   1.8      23.8   3.9

  50.4 6.1      45.9  10.0      45.6  9.4       43.6  9.4      49.6  12.3
  32.4 4.0      29.8   5.2      30.2  5.5       26.1   5.2      30.6   6.9
  31.5 5.6      26.1   6.7      26.3  6.5       27.4   8.2      24.9   7.6
  19.8 6.6      18.5   8.2       8.2  6.0       8.0  5.7      13.6   7.9
`The 1976 and 1977 surveys collected data onlv for persons aged 20 years and older. The data for 1976 and
                                     ,
1977 were statistically adjusted to produce estimates that approximate those for African American women
aged 18-44 years.
i95'"c confidence interval.
$Includes persons aged 25 years and older.
`Levels presented for 1965 are for persons who had a high school education or less and persons who attended
some college or were college graduates.
NA = data not available.
Source: National Center for Health Statistics, public use data tapes, 1965-1995.

Pnttrrns of Tobacco Use  321


Appendix 5. Validation of the Retrospective Assessment of
Smoking Prevalence

  Because the method of computing smoking
prevalences retrospectively is inherent in the birth co-
hort analyses described in this chapter, comparability
of these estimates with accepted cross-sectional
estimates was examined. At least two factors contrib-
ute to the observed difference between retrospective
and cross-sectional estimates of smoking prevalence:
how a former smoker is defined and differences in mor-
tality between smokers and nonsmokers (differential
mortality). Retrospective estimates will be greater than
cross-sectional ones because they are based on the age
at which a smoker quits wm m~df~~nll. However, cross-
sectional estimates, using the accepted definition of a
former smoker (a person who has ever smoked 100
cigarettes but does not smoke UUXJ), classify ever smok-
ers who are not currently smoking as quitters, even
though many will relapse several times before finally
quitting. Differential mortality results in retrospective

estimates smaller than cross-sectional ones because
smokers are less likely than others to survive and re-
port their smoking history. This factor affects only
the older birth cohorts (Harris 1983).

  Retrospective estimates of smoking prevalence
were assessed by comparing them with smoking
prevalence estimates from the NHISs from 1965
through 1988 and from Gallup surveys from 1944
through 1988. The NHIS and Gallup surveys both
sample adults only; thus, for the comparison, retro-
spective prevalences computed for each year included
only respondents aged 18 years and oIder in that cal-
endar year. Sample sizes for the birth cohorts in-
cluded in this analysis varied widely (Table 51)
(NCHS, public use data tapes, 1978, 1979, 1980,
1982-1984 [HHANES], and 1987 and 1988 combined).

  When this methodology was used to estimate
smoking prevalences retrospectively for the national

Table 51.  Sample sizes for birth cohorts, by gender, race/ethnicity, and education," National Health
     Interview Surveys, 1978-1980,1987 and 1988 combined, and Hispanic Health and Nutrition
     Examination Survey, 1982-1984

                      Men                             Women

          African American     Hispanic         African American      Hispanic

Birth Cohort     <HS   >HS      <HS   >HS          <HS   >HS        <HS   >HS

1908-1917       401     96       142      33           601    185        229     30

1918-1927       494     222       267     111           683    444        376    113

1928-1937       370    387       387     178           531    638        508    233

1938-1947       292     622       266     226           457   1,013        392    277

1948-1957       277   1,066       322     375           555  2,006        417    462

1958-1967+       175    755       180     255           415   1,510        224    319

*Education was identified as either ~12 years of school completed (<HS [high school]) or 212 years of school
completed (_>HS).
`The smoking p
           ex erience of this cohort is still incomplete.
Source: National Center for Health Statistics, public use data tapes, 1978, 1979,1980,1982-l 984 (Cancer
Control Supplement and Epidemiology Supplement), and 1987 and 1988 combined.


Tobn~co Use Among U.S. Racid/Etknic Minority Groups

samples of the combined 1978, 1979, 1980, 1987, and
1988 NHISs, the prevalence of smoking in the U.S.
population was estimated at approximately 10 percent
in 1910, and it gradually increased before peaking in
1960 at approximately 50 percent (Figure 16). The
prevalence then declined gradually to 28 percent in
1988.

  Data from successive Gallup polls administered
since 1944 show a somewhat lower smoking preva-
lence than do retrospective estimates, especially be-
tween 1956 and 1970. Both the NHIS and the Gallup
poll estimates follow a similar trend. For most years,
retrospective estimates are slightly higher than those

estimated from cross-sectional surveys (Table 52)
(NCHS, public use data tapes, 1978, 1979, 1980,
1982-1984 [HHANES], and 1987 and 1988 combined).
In addition, the estimate for the 1955 CPS (37.6 per-
cent) is slightly lower than that estimated from the ret-
rospective NHIS estimates (Figure 16). These findings
are probably accounted for by the surveys' differing
definitions of former smoker.

  The overall agreement of the retrospective
prevalences with cross-sectional NHIS and Gallup poll
data supports the validity of the prevalence estimates
among successive birth cohorts for the population sub-
groups presented in this chapter.

Figure 16.  Comparison of smoking prevalence estimates from selected U.S. surveys, 1910-1993

80

60

20

10

111,. Gallup polls

National
Health
Interview
Surve s
FL?
(NH1 s)

Current
Population
Survey (CPS)

Reconstructed
NHISs

1950

Year

Sources: Reconstructed estimates for 1910-1988 from the 1987-1988 combined NHISs (National Center for
Health Statistics [NCHS], public use data tapes, 1987-1988); 1944-1991 Gallup polls (Thomas and Larsen
1993); 1955 CPS (USDHHS 1988); and 1965-1991 NHISs (NCHS, public use data tapes, 1965-1991).

Pntterns of Tobacco Use  123


Surgeon Gem~l's Report

Table 52. Comparison of current smoking prevalence* (%) between reconstructed estimates from National
    Health Interview Surveys (NHISs), 1987 and 1988 combined, NHIS cross-sectional survey
    estimates, and Gallup poll estimates

Year

Reconstructed NHISs      Cross-sectional NHISs

    Estimate          Estimate   Difference+

  Gallup Polls

Estimate   Difference+

1944          42.7              NA
1949          45.4              NA
1954          46.7              NA
1957          46.7             NA
1965         45.8              42.4
1966          45.3              42.6
1969          43.2              NA
1970         42.7             37.4
1971          42.3             NA
1972          41.5              NA
1974          40.8              37.1
1976         39.9             36.4
1977         39.2              36.0
1978          38.5              34.1
1979         38.0              33.5
1980          37.4             33.2
1981         36.7              NA
1983          34.4              32.1
1985          32.1              30.1
1986          30.5              NA
1987          29.2              28.8
1988          28.2              28.1

NA
NA
NA
NA
-3.4
-2.7
NA
-5.3
NA
NA
-3.7
-3.5
-3.2
4.4
4.5
4.2
NA
-2.3
-2.0
NA
-0.4
-0.1

41         -1.7
44         -1.4
45         -1.7
42        4.7
NA        NA
NA        NA
40         -3.2
NA        NA
42         -0.3
43         +1.5
40         -0.8
NA        NA
38         -1.2
36         -2.5
NA        NA
NA        NA
35         -1.7
38         +3.6
35        +2.9
31         +0.5
30         +0.8
32         +3.8

*In the NHIS, current smokers are persons who reported smoking at least 100 cigarettes in their lives and who
reported at the time of survey that they currently smoked; in the Gallup poll, current smokers are persons who
reported at the time of poll that they had smoked any cigarettes in the past week.
+Difference between the survev estimate and the reconstructed prevalence estimate.
                        '
NA = data not available.
Sources: National Center for Health Statistics, public use data tapes, 1965,1966,1970,1974, 1976, 1977, 1978,
1979,1980,1983,1985, and 1987 and 1988 combined; Gallup and Newport 1990.

124 Chpter 2


Tnbncco Use Amor7~ U.S. RacinllEthnic Minority Groqs

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134 Chapter 2


Chapter 3
Health Consequences of Tobacco Use
Among Four Racial/Ethnic Minority Groups

Introduction 137

Lung Cancer 137

African Americans 138
American Indians and Alaska Natives  143
Asian Americans and Pacific Islanders  1 J.5
Hispanics 147

Other Cancers 149

Cervical Cancer 252
Esophageal Cancer 2.53
Oral Cancer 153
Stomach Cancer 155
Urinary Bladder Cancer 156

Chronic Obstructive Pulmonary Disease  158

African Americans 158
American Indians and Alaska Natives  158
Asian Americans and Pacific Islanders  159
Hispanics 159

Coronary Heart Disease 160

African Americans 160
American Indians and Alaska Natives  161
Asian Americans and Pacific Islanders  2 62
Hispanics 163

Cerebrovascular Disease 164

African Americans 165
American Indians and Alaska Natives  165
Asian Americans and Pacific Islanders  165
Hispanics 166

Smoking and Pregnancy 266
Studies of Low Birth Weight  167
Studies of Infant Mortality and Sudden Infant Death Syndrome  169
Health Problems Affecting Pregnant Women  171
Implications 172

Summary of Health Consequences from Active Cigarette Smoking  172


Effects of Exposure to Environmental Tobacco Smoke  172

Effects of Smokeless Tobacco Use  274

Nicotine Addiction and Racial/Ethnic Differences  175

Nature of Addiction  175
Pharmacologic Factors in Nicotine Addiction  175
Absorption, Distribution, and Elimination of Nicotine in the Body  175
Pharmacodynamics of Nicotine  2 76
Tolerance, Withdrawal, and Addictive Tobacco Use  178
Level of Addiction 179

Racial/Ethnic Differences in Nicotine Metabolites  179
Racial/Ethnic Differences in Self-Reported Nicotine Dependence  281
Racial/Ethnic Differences in Quitting Smoking  283
Addiction to Smokeless Tobacco  183

Conclusions 185

Appendix. Methodological Issues 185
Classification of Smoking Status  285
Classification of Race/Ethnicity 186
Classification of Health Outcomes  287

References 188

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

Introduction

  The fact that cigarette smoking causes cancer,
respiratory and cardiovascular diseases, and adverse
pregnancy outcomes is well established (U.S. Depart-
ment of Health and Human Services [USDHHSI
1989b). Evidence of the relationship between smok-
ing and lung cancer began to accumulate as early as
the late 1930s (Ochsner and DeBakey 1939; U.S. De-
partment of Health, Education, and Welfare
[USDHEW] 1964). In 1964, the first Surgeon General's
report linking smoking to disease concluded that ciga-
rette smoking was a cause of lung and laryngeal can-
cers in men and a probable cause of lung cancer in
women. In more recent reports, the Surgeon General
has concluded that cigarette smoking causes 87 per-
cent of lung cancer deaths, 30 percent of all cancer
deaths, 82 percent of chronic obstructive pulmonary
disease (COPD) deaths, 21 percent of coronary heart
disease (CHD) deaths, and 18 percent of deaths from
stroke (USDHHS 1989b) as well as 21-39 percent of
low-birth-weight births and 14 percent of preterm de-
liveries (USDHHS 1980, 1989b). In addition, passive
or involuntary smoking causes lung cancer in healthy
nonsmokers and respiratory problems in young chil-
dren (USDHHS 1986a; U.S. Environmental Protection
Agency 1992).

  Despite this wealth of knowledge about the
health consequences of smoking, few studies have

Lung Cancer

examined the relationship between tobacco use and
known health effects among racial/ethnic groups in
the United States. Moreover, few databases include
information on sufficient numbers of persons from
racial/ethnic groups to allow such analyses.

  Although sufficient data are often not available
for these population subgroups, the objectives of this
chapter are to assess the burden of smoking-related
diseases among U.S. racial/ethnic groups, to examine
racial/ethnic differences in tobacco-related morbidity
and mortality when possible, and to review studies
that have examined how the relationship between to-
bacco use and selected health outcomes may differ
among racial/ethnic groups. For many of the adverse
health outcomes and diseases presented in this chap-
ter, smoking is one of many contributing factors. The
focus in this chapter is on the disease burden related
to smoking among four U.S. racial/ethnic minority
groups (African Americans, American Indians and
Alaska Natives, Asian Americans and Pacific Island-
ers, and Hispanics); data on the contribution of
cigarette smoking to any differences between groups
are highlighted whenever available. A discussion of
some relevant methodological issues is provided in the
chapter appendix.

  The 1964 Surgeon General's report on smoking
and health concluded that "Cigarette smoking is caus-
ally related to lung cancer in men; the magnitude of
the effect far outweighs all other factors. The data for
women, though less extensive, point in the same di-
rection" (USDHEW 1964). That conclusion was based
on strong epidemiological evidence from case-control
and cohort studies and supporting toxicological evi-
dence. When reviewed against criteria for causality,
the evidence was initially judged to be sufficient for
men and a similar conclusion was subsequently
reached for women (USDHHS 1980).

  Since the 1964 Surgeon General's report,
voluminous evidence has accumulated about the

relationship between smoking and lung cancer
(USDHHS 1989b; Wu-Williams and Samet 1994). The
epidemiological studies consistently indicate that the
risk of lung cancer increases with the number of ciga-
rettes smoked and with the length of time a person
smokes. Furthermore, evidence shows that in com-
parison with smokers of non-filtered cigarettes, smok-
ers of filtered cigarettes have only slightly less risk of
lung cancer (Wu-Williams and Samet 1994). Although
a family history of lung cancer is associated with in-
creased risk, the genetic basis for this association has
not yet been determined (Economou et al. 1994). En-
vironmental agents other than cigarette smoke, includ-
ing certain occupational agents (Coultas and Samet

Health Coilseqzlel7ccs 237


Suqeon General's Report

1992; Coultas 1994) and indoor and outdoor air pol-
lutants (Samet 1993), also cause lung cancer. For ex-
ample, synergism between smoking and radon and
asbestos has been demonstrated in studies of worker
groups (Saracci and Boffetta 1994).

  Because nearly all cases of lung cancer are attrib-
utable to cigarette smoking, variations in lung cancer
patterns between racial/ethnic groups most likely re-
flect differences in smoking patterns. Whenever more
detailed information is available, it is included in the
appropriate sections that follow.

African Americans

  The population-based cancer registries operated
by the National Cancer Institute's (NC11 Surveillance,
Epidemiology, and End Results (SEER) Program pro-
vide cancer incidence data for several locations
throughout the United States, including Connecticut,
Hawaii, Iowa, New Mexico, and Utah and the met-
ropolitan areas of Detroit, Atlanta, San Francisco/

Oakland, and Seattle/Puget Sound. SEER data show
that African American men have had consistently
higher lung cancer incidence rates than white men
since the 1970s (Figure 1) (Kosary et al. 1995). (SEER
data cover about 10 percent of the U.S. population and
are used frequently to estimate national cancer rates
and trends.) Between 1950 and 1960, age-adjusted
death rates for malignant neoplasms of the respiratory
system (composed primarily of deaths from lung can-
cer) among African American men surpassed those
among white men and have since remained higher,
whereas death rates for African American women have
remained fairly similar to those among white women,
according to data from the National Vital Statistics
System (Table 1) (National Center for Health Statistics
[NCHSI 1997). Since 1990, respiratory cancer death
rates declined substantially for African American men;
among African American women, rates increased
through 1990 and then leveled off. From 1992-1994,
the age-adjusted death rate for cancer of the trachea,
bronchus, and lung (generally referred to as lung

Figure 1.  Incidence of cancer of the lung and bronchus, by race/ethnicity and gender, National Cancer
     Institute's Surveillance, Epidemiology, and End Results (SEER) Program, 1973-1994

10
0      I       I        I       I        I        I        I        I        I        I       I
    1974   1976    1978    1980    1982    1984    1986    1988    1990    1992    1994
                   Year of Diagnosis

- African American men - a- n * * White men

African American women -  White women

Note: Age-adjusted to the 1970 standard U.S. population.
Sources: Adapted from Kosary et al. 1995: Ries et al. 1997.

338 Chapter 3


Tobacco Use Arnmg U.S. Racial/Efhnic Minority Group

Table 1.  Death rates uer 100,000 U.S. residents for malignant diseases of the respiratory system, by race/
   ethnicity a& gender, United States, 1950-1995: selected years    -

Race/ethnicity
and gender

African American men
All ages, age-adjusted
All ages, crude
American Indian or
Alaska Native men'
All ages, age-adjusted
All ages, crude
Asian American or Pacific
Islander men5
All ages, age-adjusted
All ages, crude
Hispanic men'
All ages, age-adjusted
All ages, crude
White men
All ages, age-adjusted
All ages, crude
African American women
All ages, age-adjusted
All ages, crude
American Indian or
Alaska Native women'
All ages, age-adjusted
All ages, crude
Asian American or Pacific
Islander women5
All ages, age-adjusted
All ages, crude
Hispanic women'
All ages, age-adjusted
All ages, crude
White women
All ages, age-adjusted
All ages, crude

1950+  1960+   1970    1980   1985   1990   1992   1993   1994   1995

16.9    36.6    60.8   82.0    87.7   91.0   86.7   86.0   82.8    80.5
14.3    31.1    51.2    70.8    75.5    77.8    74.7   74.7   72.5    71.2

NA    NA    NA    23.2    28.4    29.7    31.7   31.0   31.1    32.7
NA    NA    NA    15.7    19.6    21.1    23.1   23.1   23.0   25.1

NA    NA    NA    27.6    26.9    26.8    27.4   28.4   28.0   25.8
NA    NA    NA   22.9    21.3    21.7   23.0   23.8   23.9    22.4

NA    NA    KA    NA    24.0    27.7    24.4   25.1   24.8    25.2
NA    NA    NA    NA    13.9    17.4    15.9   16.5   16.5    16.9

21.6    34.6    49.9    58.0    58.7    59.0    56.7   56.3   54.8    53.7
24.1    39.6    58.3    73.4    77.6   81.0    79.5   79.7   78.5    77.8

4.1    5.5    10.9    19.5    22.8    27.5    28.5   27.3   27.7   27.8
3.4    4.9    10.1    19.3    23.5    29.2    30.9   30.2   30.8    31.3

NA    NA    NA    8.1    11.1    13.5    15.5   16.1   17.7    16.4
NA    NA    NA    6.4    9.2    11.3    13.4   14.6   16.5    15.5

NA    NA    NA    9.5    9.2    11.3    11.1    11.7   11.2    13.0
NA    NA    NA    8.4    8.2    10.6    11.1    11.7   11.4    13.6

NA    NA
NA    NA

6.7    8.7    8.4    8.2    8.5    8.2
5.2    7.5    7.5    7.3    7.7    7.5

4.6    5.1
5.4    6.4

z::


10.1
13.1

18.2    22.7   26.5    27.4   27.6   27.7   27.9
26.5    34.8    43.4   46.2   47.3   47.9   48.9

-

Note: Data in the table on African Americans, American Indians and Alaska Natives, Asian Americans and
Pacific Islanders, and whites include persons of Hispanic and non-Hispanic origin. Conversely, in this table, the
data on Hispanic origin may include persons of any race.
*Age-adjusted to the 1940 U.S. standard population. Cause-of-death data are based on classifications from the
then-current Internntio~~al Classification @Diseases (e.g., cause-of-death codes 160-165 for the Ninth Revision).
Data for the 1980s are based on intercensal population estimates.
`Includes deaths of nonresidents of the United States,
tmterpretation of trends should consider that population estimates for American Indians and Alaska Natives
increased by 45 percent between 1980 and 1990 (because of better enumeration techniques in 1990 and an
_ increased tendency for people to denote themselves as American Indian in 1990).
%terpretation of trends should consider that the Asian population in the United States more than doubled
between 1980 and 1990, primarily because of immigration.
`Because of incomplete data, the National Center for Health Statistics (NCHS) reports 1985 death certificate data
on decedents of Hispanic origin for only 17 states and the District of Columbia. By 1990, data for 47 states and
the District of Columbia were reported. NCHS estimates that the 1990 reporting area encompassed 99.6 percent
of the U.S. Hispanic population. After 1992, only Oklahoma did not provide information on Hispanic origin.
NA = data not available.
Source: Adapted from National Center for Health Statistics 1997.


i,,nzer) WFas highest for African American men (81.6
per I r)(),oOo population) (Table 2); the lung cancer death
r,lte for African American women (27.2 per 100,000)
,,.db bimilar to that for white women (27.9 per 100,000)
,),,d ljigher than that for any other racial/ethnic group.
.\mc,n~ African Americans in 1993, the four leading
ic1Llse5 of cancer death were lung cancer (26.1 percent
(,I ;1l1 cancer deaths), cancer of the colon and rectum
( 10.4 percent), prostate cancer (9.4 percent), and can-
ik'T ()f the female breast (8.3 percent) (Parker et al. 1997).

The higher lung cancer incidence and death rates
~,mo~~g African American men have not been fully ex-
pl,lined. Two ecological analyses of population-based
in<ide1lce data for metropolitan areas have shown that
the African American-white gradient in lung cancer
occurrence among men was consistent with gradients
in socioeconomic indicators (Devesa and Diamond
1983; Baquet et al. 1991) and that the difference in lung
c`lncfr disappeared when the data were adjusted for
\,ocioeconomic status. The authors of one paper
tB,lquet et al. 1991) surmised that the differences in
+moking patterns associated with socioeconomic sta-
tLl> ,lccounted for the differences in lung cancer be-
t\\.ct'n white and African American men, whereas the
,luthors of the other paper (Devesa and Diamond 1983)
pr~~posed that cigarette smoking and other environ-
tnctntal correlates of socioeconomic status, such as
dietary habits or occupational exposure, may have
.licounted for their findings.

  Data from several National Health Interview
`;url-cvs (NHISs) were used to conduct birth cohort
,~n,>ly<es of cigarette smoking prevalence in the 1900s
tcjr African Americans and whites of both genders
(`I'~>ll~~\~ et al. 1991; Shopland 1995). Older white men
(tho5; born before 1915) experienced higher peak
\nloking rates and slightly earlier ages of initiation
th,ln older African American men. For persons born
,litc>r 1915, peak smoking rates and duration of smok-
ing tor African American men were slightly higher than
those> ior white men. In addition, Lvhite male smokers
\\`c'rt' more likely than African American male smok-
l'r\ to quit smoking in the 1950s (when the early
~it~tific studies on smoking and lung cancer were
n~p~~rted); African American male cohorts born after
IL) 15 thus experienced a greater cumulative exposure
10 cl$lrette smoke. Reflecting these trends in smok-
Ills bc+avior, lung cancer mortality rates were initially
ill&t>r for white men. The combination of less cessa-
tl~)n, ljigher peak prevalence, and longer duration
(`1 \moking in African American men after the 1940s
Ilhc'l\' cl\plains the observation that mortality rates for
-\trl~-cln American men began to exceed those for white
1111'1J Illttlr in the century (Shopland 1995).

  Lung cancer death rates have been much lower
for women than for men (reflecting historically lower
smoking prevalences) and have risen more slowly with
age in the older birth cohorts. As rates for men began
to decline in cohorts born after 1930, rates continued
to rise among women, reflecting their slower adop-
tion and increasing prevalence of cigarette smoking.
African American and white women indicated simi-
lar patterns of smoking initiation, maintenance, and
quitting; lung cancer death rates for African Ameri-
can and white women also have been similar (Tolley
et al. 1991; Shopland 1995). These data are consistent
with the interpretation that trends in smoking behav-
ior are largely responsible for 20th century lung can-
cer mortality patterns for African Americans and
whites. Tolley and colleagues (1991) further suggested
that lung cancer rates among African American men
and women may be slightly higher than those for white
men and women, even after considering differences
in their smoking behaviors.

  One study (Harris et al. 1993) showed a higher
lung cancer risk among African Americans compared
with whites who had the same level of cumulative
exposure to cigarette smoking. In this 20-year case-
control study, 2,678 cases of lung cancer were identi-
fied among white men, 238 cases among African
American men, 1,394 cases among white women, and
113 among African American women; after adjusting
the data for cumulative tar consumption and educa-
tion, the researchers found that African Americans had
a significantly higher risk of lung cancer. One limita-
tion of this study is that it uses the Federal Trade
Commission's (FTC's) estimates of tar yield to calcu-
late cumulative tar consumption. The ETC's machines
are set to parameters that have not changed for de-
cades. Because humans smoke cigarettes differently
than the machines used by the FTC, the validity of
these measures has been called into question (NC1
1996a). In the Kaiser Permanente cohort study, the
relative risks of lung cancer were approximately the
same for African Americans and whites (Friedman et
al. 1997). Dorgan and colleagues (1993) conducted a
case-control study to assess race and gender differences
in lung cancer, categorizing participants according to
consumption of fruits and vegetables. Lung cancer
risk was significantly increased for African Americans
who currently smoked (compared with never smok-
ers and former light smokers), regardless of the amount
of vegetables consumed. These analyses were statisti-
cally adjusted for gender, age, education, occupation,
passive smoking, and study phase.

  In a recent population-based case-control
study to compare the risks of lung cancer for African


73bncco USC Amo~~g U.S. Raczhl/Ethic Minority Groups

Table 2.  Age-adjusted death rates* for selected smoking-related causes of death, by race/ethnicity and
    gender, United States, 1992-1994

Disease Category
UCD-9 code)+

African    American Indian/ Asian American/
American    Alaska Native  Pacific Islander    White     Hispanic

Men Women Men Women Men Women Men Women Men Women

Cancer
Lip, oral cavity,
pharynx (140-l 49)       7.7

Esophagus (150)        11.4

Stomach (151)         9.5

Pancreas (157)         11.1

Larynx (161)           4.6

Trachea, bronchus,
lung (162)            81.6

Cervix uteri (180)       NA

Bladder (188)          3.2

Kidney, other, unspecified
urinary organs (189)      4.3


Cardiovascular diseases
Coronary heart disease
(410414)           138.3

Cerebrovascular disease
(430438)           53.1

Respiratory diseases
Bronchitis, emphysema
(491492)            4.7

Chronic airway
obstruction, not
elsewhere classified (496) 17.6

1.8     2.6    1.0    3.3    1.0    3.0    1.2    2.4    0.5

3.0     3.2    0.5    2.7    0.5     4.4    0.9    2.8    0.4

4.1     4.9    2.6    8.9    5.1    3.9    1.7    6.2    3.1

8.1     3.4    3.0    5.5    3.9    7.3    5.2    5.1    3.8

0.8    0.9    0.3    0.6    0.1     1.7    0.4    1.3    0.2

27.2    33.5   18.4    27.9   11.4    54.9   27.9    23.1    7.7

5.7    NA    3.0    NA    2.5    NA    2.2    NA    3.2

1.6     1.2    0.5     1.5    0.6    3.9    1.1     1.8    0.6

2.0     4.4    2.3    1.8    0.8    4.1    1.9    3.1    1.3

85.0

100.4

71.7   36.2   132.5   62.9    82.7   43.9

40.6

23.9

45.9



21.1





1.9





9.0

29.3   22.4    26.3   22.6    22.7   16.3

1.6

2.8

2.9    0.9    6.2    3.8    2.4

6.6

14.2

7.9    2.6    20.4   12.2     8.2

0.9




3.7

*Per 100,000, age-adjusted to the 1940 U.S. standard population. Estimates for Hispanics exclude data from
New Hampshire for 1992 and from Oklahoma for 1992-1994.
+I&rrzntiolzal Clnssificntim of Discans~s, Ninth Rcz~isio~~, World Health Organization 1977.
NA = data not available.
Sources: National Center for Health Statistics, public use data tapes, 1992-1994; U.S. Bureau of the Census 1997.

Americans and whites across categories of cigarette   Surveillance System, a participant in the NCI's SEER
smoking status, Schwartz and Swanson (1997) exam-   Program. The analyses were stratified by gender and
ined incident cases from the Occupational Cancer   statistically adjusted for age, education, and cigarette
Incidence Surveillance Study. This study operates in   smoking behaviors. The overall risks of lung cancer
conjunction with the Metropolitan Detroit Cancer   (of all histological types) were similar for African

Health Comrqzremes 142


Americans and whites. Thus, race did not appear to
be an independent predictor of lung cancer in the
population as a whole. Howelrer, African Americans
were more likely than whites to have developed squa-
mous cell carcinoma. Additionally, African American
men aged 40-54 years were 24 times more likely than
white men of the same ages to have developed lung
cancer (of several histological types). The authors con-
cluded that the increased risks among younger
African Americans may suggest a greater degree of
susceptibility to lung carcinogens or greater exposure
to other unidentified carcinogens and they called for
further research on the topic.

  Investigators have postulated that the more
frequent smoking of menthol cigarettes by African
Americans, compared with whites, contributes to their
increased rate of lung cancer (Harris et al. 1993). In a
recent experimental study of 12 persons after the
amount of menthol injected into experimental ciga-
rettes was increased, the amount of carbon monoxide
exhaled by African American smokers also increased
(Miller et al. 1994). In a comparison of smoking be-
havior associated with mentholated cigarettes and
regular cigarettes among 29 subjects, McCarthy and
colleagues (1995) found higher mean puff volume and
higher puff frequency after participants smoked regu-
lar cigarettes than after they smoked mentholated
cigarettes; however, no differences in mean expired
carbon monoxide levels were found. A\Tailable data
suggest that mentholated cigarettes are not smoked
more intensely than regular cigarettes (Jarlik et al.
1994; Miller et al. 1994; McCarthy et al. 1995; Ahijevych
et al. 1996). Thus, mentholated cigarettes may pro-
mote lung permeability and diffusibility of smoke con-
stituents (Jarvik et al. 1994; McCarthy et al. 1995; Clark
et al. 1996a).

  Recent studies have examined the possible role
of genetics in determining the risk of lung cancer
among African Americans. Crofts and colleagues
(1993) identified a restriction fragment length polymor-
phism (RFLP) in the gene (CYPIAI) that encodes the
enzyme responsible for initiating metabolism of
polyaromatic hydrocarbon compounds found in ciga-
rette smoke (Guengerich 1992, 1993). In one study of
African Americans, the risk of adenocarcinoma of the
lung was higher for smokers with the CYPlAl RFLP
than for smokers who did not have this RFLP (Taioli
et al. 1995). Two other studies, however, did not find
an association between the presence of the variant al-
lele in African Americans and increased lung cancer
risk (Kelsey et al. 1994; London et al. 1995). Taioli and
colleagues (1995) also found that persons who had
adenocarcinoma with the African American CYPZAI

RFLP had lower lifetime cigarette consumption, as
measured by pack-years, compared with those who
had adenocarcinoma without the polymorphism.
However, using a cutoff point of 35 pack-years,
London and colleagues (199.5) found no association
between the variant CYPZAI variant allele and lung
cancer risk based on smoking history. Additionally, a
homozygous rare CYPlAl allele associated with the
risk of lung cancer among persons from Japan
(Kawajiri et al. 1990) was found more often in African
Americans than in whites (Shields et al. 1993). How-
ever, in a small case-control study, no association was
observed between the presence of this polymorphism
and lung cancer risk (Shields et al. 1993).

  Despite strong research interest in this area,
scientists have been unable to consistently associate
variant alleles with lung cancer susceptibility. The fre-
quencies of the polymorphisms of interest appear to
be low in United States populations studied thus far.
Low frequencies of the alleles of interest suggest that
future investigations must allow for an adequate
sample size of the group under study and adjustment
for factors such as smoking history and age. In addi-
tion, low frequency allelic affects may be negated or
obscured by high tobacco exposure levels.

  Two phenotypes were identified in African
American and white persons representing poor and
extensive extremes of glucuronidation (Richie et al.
1997). Glucuronidation is considered a detoxification
pathway because it increases the water solubility of a
chemical substrate and facilitates excretion (Goldstein
and Faletto 1993). The ratio of conjugated metabolite
to free metabolite of a tobacco-specific nitrosamine was
30 percent higher in the urine of white smokers than
in African American smokers. This finding suggests
that African Americans are at higher risk from
nitrosamine exposure during smoking because
of a decreased capacity to detoxify carcinogenic
tobacco-specific nitrosamines. Hence, variability in
glucuronosyltransferase activity, or in clearance of glu-
curonide conjugates, may represent another determi-
nant of cancer risk.

  The genetically determined poor, intermediate,
or enhanced debrisoquine metabolizer phenotype has
been investigated as a risk factor for lung cancer.
Homozygous dominant (extensive metabolizer) indi-
viduals were found more frequently among white lung
cancer patients who smoked cigarettes than white
control patients with COPD who smoked cigarettes
(Ayes11 et al. 1984). Caporaso and colleagues confirmed
the association between the extensive debrisoquine
metabolizer phenotype and lung cancer risk. In this
study, almost equivalent numbers of extensive


metabolizers were found among African Americans
(74 percent) and whites (73 percent) (Caporaso et
al. 1990).

  Another approach in assessing the possible role
of genetics is using chromosome breaks to measure
cancer susceptibility. One research group has devel-
oped an in vitro cytogenic assay that measures
mutagen-induced chromosome breaks in short-term
lymphocyte cultures. This approach has shown a
relationship between mutagen sensitivity and elevated
lung cancer. However, attempts to use this method as
a predictive marker of racial/ethnic differences in can-
cer risk in African and Mexican Americans produced
inconsistent results (Spitz et al. 1995; Strom et al. 1995;
Wu et al. 1996).

  Carcinogenesis can in\Tolve genotoxic mecha-
nisms whereby chemical interactions at critical cellu-
lar sites go unrepaired. Alterations in certain genes,
kno\vn as proto-oncogenes and tumor suppressor
genes, are linked with cancer risk (Land et al. 1983;
Marshall et al. 1984; Slamon et al. 1984; Klein and Klein
1985; Denissenko et al. 1996). Some gene alleles that
are e\,aluated as markers of lung cancer risk Ivary in
their distributions among African Americans and
whites. For example, in a study of lung cancer cases
and trauma victim controls, Weston and colleagues
(1991) found rare Ha-ras-1 alleles more often in the
lung tissue of African Americans (17 percent) than in
whites (5 percent). For both groups, the prevalence of
rare alleles among lung cancer patients was higher than
among controls (23 percent for African American lung
cancer cases, 15 percent for African American trauma
victim controls, 6 percent for white lung cancer cases,
and 2 percent for white trauma victim controls). These
findings were confirmed in a second study (Weston
et al. 1992). African American and white differences
in distribution of alleles at the L-myc locus and ~53
genotype have also been reported. The authors con-
cluded that L-myc genotypes and p53 variants do not
predict lung cancer risk (Weston et al. 1992).

  In summary, the higher rates of lung cancer ob-
served among African American men are consistent
with historical patterns of cigarette smoking in this
century (Shopland 1995). In addition, African Ameri-
can men aged 40-54 years may be especially suscep-
tible to lung carcinogens (Schwartz and Swanson 1997),
perhaps because they detoxify them differently (Richie
et al. 1997). A genetic role in racial and ethnic-specific
risk for lung cancer cannot be ruled out, because some
studies have shown that African American populations
have increased frequencies of rare alleles associated
with greater risks for developing lung cancer than
whites. However, because of the low frequency of

these alleles in the populations under study and the
possibility of misclassification bias, studies have been
inconclusive (Shields et al. 1993; Taioli et al. 1995).
Further, African American smokers prefer mentholated
cigarettes, and menthol may promote the absorption
and diffusion of tobacco smoke constituents (Jarvik et
al. 1994; McCarthy et al. 1995; Clark et al. 1996a). This
hypothesis has received inconsistent support in the
epidemiological literature. Kabat and Herbert (1991)
found no relationship between menthol use and lung
cancer risk; however, Sidney and colleagues (1995)
suggested that smoking mentholated cigarettes in-
creased the risk of lung cancer only in male smokers.
Further research could clarify the nature of individual
susceptibility and the possible role of mentholation.
Reduction in cigarette smoking will undoubtedly lead
to reduction in the risk of lung cancer for African
Americans.

American Indians and Alaska Natives

  Since the early 19OOs, many studies have docu-
mented the low overall occurrence of cancer among
American Indians compared with whites (Hoffman
1928; Smith et al. 1956; Smith 1957; Salsbury et al. 1959;
Sievers and Cohen 1961; Kravetz 1964; Reichenbach
1967; Creagan and Fraumeni 1972; Dunham et al. 1973;
Blot et al. 1975; Lanier et al. 1976; Samet et al. 1980,
1988b; Sorem 1985; Mahoney and Michalek 1991; Nut-
ting et al. 1993). Investigations of lung cancer inci-
dence and deaths have confirmed that lung cancer is
less frequent among American Indians overall than
among whites (Coultas et al. 1994). Between 1992 and
1994, age-adjusted death rates for lung cancer per
100,000 among American Indian and Alaska Native
men (33.5) and women (18.4) were slightly higher than
those among Asian American and Pacific Islanders as
well as Hispanics, whereas they were lower than rates
among African Americans and whites (Table 2) (NCHS,
public use data tapes, 1992-1994; U.S. Bureau of the
Census 1997). Mortality rates for malignant diseases
of the respiratory system increased from 1980 through
1995 among American Indians and Alaska Natives
(Table 1) (NCHS 1997).

  Nationally, lung cancer is the leading cause of
cancer death among American Indians and Alaska
Natives. Among those who died of cancer in 1993, the
four leading causes of death were lung cancer (26.8
percent), cancer of the colon and rectum (8.9 percent),
cancer of the female breast (6.3 percent), and prostate
cancer (6.0 percent) (Parker et al. 1997). Additionally,
lung cancer was the leading cause of cancer death
among both men and women in 10 of the 12 Indian


Figure 2.  Age-adjusted lung cancer death rates among American Indian and Alaska Native men in
   seiecteh states compared with rates among all U.S. men, 1968-1987*

80 1

60

- All U.S. men

- m - 1.  Alaska


    North Dakota,
111 South Dakota,
    and Montana

   Michigan,
m--a Minnesota, and
     Wisconsin

- Oklahoma

Arizona and
New Mexico

1968-l 972           1973-l 977

Years

1978-1982           1983-1987

*Rates presented here were determined using midpoint population estimates for each 5-year time interval and
were adjusted to the 1970 U.S. standard population.
Source: Valway 1992.

Health Service (IHS) areas (Arizona and New Mexico
had low rates of lung cancer deaths) (Valway 19921.
Lung cancer death rates among American Indians and
Alaska Natives have been rising in most IHS areas (Fig-
ures 2 and 3) (Valway 1992); national death rates from
malignant diseases of the respiratory system have also
been increasing (Table 1).

  Lung cancer death rates vary by IHS area. Spe-
cifically, American Indians in the Southwest have had
the lowest lung cancer death rates, whereas American
Indians in Alaska, North Dakota, South Dakota, and
Montana have had rates nearly as high as those in the
general U.S. population (Table 3, Figures 2 and 3)
(Valway 1992). These differences are associated with
variations in smoking among American Indians and
Alaska Natives (Centers for Disease Control [CDC]
1987; Welty et al. 1993). In an analysis of data from the
1985-1988 Behavioral Risk Factor Surveillance System
(BRFSS) on 1,055 American Indians, Sugarman and
colleagues (1992) determined smoking prevalence for
three groups of states that contained three specific IHS

areas. In this study, the Plains states (Iowa, Minne-
sota, Montana, Nebraska, North Dakota, South Dakota,
and Wisconsin) contained the Aberdeen, Bemidji, and
Billings IHS areas; the West Coast states (California,
Idaho, and Washington) contained the Portland and
California IHS areas; and the Southwest states
(Arizona, New Mexico, and Utah) contained the Al-
buquerque, Navajo, Tucson, and Phoenix IHS areas.
Cigarette smoking prevalence rates were highest in the
Plains states (48.4 percent for men and 57.3 percent
for women), intermediate in the West Coast states (25.2
percent for men and 31.6 percent for women), and low-
est in the Southwestern states (18.1 percent for men
and 14.7 percent for women). These general geo-
graphic patterns of smoking prevalence paralleled
patterns of lung cancer mortality (Table 3) (Valway
1992). The smoking prevalence estimates from the
1985-1988 BRFSS analyses may be imprecise because
of relatively small samples. However, other analyses
(American Indians and Alaska Natives, in Chapter 2;
Welty et al. 1995) show similar patterns. Another


TO~CCCJ USC Amng U.S. Racial/Efhnic Minorify Groups

Figure 3.  Age-adjusted lung cancer death rates among American Indian and Alaska Native women in
     selected states compared with rates among all U.S. women, 196%1987*

a *, I II  All U.S. women

Alaska

North Dakota,
South Dakota,
and Montana

Michigan,
Minnesota, and
Wisconsin

Oklahoma

Arizona and
New Mexico

        I    I     I     I     I    I    I     I     I     I     I    I     I    I    I
1968-1972           1973-1977           1978-1982           1983-1987
                         Years

*Rates presented here were determined using midpoint population estimates for each S-year time interval and
were adjusted to the 1970 U.S. standard population
Source: Valway 1992.

potential limitation is that American Indians living in
the California and Portland IHS areas may be more
likely than American Indians from other IHS areas to
be misclassified on death certificates as being of other
racial/ethnic categories (Valway 1992), suggesting that
death rates for American Indians may be underesti-
mated in these areas (Sorlie et al. 1992).

  Lanier and colleagues (1996) recently reported on
lung cancer incidence rates for Alaska Native men and
women. Lung cancer incidence was higher for Alaska
Natives than it was for the general U.S. population.
In addition, lung cancer was the most common inci-
dent cancer among men and the third most common
incident cancer among women (after breast cancer and
cancer of the colon/rectum). Lung cancer incidence
increased substantially among Alaska Native men
(by 93 percent) and women (by 241 percent) between
1969-1973 and 1989-1993. The authors concluded,
"Reduction in tobacco use would result in the greatest
decreases in cancer rates in this population" (p. 751).

Asian Americans and Pacific Islanders

  Two issues should always be kept in mind when
interpreting data about the health consequences of
cigarette smoking among Asian Americans and Pacific
Islanders: the diversity of this group and the paucity
of data. The Asian American and Pacific Islander
population of the United States includes approxi-
mately 32 national and racial/ethnic groups and nearly
500 languages and dialects. Although many of these
persons were born in the United States, many others
are recent immigrants (see Chapters 1 and 2); yet the
national data do not indicate these distinctions. Envi-
ronmental exposures experienced in Asia, such as
women's exposure to smoke from cooking fuels, may
influence lung cancer occurrence among recent immi-
grants (Co&as et al. 1994).

  From 1980 through 1995, age-adjusted death rate
for malignant neoplasms of the respiratory system
(primarily deaths from lung cancer) among Asian


Table 3.  Death rates for lung cancer among
     American Indians and Alaska Natives,
    by Indian Health Service (IHS) area,
      1984-1988

Areas

  Men        Women

N    Rate*    N   Rate*

U.S., all ethnicities
Nine IHS areas*+
All 12 IHS areas
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California+
Nashville
Navajo
Oklahoma+
Phoenix
Portland+
Tucson

     74.2         27.3
307   38.5$    203   27.2
562   40.1t    296   21.4i
63    68.7     41   45.01
80    75.5     62   68.5$
12   18.8$     5   7.8$
41   63.4$     24   40.71
36    65.3     33   65.7i
33   33.2'      8   6.6$
24   41.8t     15   25.1
25   11.4i      7   4.0$
167   46.0i     55   14.0$
20   17.2$     13   11.5*
55   40.5f     30   23.4
6   25.9i     3   13.5i

*Per 100,000, age-adjusted to the 1970 U.S. standard
population. Rates based on a small number of
deaths should be interpreted with caution.
`The California, Oklahoma, and Portland IHS areas
appear to have a problem with underreporting
Indian ethnicity on death certificates; therefore, a
separate total is presented for the nine other IHS
areas, excluding these three areas.
iDenotes a rate significantlv different from the rate
for the overall U.S. population.
Source: Valway 1992.

  During 1988-1992, the age-adjusted (to the 1970
U.S. standard population) incidence per 100,000 popu-
lation of lung cancer for men was 89.0 for Hawaiians,
70.9 for Vietnamese, 53.2 for Koreans, 52.6 for Filipi-
nos, 52.1 for Chinese, and 43.0 for Japanese. For com-
parison purposes, the lung cancer incidence rates were
117.0 for African American men, 76.0 for white men,
and 41.8 for Hispanic men. For women, the lung can-
cer incidence rates were 43.1 for Hawaiians, 31.2 for
Vietnamese, 25.3 for Chinese, 17.5 for Filipinos, 16.0
for Koreans, and 15.2 for Japanese. In comparison, the
lung cancer incidence rates were 44.2 for African
American women, 41.5 for white women, and 19.5 for
Hispanic women.

American and Pacific Islander men remained fairly     Age-adjusted lung cancer death rates during
constant; this death rate for Asian American and Pa-   1988-1992 were, per 100,000 men, 88.9 for Hawaiians,
cific Islander women increased slightly between 1980   40.1 for Chinese, 32.4 for Japanese, and 29.8 for Filipi-
and 1995 but was substantially lower than for men   nos; mortality estimates were not available for Kore-
(Table 1) (NCHS 1997). Trends should be interpreted   ans and Vietnamese of either gender. In comparison,
with caution because the large numbers of immigrants   the lung cancer death rates were 105.6 for African
from Asia and the Pacific Islands that came to the   American men, 72.6 for white men, and 32.4 for His-
United States during that time may have influenced   panic men. For women, the lung cancer death rates
both disease prevalence in and the age structure of this   were 44.1 for Hawaiians, 18.5 for Chinese, 12.9 for Japa-
group. During 1992-1994, the age-adjusted death rate   nese, and 10.0 for Filipinos. In comparison, the lung
for lung cancer was 27.9 per 100,000 for Asian Ameri-   cancer death rates were 31.9 for white women, 31.5
can and Pacific Islander men and 11.4 per 100,000 for   for African American women, and 10.8 for Hispanic
women (Table 2). These rates were slightly higher than   women (NC1 1996b). The lung cancer rates reflect gen-
those for Hispanics and slightly lower than those for   der differences in smoking rates among Asian Ameri-
American Indians and Alaska Natives. In 1993, the   can and Pacific Islander populations, as indicated by
four leading causes of cancer death among Asian   1978-1995 data from the NHISs (see Chapter 2).

Americans and Pacific Islanders were lung cancer (22.3
percent of all cancer deaths), cancer of the colon and
rectum (10.4 percent), cancer of the liver and intrahe-
patic bile duct (8.6 percent), and stomach cancer (7.7
percent) (Parker et al. 1997).

  Data on lung cancer for more specific subgroups
have been published in several reports (Baquet et al.
1986; Ross et al. 1991; Zane et al. 1994; NC1 1996b).
The most recent data are from NCI's SEER program
and provide information for 1988-1992. This report
includes incidence data from the nine areas included
in the annual SEER reports (e.g., Kosary et al. 1995)
and from Los Angeles, San Jose/Monterey, and the
Alaska Area Native Health Service. Data on Hispan-
ics are predominantly from Los Angeles, New Mexico,
San Francisco, and San Jose/Monterey. Most Hispan-
ics represented in SEER are Mexican Americans. Data
on Asian Americans and Pacific Islanders are mainly
from Los Angeles, Hawaii, San Francisco/Oakland,
San Jose/Monterey, and Seattle/Puget Sound. Data
on American Indians are from New Mexico; data from
the Alaska Native Area Health Service provide infor-
mation on Alaska Natives (NC1 1996b).


Tohncco Use Among U.S. Racinl/Ethic Mirzority Groups

  Several studies have identified high rates of lung
cancer among Native Hawaiians. Data on lung cancer
among Pacific Islanders from the Hawaii Tumor Regis-
try indicate that Native Hawaiians have the highest
lung cancer incidence rates among the islands' other
racial/ethnic groups, including Japanese, Filipinos, and
Chinese (Kolonell980; Hinds et al. 1981). Using medi-
cal records of lung cancer patients and data from a
population-based survey, Hinds and colleagues (19811
assessed the risk of developing lung cancer associated
with smoking among M'omen in Hawaii. The risk for
developing lung cancer among women ~~110 had e\`er
smoked compared with those ~`1~0 had never smoked
w'as substantially greater among Nati\-e Harvaiian
women (tenfold higher) than among Japanese women
(fivefold higher) and Chinese women (tlvofold higher).
In a comparison of the risks of smoking among Natilre
Hawaiians, Filipinos, Japanese, and Chinese in HawFaii,
Le Marchand and colleagues (1992) found that Native
Hawaiian men had the highest risk and that lvhite and
Filipino women had higher risks than Native Hawai-
ian women. The pattern of variation of smoking's
effect on lung cancer \vas statistically significant for
men. These differences persisted after variables for
beta-carotene and cholesterol intake were included in
the statistical model. The observation that the risk of
lung cancer related to smoking may vary among sub-
groups requires further elucidation. In a cohort study
of 7,961 Japanese American men who were living in
Hawaii, the incidence of lung cancer was 11.4 times
higher in current smokers than in persons ~`110 had
never smoked; the risk for former smokers was 3.1 times
higher than for never smokers (Chyou et al. 1993).

Hispanics

  According to NCHS data from 1985 through 1995,
the age-adjusted death rate for malignant neoplasms
of the respiratory system (primarily deaths from lung
cancer) among Hispanic men was about three times
higher than that for Hispanic women (Table 1) (NCHS
1997). Trends should be interpreted with caution, be-
cause only 17 states and the District of Columbia con-
tributed death certificate data on Hispanics for 1985;
by 1990, however, 47 states and the District of Colum-
bia, covering 99.6 percent of the U.S. Hispanic popu-
lation, contributed relevant data (Table 1) (NCHS 1997).
From 1992 through 1994, the age-adjusted death rate
for cancer of the trachea, bronchus, and lung (gener-
ally referred to as lung cancer) was 23.1 per 100,000
for Hispanic men and 7.7 per 100,000 for Hispanic
women (Table 2). Overall, lung cancer is the leading
cause of cancer death among Hispanics. Among those

who died of cancer in 1993, the four leading causes of
death were lung cancer (17.9 percent), cancer of the
colon and rectum (9.6 percent), cancer of the female
breast (8.2 percent), and cancer of the liver and other
biliary organs (6.0 percent) (Parker et al. 1997). Among
Hispanic women, however, breast cancer mortality
exceeds that of lung cancer (NC1 1996b).

  National mortality data for 1992-1994 (Table 4)
also indicate that rates of lung cancer per 100,000
were higher among Cuban men (33.7) than among
Mexican American (28.3) and Puerto Rican men (21.9).
Among women, little variation is evident across His-
panic subgroups (Table 4). An earlier nationwide
analysis limited to foreign-born Cubans, Mexicans, and
Puerto Ricans provided similar results for 1979-1981
(Rosenwaike 1987).

  Some regional data suggest that rates of lung
cancer among Hispanics increased rapidly. For ex-
ample, New Mexico mortality data for 1958-1982
indicate that lung cancer death rates increased for suc-
cessive birth cohorts of Hispanics (Samet et al. 1988b).
Between 1958-1962 and 19781982, lung cancer death
rates per 100,000 increased from 10.1 to 28.8 among
Hispanic men and from 4.8 to 11.2 among
Hispanic women (Samet et al. 1988b). However, lung
cancer death rates among Hispanics remained below
those of the general U.S. population. Moreover, be-
tween 1969-1971 and 1979-1981, lung cancer incidence
rates doubled for persons with Spanish surnames (not
necessarily all persons were Hispanic) residing in the
Denver, Colorado, area (Savitz 1986).

  National and regional vital statistics have shown
that patterns of lung cancer incidence differ among
Hispanics and whites throughout the United States
(NCHS 1994). Much of the information available on
lung cancer incidence has relied on the SEER Program,
which for many years included only one subgroup of
Hispanics-those residing in New Mexico.

  Since the 195Os, descriptive studies of death have
documented differing patterns of lung cancer among
Hispanics and whites in the western and southwestern
United States. In California, during the 1950s and 196Os,
age-specific death rates from lung cancer among older
Mexican-born women were two to three times the rates
among California women of all ages (Buechley et al.
1957; Buell et al. 1968). Lung cancer death rates for
women in Texas and New Mexico during the 1960s and
1970s showed a similar pattern of age-specific rates (Lee
et al. 1976; Samet et al. 1980,1988b), although Hispanic
women in the West and Southwest have had lower over-
all lung cancer death rates than white women (Savitz
1986; Martin and Suarez 1987; Samet et al. 1988b;
Bernstein and Ross 1991).


Table 4.  Age-adjusted death rates* for selected smoking-related causes of death among Mexican
     Americans, Puerto Rican Americans, and Cuban Americans, United States, 1992-1994

Disease category
(ICD-9 code)+

  Mexican

Men   Women

Puerto Rican

Men   Women

  Cuban

Men   Women

Cancer
Lip, oral cavity, pharynx (140-149)
Esophagus (150)
Stomach (151)

Pancreas (157)
Larynx (161)
Trachea, bronchus, lung (162)
Cervix uteri (180)
Bladder (188)
Kidney, other, unspecified
urinary organs (189)

Cardiovascular diseases
Coronary heart disease (410-414)
Cerebrovascular disease (430338)

2.0      0.4      5.5      0.9     3.3      0.7

2.7      0.3      6.1      1.1      2.7      0.4

6.8      3.5      7.7      3.9      3.1      1.3

5.4      4.3      5.0      3.6      5.0      4.1

1.1      0.1      2.6      0.3      2.2      0.1

21.9      8.0     28.3      9.6     33.7     8.9

NA      3.7     NA      3.7     NA      1.6

1.4      0.5      2.1      1.0      3.5      0.5

3.7      1.6      1.9      1.0      2.7      1.0

82.3     44.2

25.5

18.9

118.6     67.3     95.2     42.4

27.3     16.5     17.1     11.5

Respiratory diseases
Bronchitis, emphysema (491-492)

Chronic airway obstruction,
not elsewhere classified (496)

2.2      0.9      3.2      1.3      3.3      1.0

7.6

3.7

10.5      5.3

9.1

3.1

*Per 100,000, age-adjusted to the 1940 U.S. standard population. Death rates are not available from New
Hampshire for 1992 and from Oklahoma for 1992-1994. Due to limitations in the data, the population
estimates for Oklahoma and New, Hampshire were not subtracted from the denominator. Based on the
1990 Census, the number of persons of Hispanic origin from New, Hampshire and Oklahoma represented
about 0.04 percent of the U.S. Hispanic population.
+l~zfernnfio~~~/ Clnssificnfior~ of Disen.scs, Nirlfh R~~isicjr~, World Health Organization 1977.
NA = data not available.

Sources: National Center for Health Statistics, public use data tapes, 1992-1994; U.S. Bureau of the Census 1997.

  In 1982 and 1983, lung cancer rates among   Hispanic men than among white men in New Mex-
Hispanic men and women in Florida also were lower   ico (Samet et al. 1980), Texas (Lee et al. 1976), Califor-
than the rates among whites (Trapido et al. 1990a,b).   nia (Menck et al. 1975; Bernstein and Ross 1991),
More recent data (1981-1989) from Dade County,   Connecticut (Polednak 19931, and Colorado (Savitz
Florida, again show the incidence of lung cancer to be   1986). Mortality data indicate that Puerto Ricans
lower among Hispanic men than among white men   living on Long Island, New York, had slightly
and lower among Hispanic women than white women   lower death rates for lung cancer than Puerto Ricans
(Trapido et al. 1994a,b). Similarly, Mexican and Puerto   living elsewhere in the United States (except Puerto
Rican immigrants in Illinois have had lower standard-   Rico) (Polednak 1991). However, Puerto Rican men
ized lung cancer death rates than whites (Mallin and   and women residing on Long Island had lung cancer
Anderson 1988). In addition, lung cancer incidence    death rates that were three to four times the rates
and death rates have been much lower among   among Puerto Rico residents.


  These lower rates of lung cancer among Hispan-
ics appear to reflect differences in smoking between
Hispanics and whites.  The results of a 1980-1982
case-control study of lung cancer cases among Hispan-
ics and whites residing in New Mexico indicate that
the risks (adjusted for gender and age) across catego-
ries of smoking consumption among both groups were
comparable (Table 5) (Humble et al. 1985). This find-
ing suggests that the reduced rates of lung cancer
deaths among Hispanics are attributable to their lower
cigarette consumption (number of cigarettes smoked
daily) and not to some other correlate of Hispanic race/
ethnicity. In a mortality study conducted in Texas be-
tween 1970 and 1979 using age-standardized death
rates, Holck and colleagues (1982) found that Mexi-
can American women had stable lung cancer death
rates (approximatelv 30 per lOO,OOO), whereas white
Lvomen had increasing rates of death from lung
cancer. The lower lung cancer rates for Mexican
American women were consistent with their lower
prevalence of smoking (18.5 percent of Mexican Ameri-
can women vs. 31.6 percent of white women).

  The elevated rates of lung cancer death among
older Hispanic women in the West and Southwest ha\re
been attributed to a possible pattern of early initiation
of smoking among women born in Mexico before 1900
as well as the custom of cooking indoors with an open
fire (Buell et al. 1968; Lee et al. 1976). The findings of a
1980-1982 case-control study in Ne\v Mexico indicate
that older Hispanic women smoked hand-rolled ciga-
rettes, which may have contributed to the high lung
cancer death rate among older Mexican American
women (Humble et al. 1985).

Table 5.  Odds ratios for the risk of lung cancer,
    by gender, racejethnicity, and smoking
    status, case-control study, New Mexico,*
      1980-1982

Men

Smoking status

Former smokers


Current smokers
~20 cigarettes per day
220 cigarettes per day

Hispanic     White

8.0+        7.2
(1.942.2$    (3.0-17.6)

  11.6         9.2
(2.7-61.5)    (3.3-25.8)

  26.1        24.7
(5.6-146.6)   (10.0-59.9)

Women

Hispanic     White

Former smokers



Current smokers
~20 cigarettes per day
~20 cigarettes per day

6.3+        6.5
(1.5-27.8)    (2.8-15.4)

  18.5        19.2
(4.9-72.4)    (6.5-60.8)

  36.9        16.0
(7.6-217.1)    (6.7-36.3)

"Mantel-Haenszel estimates of exposure odds ratios
were calculated for two age strata: ~65 years of age
and 265 years of age. Odds ratios are relative to
persons who never smoked.
+p <O.Ol.

t95% Cornfield confidence limits; unless otherwise
indicated, p <O.OOOl.
Source: Adapted from Humble et al. 1985.

Other Cancers

  Cigarette smoking causes cancers of the lung,
larynx, mouth, esophagus, and bladder; is a contrib-
uting factor for cancers of the pancreas, kidney, and
cervix; and is associated with cancer of the stomach
(USDHHS 1989b, 1990). Cigarette smoking is also sus-
pected of contributing to colon cancer (Giovanucci et
al. 1994), liver cancer (Doll et al. 1994), and acute
myeloid leukemia (Siegel 1993). Little information is
available on cigarette smoking as a risk factor for these
cancers among members of racial/ethnic minority
groups. In the annual Cancer Statistics Review of the

SEER Program, cancer incidence and death rates are
reported for African Americans and whites (Kosary et
al. 1995). A special 1986 report provides more detailed
information on African Americans and other ethnic
groups for 1978-1981 (Baquet et al. 1986). A more re-
cent report provides detailed information on several
ethnic groups for 1988-1992 (NC1 1996b). Other
population-based cancer registries are also beginning
to contribute relevant information.

  Several recently published sources of information
on cancer among American Indians include an IHS


report, which describes regional differences in cancer
deaths among American Indians in the United States
for 1984-1988 and time trends for 1968-1987 (Valway
1992); two reports from the Alaska Area Native Health
Service (Lanier et al. 1993, 1996), which describe can-
cer incidence in the state's Eskimo, Aleut, and Indian

populations; and an NC1 monograph that documents
the status of the evidence on cancer and the need for
additional research regarding cancer among American
Indians and Alaska Natives (Burhansstipanov and
Dresser 1993).

Table 6.  Age-adjusted incidence and death rates* for selected smoking-related cancers, by race/ethnicity and
    gender, National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program,
      1988-1992

Primary cancer site       African
UCD-9 code)+          American

Alaska
Native

American
  Indian
(New Mexico)

Chinese

Filipino

All sites
Incidence rate,5 men
Incidence rate, women
Death rate,1 men
Death rate, women

Cervix uteri (180)
Incidence rate, women
Death rate, women

560,'        372         196         282        274
326        348         180         213         224
319         225         123         139         105
168         179         99          86         63

13.2        15.8
6.7           -**

9.9         7.3         9.6
-           2.6         2.4

Esophagus (150)
Incidence rate, men
Incidence rate, women
Death rate, men
Death rate, women

Kidney and renal pelvis
(189.0-189.1)
Incidence rate, men
Incidence rate, women
Death rate, men
Death rate, women

Larynx (161)
Incidence rate, men
Incidence rate, women
Death rate, men
Death rate, women

Lung and bronchus
(162.2-162.9)
Incidence rate, men
Incidence rate, women
Death rate, men
Death rate, women

15.0
4.4
14.8
3.7

5.3
-
4.2
-

2.9
2.2
-

-

-

-

-

12.8
6.0
5.1
2.2

15.6
-

4.6         5.8
2.3         2.8
1.3         1.9
0.9            -

-

-

12.7
2.5
5.6
0.9

2.8
-
0.9
-

2.4
-

-

-

-

117.0        81.1
44.2        50.6
105.6        69.4
31.5        45.3

52.1         52.6
25.3        17.5
40.1        29.8
18.5        10.0

*Rates per 100,000, age-adjusted to the 1970 U.S. standard population.
W.S. Department of Health and Human Services 1989a.
`Includes persons of other ethnic groups who designated themselves as of Hispanic origin.
$A11 incidence data are from five states: Connecticut, Hawaii, Iowa, New Mexico, and Utah; from six
metropolitan areas: Atlanta (including 10 rural counties), Detroit, Los Angeles, San Francisco/Oakland,
San Jose/Monterey, and Seattle/Puget Sound; and from the Alaska Area Native Health Service.

1.50 Chnyter 3


7obclcco Use Ammo U.S. RnciallEfhnic Minority Groups

   Death and incidence data both indicate marked   than whites for a number of smoking-related cancer sites,
heterogeneity of cancer occurrence among racial/   including the oral cavity and pharynx, esophagus, cer-
ethnic groups in the United States, and this heteroge-   vix uteri, larynx, stomach, pancreas, and lung (Table 6;
neity extends to the cancer sites associated with ciga-   Figure 4) (Kosary et al. 1995; NC1 1996b). When the ra-
rette smoking. For example, SEER data indicate that   tios of African American to white incidence and death
African Americans have higher incidence and death rates   rates exceed 1.0 in Figure 4, then African Americans

Hawaiian

Japanese

Korean

Vietnamese

White

Hispanic%

340         322         266
321         241         180
239         133        NA
168          88         NA

326        469        319
273         346         243
NA         213        129
NA         140         85

9.3
-

5.8         15.2
1.5       NA

43.0         8.7        16.2
NA          2.5         3.4

9.4
-

5.6

5.4
1.7
5.3
1.2

4.4
0.9
3.4
0.7

-

-
NA
NA

NA
NA

4.8
0.9

9.8
-

7.3
2.3
2.4
0.8

6.3
NA
NA

11.9
5.9
5.0
2.3

10.0
5.5
3.7
1.7



5.1
0.7
1.9
0.2

  -
NA
NA

2.5

7.5
1.5
2.3
0.5

-

  -
NA
NA

-

70.9        76.0        41.8
31.2        41.5        19.5
NA         72.6        32.4
NA          31.9        10.8

89.0        43.0        53.2
43.1         15.2        16.0
88.9        32.4        NA
44.1        12.9       NA

`Estimates for all cancer sites are rounded to the nearest integer.
TNational Center for Health Statistics, public use data tapes, 1988-1992, is the source for all death rates
in this table. Death rates are U.S. mortality rates.
**A dash means that the rate was not calculated for fewer than 25 cases.
NA = data not available.
Source: National Cancer Institute 1996b; National Center for Health Statistics, public use data tapes, 1988-1992.

Hmltlr Consequences 152


Table 6. Continued

                                      American
Primary cancer site        African      Alaska      Indian
(ZCD-9 code)+           American     Native    (New Mexico)    Chinese    Filipino

Oral cavity excluding
nasopharynx
(140.0-146.9; 148.0-149.9)
Incidence rate,+ men        20.4'           -**            -           5.3         5.4
Incidence rate, women       5.8            -                     2.3         5.3
Death rate, men           8.7            -                    1.6         1.2
Death rate, women         2.1            -             -           0.7         1.3

Pancreas (1.57)
Incidence rate, men        14.0            -                    8.0         6.5
Incidence rate, women      11.5            -                     4.9         6.0
Death rate,' men          14.4            -                     6.7         4.5
Death rate, women         10.4            -             -           5.1         3.5

Stomach (151)
Incidence rate, men        17.9        27.2                   15.7         8.5
Incidence rate, women       7.6            -             -          8.3         5.3
Death rate, men           13.6            -             -          10.5         3.6
Death rate, women         5.6            -             -           4.8         2.5

Urinary bladder (188)
Incidence rate, men         15.2            -             -          13.0         8.3
Incidence rate, women       5.8            -             -           3.7         2.1
Death rate, men           4.8            -             -           2.0          1.2
Death rate, women          2.4            -             -          1.0            -

*Rates per 100,000, age-adjusted to the 1970 U.S. standard population.
W.S. Department of Health and Human Services 1989a.
XIncludes persons of other ethnic groups who designated themselves as of Hispanic origin.
<All incidence data are from five states: Connecticut, Hawaii, Iowa, New Mexico, and Utah; from six
metropolitan areas: Atlanta (including 10 rural counties), Detroit, Los Angeles, San Francisco/Oakland,
San Jose/Monterey, and Seattle/Puget Sound; and from the Alaska Area Native Health Service.

experience excess morbidity and mortality from the can
cers shown. Also, SEER data for 1988-1992 show that
whites have higher rates of some cancers than Hispan-
ics, Asian Americans, Pacific Islanders, American In-
dians, and Alaska Natives (Table 6) (NC1 1996b). U.S.
mortality data for 1984-1988 show that American In-
dians have a lower mortality rate from lung cancer than
the general U.S. population but a higher mortality rate
from cervical cancer (Table 7) (Valway 19921.

Cervical Cancer

  In a case-control Los Angeles County study of
invasive cervical cancer that included 98 English-
speaking case-control pairs and 102 Spanish-speaking

pairs, Peters and colleagues (1986) found that the over-
all risk of such cancer was increased by cigarette smok-
ing. The cervical cancer risk related to smoking was
comparable in the two groups. In a more recent study
of the risk factors for cervical dysplasia among
Hispanic and white women in New Mexico (Becker et
al. 1994a,b), cigarette smoking was significantly asso-
ciated with high-grade cervical dysplasia among white
women but not among Hispanic women; however, this
difference in risk was not statistically significant. In
addition, in a recent pilot study of American Indian
women in the Albuquerque IHS area, Becker and
colleagues (1993) found that cigarette smoking was
associated with cervical dysplasia; however, the results
were not statistically significant.


Hawaiian    Japanese

Korean

Vietnamese

White

Hispanid

11.7
-

-

10.9
8.7
12.8
9.1

20.5        30.5        38.9        25.8        10.2        15.3
13.0         15.3         19.1         25.8         4.4         8.0
14.4         17.4        NA        NA          6.1         8.4
12.8         9.3        IiA        NA          2.8         4.2

7.0
3. 3
2.1
0.X

8.7            -
7.3         7.6
8.5        NA
6.7        NA

13.7
4.1
2.0
1.2

-
NA
NA

10.4
NA
NA

11.6
NA
NA

-
NA
NA

NA
NA

14.6         8.9
5.8         2.7
3.8         2.7
IS         0.7

9.8         8.0
7.4         6.9
9.7         7.1
6.9         5.2

31.7        15.8
7.8         4.3
5.8         2.8
1.7         0.9

IEstimates for all cancer sites are rounded to the nearest integer.
YNational Center for Health Statistics, public use data tapes, 1988-1992, is the source for all death rates
in this table. Death rates are U.S. mortality rates.
**A dash means that the rate was not calculated for fewer than 25 cases.
VA = data not available.
Source: National Cancer Institute 1996b; National Center for Health Statistics, public use data tapes, 1988-1992.

Esophageal Cancer

  Esophageal cancer incidence and death rates in
the United States are highest among African Ameri-
cans (Tables 2 and 6) (NC1 1996b). To assess potential
causes of the high rates of death from esophageal can-
cer found among African American men, Pottern and
colleagues (1981) conducted a case-control study in
Washington, D.C. After adjusting the data for alcohol
consumption, they found that the relative risk of
esophageal cancer among smokers was only margin-
ally higher than among nonsmokers. In a more recent
study, the risk for African American men of develop-
ing squamous cell carcinoma of the esophagus was
significantly elevated for smokers, even after adjust-
ing statistically for age, geographic area, alcohol
consumption, and income (Brown et al. 1994).

  Smoking mentholated cigarettes may also be a
cause of the high and rising esophageal cancer rates
among African Americans. In a case-control study of
data from the American Health Foundation's ongoing
tobacco study, Hebert and Kabat (1989) failed to show
a consistent effect of smoking mentholated cigarettes
on the risk of esophageal cancer among African Ameri-
cans. Better designed studies are needed to adequately
address this hypothesis.

Oral Cancer

  Tobacco use and alcohol use are the predominant
risk factors for cancers of the oral cavity and pharynx
(commonly referred to as oral cancer) (USDHHS
7989b). African Americans have the highest oral


Figure 4.  SEER* cancer incidence and U.S. death rates, 1988-1992, ratio of African American rate to white
     rate for all ages, by cancer site

  2.5
8
j 2.0
3
'0 1.5
5
  1.0

  2.5
Y
z
b  2.0
c
5  1.5
n
  1.0

Cancer Site

*National Cancer Institute's Surveillance, Epidemiology, and End Results Program; rates are age-adjusted to
the 1970 U.S. standard population.
+Not otherwise specified.
Source: Kosary et al. 1995.

cancer incidence and death rates in the United States   American men, the death rate increased from 4.8 in
(Tables 2 and 6) (NC1 1996b). Using underlying cause-   1950 to 11.0 in 1980 and subsequently decreased
of-death data compiled by NCHS and U.S. census   slightly, to 9.8 in 1990. From 1980 through 1990, the
population enumerations and intercensal population   rate for African American men was approximately
estimates, investigators found that from 1950 to 1990,   twice as high as that for white men. The death rate for
the death rate for cancers of the oral cavity and phar-   cancers of the oral cavity and pharynx for African
ynx (age-adjusted to the 1970 age distribution of the   American women exceeded the rate for white women
U.S. population) decreased for white men from 6.6 to   for nearly all of the 41-year period. The death rate
4.2 per 100,000 population. However, for African   increased slightly for white women, from 1.5 to 1.6,


Table 8.  Odds ratios (ORs) and 95% confidence
     intervals (Us) for the risk of oral cancer
    associated with cigarette smoking, by
    raceiethnicity and smoking sfafus,
      1984-1985*

Smoking status

African
American

OR+   XI

White

OR+ XI

Never smoked      1.0

No. of cigarettes
per da9
1-19
20-39
240

Years of cigarette
smoking
l-19
20-39
240

Age at smoking
initiation (years)
<17
17-24
225

Years since stopped
smoking
0 (never quit)
1-9
10-19
220

1.2  0.5-2.6   1.2 0.8-1.7
2.1   1.04.4   2.2 1.6-2.9
2.8   1 .o-7.7   2.8 2.04.0

0.9   0.3-2.4   0.6 0.4-l .O
1.6   0.7-3.3    1.9 1.3-2.5
2.9   1.2-7.2    3.3 2.34.6

1.8   0.8-3.9    2.0 1.4-2.7
1.7   0.8-3.8    1.9 1.4-2.6
1.2   0.4-3.6   2.2 1.4-3.5

2.3   1.1-4.7    3.6  2.64.8
1.1   0.4-3.1    1.1   0.7-l .6
0.1   0.0-l .3    1.1   0.7-l .6
0.3  0.1-1.7   0.6   0.3-0.9

1.0

*Data from four population-based cancer registries in
Los Angeles County and Santa Clara and San Mateo
Counties near San Francisco-Oakland, metropolitan
Atlanta, and the state of New Jersey.
`ORs are adjusted for alcohol consumption, gender, age,
study location, and respondent status and are rela-
tive to persons who never smoked.
*Usual number of cigarettes smoked daily when the
persons smoked.
Source: Day et al. 1993.

Urinary Bladder Cancer

  The incidence of urinary bladder cancer in the
United States is highest for whites (Table 6) (NC1
1996b). Among men, mortality is highest for whites;
among women, mortality is highest for African Ameri-
cans (Tables 2 and 6) (NC1 199613). Differences in blad-
der cancer risk associated with cigarette smoking for
African Americans and whites have been examined in
several case-control studies (Table 9), including the
ongoing study conducted by the American Health
Foundation (Harris et al. 1990), a population-based
study conducted in the Detroit metropolitan area
(Burns and Swanson 1991), and a population-based
study carried out through SEER registries in 1978
(Hartge et al. 1993). In the American Health Founda-
tion study, investigators found that although cigarette
smoking was a significant risk factor for bladder can-
cer among both whites and African Americans, the
data suggested a steeper exposure-response relation-
ship among whites (with significant increased risk
beginning at exposures of 20 pack-years) than among
African American men (with increased risk beginning
only after 60 pack-years). However, in a multivariate
analysis of the data for men, the risk of bladder cancer
did not differ by race. The other two studies showed
similar findings for both whites and African Ameri-
cans in the association between cigarette smoking and
bladder cancer. In a smaller case-control study in Or-
ange County, California, no significant interactions
were found between smoking and race/ethnicity
among whites, Hispanics, Asian Americans, or Pacific
Islanders (Anton-Culver et al. 1993). Thus, informa-
tion currently available suggests that smoking in-
creases the risk of bladder cancer in a similar fashion
among both whites and African Americans. In a co-
hort study of 7,995 Japanese American men who were
living in Hawaii, the risk of bladder cancer was 2.9
times higher in current smokers than in nonsmokers
(Chyou et al. 1993).

  Aromatic amines, such as 4-aminobiphenyl, are
considered causative chemical agents in cigarette
smoke-induced bladder cancer (Bartsch et al. 1993). As
with other potential carcinogens in tobacco smoke,
aromatic amines require metabolic activation before
interacting with DNA (Miller and Miller 1981). Acom-
peting chemical pathway (i.e., acetylation) exists and
serves as a detoxification mechanism. Genotyping
studies have characterized several variant alleles of the
N-acetyltransferase gene, which can result in differ-
ent rates of chemical acetylation. People who are slow
acetylators have increased risk for bladder cancer
(Hein 1988). Bell and colleagues (1993) determined


Tobacco USC Among U.S. RacinllEthnic Minority Groups

Table 9.  Odds ratios for the risk of urinary bladder cancer associated with smoking, by gender, race/
    ethnicity, and smoking status

Reference, study type,
and year

Smoking
status

      Men                 Women

African                African
American    White       American    White

Harris et al. 1990          Nei~er           1.0        1.0
Multicenter, hospital-based,    Former           1.6        2.1
1973-l 985               Current           2.0        3.2

Burns and Swanson 1991
Detroit, population-based

Never
Ever
Pack-years
  <30
   30-59.9
   60-89.9
  >90

1.0        1.0          1.0        1.0
3.0        2.3          3.8        2.4

1.9        1.5           3.1        1.7
4.0        2.6          3.8        2.9
4.7        2.7          5.0       3.5
4.8        3.0          5.2        2.7

Hartge et al. 1993
SEER+ registries,
population-based, 1978

Never
Former

1.0

1.0

Cigarettes smoked
   <: 20 per day     1.6        1.3          3.6        2.0
  L 20 per day     1.8        1.9          5.0        1.3
Current
Cigarettes smoked
   c 20 per day     2.2        2.1           1.7        2.0
  2 20 per day     4.5        3.0           2.1        3.1

1.0

3.9*

1.0

1.0
1.3
3.2

1.0

*Ever smokers.
`National Cancer Institute's Surveillance, Epidemiology, and End Results Program.

that 41 percent of African Americans and 55 percent
of whites were slow acetylators. A phenotyping study
also found the highest percentage of slow acetylators
among whites (54 percent), compared with African
Americans (34 percent) and Asians (14 percent) (Yu et
al. 1994).

  In the 1994 study by Yu and colleagues,
slow acetylators had higher levels of 3- and
4-aminobiphenyl-hemoglobin adducts, regardless of
race and level of smoking (Yu et al. 1994). For African
Americans, Asians, and whites, however, the levels of
3- and 4-aminobiphenyl-hemoglobin adducts in-
creased proportionately more for cigarette smokers
compared with nonsmokers than for slow acetylators
compared to rapid acetylators. In a subsequent study
by Yu and colleagues (3995), the slow acetylation

phenotype combined with the null genotype of the
gene lGSTMl) for a phase II detoxification enzyme
(glutathione S-transferase) resulted in higher levels of
3-and 4-aminobiphenyl-hemoglobin adducts than did
lower risk profiles (i.e., rapid acetylator and/or at least
one functional GSTMI gene allele). The highest risk
profile was seen in 27 percent of whites, 15 percent of
African Americans, and 3 percent of Asians.

  Several studies show that the highest levels of
risk are experienced by smokers, because high levels
of exposure to tobacco smoke overwhelm the various
phenotypic traits. The differences in risks for various
detoxification and activation pathways appear to be
most significant among persons who did not smoke
or who smoked at very low levels (Yu et al. 1994,1995;
Landi et al. 1996).

Health Comeyrrerrces 157


Chronic Obstructive Pulmonary Disease

  In addition to causing lung cancer, tobacco smok-
ing aIso causes several non-malignant diseases of
the lung and increases the frequency of respiratory
symptoms and illnesses (USDHHS 1989b, 1990).
Chronic obstructive pulmonary disease (COPD) is
a clinical term applied to persons with a permanent
airflow obstruction associated with significant impair-
ment (Samet 1989; USDHHS 1989b). Cigarette smok-
ers with COPD have impaired breathing as a result of
emphysema (air space enlargement and destruction)
and damage to the airways (USDHHS 1984). These
smokers also may have chronic bronchitis, which is
the term used by epidemiologists and clinicians for
chronic sputum production.

  Longitudinal studies show that the development
of COPD follows sustained excessive loss of ventila-
tory function of the lung caused by cigarette smoking
(USDHHS 1984, 1990). The rate at which ventilatory
function declines tends to increase with the amount
smoked and to revert to the rate associated with aging
after smoking cessation (USDHHS 1990). The fre-
quency of chronic bronchitis is similarly related to
smoking pattern.

African Americans

  Data from several national surveys have been
used to compare the prevalence of COPD among Afri-
can Americans and whites. McWhorter and colleagues
(1989) used data from the 1971-1975 National Health
and Nutrition Examination Survey (NHANES I) and
the 1982-1984 NHANES I Epidemiologic Follow-up
Study (NHEFS) to determine the prevalence of COPD
among 14,404 adults aged 25-74 years. African Ameri-
can race/ethnicity was associated with a lower risk
for having COPD; 6.2 percent of whites and 3.2 per-
cent of African Americans had COPD.

  In the 1990 NHIS, the prevalence of self-reported
chronic bronchitis was 55.2 per 1,000 African Ameri-
cans aged 45-64 years and 42.7 per 1,000 African
Americans aged 65 years and older (USDHHS 1991).
The prevalence of self-reported emphysema was 3.6
per 1,000 middle-aged African Americans and 41.5 per
1,000 older African Americans. Compared with Afri-
can Americans, whites in both age groups reported
higher prevalences of chronic bronchitis (59.7 for those
aged 45-64 years and 73.8 for those aged 65 years and
older) and emphysema (13.8 for those aged 45564 years

158 Chnpter 3

and 46.1 for those aged 65 years and older). However,
self-reports of chronic bronchitis and emphysema,
without further validation, are probably subject to sub-
stantial misclassification.

  African Americans are also less likely than whites
to die of COPD (Evans et al. 1987; NCHS 1991). Evans
and colleagues (1987) found that in 1982, the age-
adjusted COPD death rate was 16.6 per 100,000 whites
and 12.8 per 100,000 African Americans. Data for 1986
1988 also show lower death rates from COPD among
African Americans than among whites (Desenclos and
Hahn 1992). More recent data (Table 2) show that Af-
rican American men have higher death rates (17.6) for
chronic airway obstruction than men in the other three
racial/ethnic minority groups, although their rates are
lower than rates among white men (20.4). The same
pattern is also evident for deaths due to bronchitis and
emphysema. The rate of COPD mortality is unexpect-
edly low among African Americans, given their high
prevalence of smoking and related high lung cancer
rates. The reasons for this discrepancy remain to be
explored. However, whites are more likely than Afri-
can Americans to have ever smoked and to be former
smokers (see Table 37 in Chapter 2). Mannino and
colleagues (1997) have observed that death rates from
obstructive lung disease relate to rates of ever smok-
ing. These authors suggest that the differences in the
race- and gender-specific relative rankings for obstruc-
tive lung disease and lung cancer may be because
long-term former smokers are more likely to develop
obstructive lung disease than lung cancer.

American Indians and Alaska Natives

   Little information is available on the occurrence
of COPD among American Indians and Alaska
Natives. In a 1987 survey of approximately 6,500
American Indians and Alaska Natives aged 19 years
and older, 2.4 percent of men and 1.4 percent of women
reported having emphysema, compared with 2.7 per-
cent of men and 2.3 percent of women in the general
U.S. population (Johnson and Taylor 1991). Rhoades
(1990) studied hospitalization and death rates for
COPD in American Indians and Alaska Natives.
Although the death rates for COPD were lower than
from other competing causes, such as chronic liver
disease, diabetes, and injuries, the hospitalization rates
for COI'D exceeded those for cancer and tuberculosis.


Additionally, hospitalization rates and death rates for
COPD varied widely between geographic regions. The
contribution of COPD to hospitalization rates ranged
from 1.6 percent in the Navajo IHS area to 5.1 percent
in the Bemidji area; COPD death rates per 100,000
ranged from 1.7 in the Albuquerque area to 10.3 in the
Billings area (Rhoades 19901.

  Between 1992 and 1994, COPD death rates among
American Indian men were approximately two-thirds
the rates among whites (Table 2). Data from the Alaska
area indicate that from 1979 through 1986, COPD death
rates per 100,000 were 31.6 for Alaska Native men,
compared with 40.3 for white men in Alaska and 38.3
for men in the United States as a whole (Coultas et al.
1994). The COPD death rates per 100,000 were 22.3
for Alaska Native women, compared with 31.8 for
white women in Alaska and 18.6 for women in the
United States as a whole. Similarly, death rates for
COPD in New Mexico (Samet et al. 1988bj reflect the
nationwide pattern of lower rates of death among
American Indians compared with whites and are con-
sistent with the lower smoking prevalence among
tribes in the southwestern United States (Sugarman et
al. 1992). The high rates of COPD among Alaska
Natives are probably related to the fact that rates of
smoking among Alaska Natives are higher than rates
among American Indians elsewhere, particularly in the
Southwest.

Asian Americans and Pacific Islanders

  Information on COPD morbidity and death
among Asian Americans and Pacific Islanders is sparse.
National mortality data indicate that the prevalence
of deaths from bronchitis and emphysema is lower in
this group than among African Americans and whites
(Table 2); the death rate from chronic airways obstruc-
tion is lowest for Asian Americans and Pacific Island-
ers. Data from California show that from 1986 through
1987, the overall prevalence of COPD deaths among
"Asian and other" persons was lower than among
whites but varied widely for specific Asian American
and Pacific Islander subgroups (Asian American
Health Forum, Inc. 1990).

   One of the oldest studies of Asian Americans-
the Honolulu Heart Study, conducted in 196Lprovides
valuable age-related information on smoking and lung
function among Japanese Americans. Of the 6,346
Japanese American men aged 46-68 years who under-
went spirometric testing, 48 percent were current ciga-
rette smokers, 25 percent were former smokers, and
27 percent had never smoked (Marcus et al. 1988).

Airflow obstruction was found in 11.7 percent of the
participants. The prevalence of airflow obstruction
increased with age and with the amount smoked. For
most age and smoking categories, the prevalence of
airflow obstruction was lower among JapaneseAmeri-
can men than among white men from Connecticut
participating in the same study (Beck et al. 1981).

  In another recent analysis of data from the Ho-
nolulu Heart Program, Japanese American men who
continued to smoke showed steeper rates of decline in
forced expiratory volume after one second (FEV,), a
measure of pulmonary function, compared with never
smokers. Among continuing smokers, FEV, decline
was significantly associated with duration of smok-
ing. Additionally, the rate of decline in FEV, among
former smokers became more like that of persons who
had never smoked (Burchfiel et al. 19951, consistent
with previous reports on the benefits of quitting smok-
ing WSDHHS 1990). In another analysis of data from
the same study, Sharp and colleagues (1994) found that
a diet composed of large amounts of fish may protect
the lungs against damage from cigarette smoking.
However, fish consumption was not associated with
pulmonary function at higher levels of cigarette smok-
ing (>30 cigarettes/day).

Hispanics

  In the 1982-1984 Hispanic Health and Nutrition
Examination Survey (HHANES), Puerto Ricans (2.9
percent) had a higher prevalence of reported chronic
bronchitis than Mexican Americans (1.7 percent) or
Cuban Americans (1.7 percent) (Bang et al. 1990).
Chronic airflow obstruction (assessed using spirom-
etryj was present in less than 1 percent of Hispanic
adults surveyed in a New Mexico community (Samet
et al. 1988a). Similarly, investigators who surveyed
Mexican Americans in Tucson, Arizona, found a rela-
tively low prevalence of physician-diagnosed COPD
or related diagnoses (Di Pede et al. 1991).

  COPD has been reported to occur less frequently
among Hispanics than among whites. Surveys in New
Mexico have shown, for example, that physician-
diagnosed chronic bronchitis or emphysema is less
common among Hispanics than among whites (Samet
et al. 1982, 1988a). Death rates from chronic obstruc-
tive lung diseases and allied conditions are also lower
among Hispanics than among whites (Tables 2 and 4).
Mortality data for New Mexico indicate that between
1958 and 1982, Hispanic men had a lower death
rate from COPD than white men; however, from
1958 through 1982, the death rate from COPD rose


steeply among Hispanic men--from 5.0 per 100,000 in
1958-1962 to 30.1 per 100,000 in 1978-1982 (Samet et al.
1988b). During this same time, COPD death rates in-
creased among Hispanic women but remained compa-
rable to rates among white women (Samet et al. 1988b).

  Little information is available on the risk of
COPD among Hispanic smokers. In a 1979 respira-
tory disease survey of Hispanic and white residents
of New Mexico's Bernalillo County, Samet and
colleagues (1982) found that race/ethnicity was not a
significant predictor of current or previous physician-
diagnosed chronic bronchitis and emphysema and that
no significant interaction existed between race/
ethnicity and cigarette smoking. Hispanic ethnicity
also was not a significant predictor of the symptoms
of chronic cough, chronic phlegm, or persistent
wheeze. Similarly, the results of a survey of Hispanics

Coronary Heart Disease

and whites in Tucson indicated that race/ethnicity was
not a significant determinant of respiratory symptoms,
after survey data were adjusted for cigarette smoking
(Di Pede et al. 1991). However, a recent cross-sectional
study of urban pregnant women indicated that the
prevalence of either doctor-diagnosed asthma or per-
sistent wheeze without asthma was lower among a het-
erogenous Hispanic population than among white
women of similar socioeconomic background (these
data were adjusted for cigarette smoking status, fam-
ily history of asthma, educational level, household
exposure to pets, and level of lung function). The au-
thors did not conclude that their data provided evi-
dence of biological protection from wheeze syndromes.
An almost fivefold excess risk of persistent wheeze was
detected in the total population of urban women who
are current smokers (David et al. 1996).

  In 1994, cardiovascular diseases, comprising a
diverse group of disorders including coronary heart
disease (CHD), hypertension, stroke, and rheumatic
heart disease, caused approximately 940,000 deaths in
the United States (NCHS 1996a). The occurrence of
specific cardiovascular diseases and their risk factors
varies widely among the different racial/ethnic mi-
nority groups. Of the cardiovascular diseases, CHD
is the single largest cause of death; it results in approxi-
mately 480,000 deaths annually in the United States.
This section of the report focuses on CHD, lvhich is
also termed coronary artery disease or ischemic heart
disease (IHD).

  Coronary artery disease results from atheroscle-
rosis of coronary arteries. Anatomical lesions become
evident in young adults and are usually clinically
manifest in the fifth through seventh decades as
angina pectoris, myocardial infarction, and sudden
cardiac death (Enos et al. 1986; Strong 1986). In this
chapter, these clinical manifestations of coronary
artery disease are collectively termed CHD.

  Numerous non-modifiable and modifiable risk
factors contribute to the devrelopment of CHD. The
non-modifiable factors include aging, gender (men
have greater risk), and family history of CHD. The
major risk factors that are potentially modifiable
include hypertension, cigarette smoking, obesity,
hypercholesterolemia, diabetes mellitus, and physical

inactivity (Smith and Pratt 1993). The 1983 Surgeon
General's report on smoking and health concluded that
"Cigarette smoking should be considered the most
important of the known modifiable risk factors for
coronary heart disease in the United States" (USDHHS
1983, p. iv).

African Americans

  The first population-based epidemiological in-
vestigations of cardiovascular diseases in the United
States that included substantial numbers of African
American and white participants began in 1960 in
Evans County, Georgia, and Charleston, South Caro-
lina (Saunders 1991). Since 1960, follow-up data for
these cohorts and a number of other epidemiological
studies have provided information on the combined
effects of race/ethnicity and various risk factors for
cardiovascular disease. Consistent with findings for
the general population, cigarette smoking increased
risk of death from CHD among African Americans
(Hames et al. 1993; Keil et al. 1995).

  Tyroler and colleagues (1984) examined deaths
from CHD among the Evans County men, who were
followed from 1960 through 1980, and found that the
overall rate of death from CHD was lower among Af-
rican Americans than among whites, with a ratio of
0.86. For current and former smokers, the probability


of dying from all causes and from CHD was higher
among whites with a low-socioeconomic status (on the
basis of occupation, education, and source of income
of the head of household) than among their African
American counterparts. However, the analysis did not
control for the number of cigarettes smoked, and the
data were limited because of the small number of CHD
deaths (31) among African Americans.

  In the Charleston Heart Study of CHD death rates
between 1960 and 1990, Keil and colleagues (1993)
found that the age-adjusted, African American-
to-white death rate ratios were 0.90 for men and 1.2
for women. After controlling for age and other car-
diac risk factors, the researchers found that smoking
was associated with a slightly higher risk of dying of
CHD among African American men than among lvhite
men. White women had a slightly higher risk of
dying of CHD than did African American women.
These racial/ethnic group differences were not tested
for statistical significance, liokvever.

  Other investigations that provide information on
the risks for CHD and the modification of the effects
of smoking, by race/ethnicity, include the Cancer Pre-
lrention Study I (CI'S-I) (Garfinkel 19811, the NHEFS
(Cooper and Ford 1992), the National Mortality
Followback Survey (NMFS) (DeStefano and Newman
19931, and the ongoing study of Kaiser Permanente
enrollees (Friedman et al. 7997). As part of the CPS-I,
death patterns in the original cohort of one million
people were described for 1959-1972. The observed-
to-expected death rate ratios from CHD among Afri-
can Americans and whites followed the same pattern
as nationwide vital statistics described previously.
Overall, the African American-to-white ratios of CHD
deaths were 0.78 for men and 1.07 for women. Strati-
fied analyses, by gender, of any effects that the amount
of cigarettes smoked might have on CHD deaths
showed little difference between African Americans
and whites.

  Participants in the NHANES I, conducted be-
tween 1971 and 1975, were reexamined between 1982
and 1984 as part of the NHEFS (Cooper and Ford 1992).
Of the 12,599 participants in the follow-up survey,
10,741 were white and 1,858 were African American.
The study showed that cumulative incidence rates of
fatal CHD were higher among African Americans (6.2
percent of men and 3.7 percent of women) than among
whites (5.6 percent of men and 2.6 percent of women).
In contrast, cumulative incidence rates of nonfatal
CHD were higher among whites (7.0 percent of men
and 4.7 percent of women) than among African Ameri-
cans (5.0 percent of men and 3.9 percent of women).
The risk of new CHD events associated with cigarette

smoking was similar among whites and African Ameri-
cans. These results, however, are limited by the small
number of new CHD events among African Ameri-
cans and the low proportion (approximately 50 per-
cent) of respondents for whom smoking information
was collected at baseline.

  In a case-control study of CHD deaths among
African Americans and whites, DeStefano and
Newman (1993) used data from the 1986 NMFS to iden-
tify case subjects (n = 803) and 1988 data from the
BRFSS to identify control subjects (n = 25,398). When
they compared the risk of death among smokers vs.
persons who have never smoked (men aged 25-44
vears and women aged 25-54 years), the investigators
found that among persons without diabetes, African
American smokers had a lower relative risk for CHD
death than white smokers. However, the 95 percent
confidence intervals associated with these odds ratios
ofrerlapped each other-an indication that the differ-
ence in risk was not statistically significant. In the
Kaiser study, the risk of death from CHD has varied
among African Americans and whites, but small num-
bers limit interpretation of these findings (Friedman
et al. 1997).

American Indians and Alaska Natives

  Most of the available data on CHD among Ameri-
can Indians and Alaska Natives have originated from
studies of selected tribes, as reviewed by Young (1994).
Investigations of heart disease in southwestern Ameri-
can Indians and Alaska Natives conducted several
decades ago showed a low prevalence of CHD rela-
tive to the U.S. population and other racial/ethnic
groups (Welty and Coulehan 1993). In a descriptive
study of CHD deaths occurring from 1948 through
1952 among the Navajos, Smith (1957) found that the
standardized death rate ratios for CHD among the
Navajos compared with whites were 0.10 for men and
0.12 for women. Since then, numerous other regional
investigations of CHD deaths and the incidence of
CHD in other tribes of the United States and Canada
have been reported. Overall, for studies conducted in
the 1950s and 196Os, the ratios of CHD death rates
among American Indians and Alaska Natives com-
pared with nationwide rates have ranged from 0.1 to
0.5. An analysis of death statistics from the NCHS
showed that crude CHD death rates for individuals
classified as American Indians, Eskimos, or Aleuts
declined from 100 per 100,000 in 1969-1971 to 67 per
100,000 for the years 1979-1981 (Gillurn 1988). A re-
view of New Mexico's vital statistics for 195881982
indicates that for American Indian men, CHD death


rates peaked at 101.7 per 100,000 between 1968 and
1972 and fell to 76.6 per 100,000 between 1978 and 1982
(Becker et al. 1988). For American Indian women, the
CHD death rate peaked at 63.0 per 100,000 between
1963 and 1967 and declined to a low of 28.3 per 100,000
between 1978 and 1982.

  In a recent analysis of mortality data for 1992-
1994 (Table 21, the rate of death due to CHD was lower
among American Indian and Alaska Native men
(100.4) and women (45.9) than among white men
(132.5) and women (62.9). The ratio of CHDdeath rates
among American Indians and Alaska Natives com-
pared with whites was .76 for men and .73 for women.
The fact that these ratios are higher than ratios from
earlier studies suggests that CHD deaths among
American Indians and Alaska Natives may be increas-
ing (Welty and Coulehan 1993; Young 1994).

   Risk factors for cardiovascular disease were in-
vestigated recently in a large multi-tribal study of
American Indians. The results showed that mean lev-
els of total, low density lipoprotein, and high density
lipoprotein cholesterol were lower in American Indi-
ans than in the U.S. general population. Prevalence of
hypertension, non-insulin dependent diabetes melli-
tus, and obesity were very high, but varied consider-
ably among tribes and geographic regions (Welty et
al. 1995). A second study found that levels of serum
cholesterol were lower in American Indian smokers
who attended a stop smoking clinic than in African
American and white smokers from population-based
samples (Folsom et al. 1993). However, fibrinogen lev-
els and the prevalence of abdominal obesity were
higher in American Indian smokers than in African
Americans and whites.

   The IHS is another source of nationwide and re-
gional health statistics on CHD deaths. Because the
mortality data in IHS reports combine all cardiovas-
cular diseases under "diseases of the heart" (IHS
1994b), this information cannot be compared directly
with CHD data from other sources. Between 1989 and
1991, diseases of the heart accounted for 21.9 percent
of deaths in all IHS areas, with a crude death rate
of 115.1 per 100,000 (IHS 199413). These data indicate
cardiovascular diseases were the leading cause of
death among American Indians. However, because
Indian race/ethnicity was underreported on death cer-
tificates in several IHS areas, including California and
Oklahoma as well as Portland, Oregon, this death rate
may be incorrect.

  Death rates from heart diseases vary widely
among people in the 12 IHS areas. From 1989 through
1991, the rate of death from heart diseases per 100,000
was lowest in the Albuquerque area (88.0) and high-

est in the Aberdeen area (249.0) (IHS 1994a). These
wide variations in deaths from diseases of the heart
parallel the wide variations in the prevalence of ciga-
rette smoking among the various tribes (Sugarman et
al. 1992; Coultas et al. 1994) (see also Chapter 2). For
example, in a 1985-1988 survey of adult American In-
dians in the southwestern United States, 18.1 percent
of men and 14.7 percent of women reported current
smoking, compared with 48.4 percent of men and 57.3
percent of women in the Plains states (Sugarman et al.
1992).

   Data to assess the influence of tobacco use on
the risk of cardiovascular disease among American
Indians are extremely limited. One study has shown
that cigarette smoking increases the risk for CHD
among American Indians, after adjustment for other
risk factors (Howard et al. 19951. In fact, most studies
presented in this section describe cardiovascular dis-
ease morbidity and mortality without ever assessing
the influence of tobacco use. Nevertheless, cardiovas-
cular disease is the leading cause of death among
American Indians and Alaska Natives (NCHS 1996b),
and tobacco use is an important risk factor for this
disease. More studies are needed to evaluate the in-
dependent effect of tobacco use on the risk of cardio-
vascular disease among American Indians and Alaska
Natives.

Asian Americans and Pacific Islanders

   Limited data are available on risk factors and
CHD among Asian Americans and Pacific Islanders
in the United States (Yu 1991). A recent study of na-
tionwide mortality indicated that Asian Americans and
Pacific Islanders have lower rates of death from CHD
than whites (Table 2).

  In an analysis of 1980 death rates in Los Angeles
County, Frerichs and colleagues (1984) found that the
age- and gender-adjusted death rates for cardiovascu-
lar diseases varied widely among Asian Americans and
Pacific Islanders. Koreans had the lowest rate per
100,000 (821, and Japanese had the highest rate (162).
These rates were substantially lower than the overall
rate for the county population, with rate ratios of 0.26
for Koreans and 0.52 for Japanese. Specific data on
CHD deaths and cigarette smoking prevalence were
not available.

  In another study, Reed and colleagues (1983) used
death records from Hawaii to describe age-adjusted,
gender-specific, and racial- and ethnic-specific rates
of CHD deaths occurring from 1940 through 1978. For
all racial/ethnic minority groups, CHD death rates
were higher among men than among women. Death

162 Cllnrter 3


Tobacco Use A~~otzg U.S. Racin//Efhnic Mixorify Groups

rates and the temporal trends in deaths varied widely
between the different groups, with the highest death
rates among Native Hawaiians and the lowest among
Japanese. Filipino men had the greatest increase in
CHD death rates, surpassing the rates for whites in
1978. Although most of the other groups had declines
in CHD death rates between 1960 and 1970, CHD death
rates for Native Hawaiian men remained level.

  In 1965, three cohorts of Japanese men were as-
sembled in Japan, Honolulu, and San Francisco to in-
vestigate the differences in CHD deaths observed
among Japanese men living in the three locales (Worth
et al. 1975; Yano et al. 1988). From 1965 through 1972,
Worth and colleagues (1975) found that age-specific
death rates were highest among the San Francisco men,
intermediate among those living in Honolulu, and low-
est among those living in Japan. For example, among
men 60-64 years of age, the annual CHD death rates
per 1,000 were 4.9 in San Francisco, 3.9 in Honolulu,
and 2.1 in Japan. Mortality data for 1965-1980 indi-
cate that the age-adjusted CHD death rate ratio for men
in Honolulu compared writ11 men in Japan was 1.3
(Yano et al. 1988). The age-adjusted mean levels of
most CHD risk factors, including cigarette smoking
(measured in cigarette-years), were also higher among
Honolulu men. After adjusting for these risk factors,
the rate ratio for CHD declined to 1.17, indicating that
more than half of the elevated CHD death rate was
due to the higher mean levels of CHD risk factors
among Honolulu men.

  In the Honolulu Heart Program cohort, com-
posed of 7,705 Japanese men 45-68 years of age living
in Hawaii who had no evidence of CHD at enrollment
between 1965 and 1968, numerous analyses were con-
ducted to further examine predictors of CHD incidence
and death (Reed et al. 1982, 1987; Yano et al. 1984;
Benfante et al. 1991). A higher level of acculturation
was found to be associated with CHD risk factors and
incidence during the 1971-l 979 follow,-up (Reed et al.
1982). Men who were primarily Japanese in culture
smoked an average of seven cigarettes per day,
whereas men who were more acculturated smoked an
average of 11 cigarettes per day. A similar pattern was
seen for total CHD incidence, which was highest
among the men who were more acculturated (62 per
1,000) and lowest among the men who were primarily
Japanese in culture (35 per 1,000).

  Yano and coworkers (1984) conducted detailed
analyses of the relationship between risk factors and
the incidence of CHD during a 1 O-year period, begin-
ning after the enrollment period (1965-1968). Systolic
blood pressure, number of cigarettes smoked, and cho-
lesterol level were all independently associated with

the occurrence of all CHD events. Alcohol consump-
tion was found to be a protective factor. Subsequent
analyses of 20-year follow-up data from the same study
showed that cigarette smoking was independently
associated, in a dose-response manner, with increased
risk of CHD (fatal or nonfatal) and aortic aneurysm
(Goldberg et al. 1995). The risk for angina was elevated
in persons who smoked more than 20 cigarettes per
day. Another analysis suggested that high levels of
fish intake might limit the increased risk among heavy
smokers, although these findings should be consid-
ered preliminary (Rodriguez et al. 1996). In addition,
cigarette smoking was found to be independently
associated with increased prevalence of myocardial
lesions in Japanese men with minimal evidence of coro-
nary atherosclerosis at autopsy (Burchfiel et al. 1996).

Hispanics

  Because of incomplete data, the NCHS reported
data from 1985 death certificates on decedents of His-
panic origin for only 17 states and the District of
Columbia (NCHS 1996b). By 1990, data for 47 states
and the District of Columbia were reported. The NCHS
estimated that the 1990 reporting area encompassed
99.6 percent of the U.S. Hispanic population (NCHS
1996b). In 1993 and 1994, only Oklahoma did not pro-
\ide information on Hispanic origin (NCHS 1996a,b).

  Between 1992 and 1994, the overall rate of death
from CHD in the United States was lower among His-
panics than among whites (Table 2). Among the vari-
ous Hispanic subgroups, Puerto Rican men had the
highest death rates per 100,000 (118.6); similarly, CHD
death rates among Puerto Rican women (67.3) were
higher than among Mexican (44.2) and Hispanic (42.4)
women.

  Nationwide death rates among Hispanics and
whites have been estimated by using data collected
by the U.S. Bureau of the Census as part of the Cur-
rent Population Survey (CPS) (Sorlie et al. 1993).
Baseline interview data were obtained between 1973
and 1985 from approximately 40,000 Hispanics and
660,000 non-Hispanics aged 25 years and older. Death
rates for these two groups were ascertained up to nine
years after the initial interview through the National
Death Index. Age-adjusted death rate ratios for
CHD were lower among Hispanics than among non-
Hispanics (0.60 for men and 0.75 for women). Further
details for the different Hispanic subgroups were
not provided.

   In addition to nationwide data on the occurrence
of CHD among Hispanics, regional studies have been
conducted in California (Schoen and Nelson 1981;


Frerichs et al. 1984), Colorado (Rewers et al. 1993), New
Mexico (Buechley et al. 1979; Becker et al. 1988), and
Texas (Stern and Gaskill 1978; Stern et al. 1987; Mitchell
et al. 1991; Goff et al. 1993). In general, these investi-
gations have consistently shown that Hispanic men
have lower CHD death rates than white men, although
the Colorado study found little evidence for lower
CHD death rates among Hispanics without diabetes
(Rewers et al. 1993).

  The prevalence of angina was also found to be
lower among Hispanics than among whites in a re-
view of data from a sample of Mexican Americans
participating in the 198221984 HHANES and of whites
surveyed in the 1976-1980 NHANES II (LaCroix et al.
1989). Prevalence rates based on self-reports were 2.8
percent among Mexican American men and 3.9 per-
cent among white men, and they were 5.4 percent
among Mexican American women and 6.3 percent
among white women. As with African Americans, no
significant differences were observed in the distribu-
tion of cardiovascular disease risk factors among Mexi-
can Americans with and without self-reported angina.
The results of this survey were limited by the lack of
smoking-specific analyses for Mexican Americans.

  Several investigators also have examined the car-
diovascular disease risk factor profiles of Hispanics
(Mitchell et al. 1991; Shea et al. 1991; Winkleby et al.
1993). Shea and colleagues (1991) analyzed 1989 BRFSS
data on 636 Hispanics, most of whom were Puerto
Ricans, Dominicans, and Cubans living in New York
City. Although the overall risk factor profile was high
among these Hispanic subgroups, the prevalence of
current cigarette smoking varied by level of educa tion.
LMitchell and colleagues (1991) obtained information

Cerebrovascular Disease

on cardiovascular disease risk factors from 5,148
subjects, including 3,281 Mexican Americans, who
participated in the San Antonio Heart Study from 1979
through 1988. The overall risk profiles were higher
among Mexican Americans. For men of all ages, the
prevalence of current smoking was higher among
Mexican American men (36.7 percent) than among
white men (30.4 percent). For women of all ages, how-
ever, the prevalence of current smoking was lower
among Mexican American women (21.0 percent) than
among white women (26.8 percent). For both men and
women, the number of cigarettes smoked per day was
consistently lower among Mexican Americans than
among whites. More recently, Winkleby and col-
leagues (1993) examined the cardiovascular disease
risk profiles of 756 Hispanics and 756 whites partici-
pating in California surveys from 1979 through 1990.
Hispanics and whites were matched by age, gender,
educational level, city of residence, and time of sur-
vey. Whites had a higher prevalence of smoking (34.2
percent) than Hispanics (24.0 percent), and they smoked
more cigarettes per day (19.7) than Hispanics (11.4).

  Few investigators have compared the risk of
smoking-related CHD between Hispanics and mem-
bers of other racial/ethnic groups. Mitchell and co-
workers (1991) determined the 1979-1988 prevalence
of myocardial infarction among 3,281 Mexican Ameri-
cans and 1,867 whites who participated in the San
Antonio Heart Study. On the basis of either electro-
cardiograms or self-reports, the risk of myocardial in-
farction among Mexican Americans compared with
whites was 24 percent lower for men but 40 percent
higher for women. Race/ethnicity did not appear to
modify the risk for myocardial infarction.

  Cerebrovascular disease is a major cause of
mortality and morbidity in the United States every
year. In 1994, a total of 153,306 deaths in the United
States were caused by cerebrovascular disease (NCHS
1996a).

  Stroke, the major form of cerebrovascular disease,
results from an interruption of the arterial blood sup-
ply to the central nervous system, primarily the brain.
Most commonly, the interruption of the arterial blood
supply results from an occlusion of an artery in the
brain by a thrombus, which may have resulted from
atherosclerosis or blood clots from a diseased heart. A

less common mechanism for development of stroke
is rupture of a blood vessel in the brain. Other diag-
noses under the general rubric of cerebrovascular
disease include transient cerebral ischemia and cere-
bral arteriosclerosis.

  As for CHD, risk factors for stroke may be
divided into non-modifiable and modifiable charac-
teristics. The non-modifiable factors include aging,
gender, and family history of stroke. The major risk
factors that are potentially modifiable include hyper-
tension, hypercholesterolemia, diabetes mellitus, ciga-
rette smoking, and heart disease (USDHHS 1989b).


African Americans

   The rate of death from cerebrovascular disease
in the United States is higher among African Ameri-
cans than other racial/ethnic groups and whites (Table
2). For 1992-1994, the rate of death (per 100,000 pop~i-
lation) from cerebrovascular disease M'as twice as high
among African American men (53.1) as among white
men (26.3) and almost twice as high among African
American women (40.6) as among white women (22.6).

  Similar patterns have been observed in studies
of persons belonging to health plans. Klatsky and col-
leagues (1991) determined the incidence of hospital-
ization for cerebrovascular disease among 74,096
whites and 33,041 African Americans who were mrm-
bers of a prepaid health plan in northern California
from 1978 through 1984. The relatille risks for hospi-
talization for hemorrhagic cerebrovascular disease,
cerebral thrombosis, and nonspecific cerebrovascular
disease were higher among African Americans than
among whites. Because hypertension is the strongest
risk factor for stroke, the high prevalence of hyperten-
sion among African Americans partially explains this
pattern (Braithwaite and Taylor 1992). Despite lim-
ited data on the link bet\veen smoking and stroke
among African Americans, the high rate of cigarette
smoking among African Americans (see Chapter 2)
clearly appears to have played a significant role in el-
evating the risks of stroke in this population (USDHHS
1983).

American Indians and Alaska Natives

  In recent years, age-adjusted death rates for cere-
brovascular disease were slightly lower among Ameri-
can Indian and Alaska Native men and women than
among white men and women (Table 2). For example,
from 1992-1994, the age-adjusted death rate per
100,000 population for cerebrovascular disease was
23.9 for American Indian and Alaska Native men, 26.3
for white men, 21.1 for American Indian and Alaska
Native women, and 22.6 for white women.

  Young's (1994) recent review of the literature in-
dicates that few investigations have focused on cere-
brovascular disease among American Indians or
Alaska Natives. Middaugh (19901 found little differ-
ence between the death rate from cerebrovascular dis-
ease among Alaska Natives and persons of other race/
ethnicities, with death rate ratios of 1.13 for men and
1.03 for women. In a review of 1958-1987 vital statis-
tics data from New Mexico, Kattapong and Becker
(1993) observed lower rates of death from cerebrovas-
cular disease among American Indians than among

Hispanics and whites. For American Indian men, cere-
brovascular disease death rates per 100,000 peaked at
70.1 between 1968 and 1972 and fell to 31.3 between
1983 and 1987. Cerebrovascular disease death rates
for American Indian women also peaked at 55.7
between 1968 and 1972 and declined to a low of 19.3
between 1983 and 1987.

Asian Americans and Pacific Islanders

  From 1992 through 1994, the age-adjusted death
rate per 100,000 population for cerebrovascular dis-
ease was 29.3 for Asian American and Pacific Islander
men, 26.3 for white men, 22.4 for Asian American and
Pacific Islander women, and 22.6 for white women
(Table 2).

  In a study of stroke deaths occurring between
1965 and 1972 among Japanese men living in Japan,
Honolulu, and San Francisco, age-specific stroke death
rates were highest among men living in Japan (Worth
et al. 1975). Among men 60-64 years of age, annual
death rates per 1,000 men were 5.4 in Japan, compared
with 2.5 in San Francisco and 1.1 in Honolulu. For
CHD, however, the death rates in Japan were lower
than rates in Honolulu and San Francisco. Data from
the Honolulu Heart Program suggest that other risk
or protective factors associated with a Japanese diet,
such as high alcohol intake and low, intake of food from
animal sources, may play important roles in the de-
velopment of stroke and CHD in Honolulu and Japan,
along with smoking, older age, high systolic blood
pressure, and high serum cholesterol and glucose lev-
els (Reed 1990).

  In a study of 1980 death rates among Asian
Americans in Los Angeles, Frerichs and colleagues
(1984) found that Koreans had the lowest age- and
gender-adjusted death rate for cerebrovascular disease
(48 per 100,000) and that Japanese had the highest rate
(80 per 100,000). When the investigators compared the
average age- and gender-adjusted death rates for these
Asian Americans with rates for the entire county,
the mortality ratio was 1.07 for Japanese and 0.65 for
Koreans.

  Cigarette smoking was found to be an indepen-
dent risk factor for stroke among men of Japanese
ancestry who participated in the Honolulu Heart
Program (Abbott et al. 1986). For all types of stroke,
the estimated relative risk of smoking, adjusted for age
and other major risk factors, was 2.5. This risk de-
creased to 1.5 among men who quit smoking during
the six-year follow-up period and increased to 3.5
among men who continued to smoke, indicating that
cigarette smoking is a cause of stroke in Japanese men.


A subsequent analysis of plrtlcipants in the Honolulu
Heart Program iniicated that cigarette smoking sig-
nificantlv increased the risk for thromboembolic stroke
(Goldbe;g et al. 1995).

Hispanics

  Studies about stroke among Hispanics have fo-
cused on the magnitude of this outcome in relation to
other racial/ethnic groups. Between 1986 and 1988,
the overall rate of death from cerebrovascular disease
was lower among Hispanics than among whites in the
United States (Desenclos and Hahn 1992). When cere-
brovascular disease death rates for Hispanics and
whites were compared, the mortality ratio for Hispanic
men was 0.89, and the ratio for Hispanic women was
0.84. Of the different Hispanic subgroups, Mexican
Americans had the highest death rates from cere-
brovascular disease. Sorlie and colleagues (1993) had
similar observations when they estimated death rates
using census data collected between 1973 and 1985.
Age-adjusted death rate ratios for cercbrovascular dis-
ease were lower among Hispanics than among whites
(0.60 for men and 0.76 for women). No details were
provided for the different Hispanic subgroups. In
more recent years, age-adjusted death rates for cere-
brovascular disease were slightly lorcer among His-
panic men and women than among \\rhite men and
women. For example, from 1992-1994, the age-
adjusted death rate per 100,000 population for cere-
brovascular disease was 22.7 for Hispanic men, 26.3
for white men, 16.7 for Hispanic M'ornen, and 22.6 for
white women (Table 2).

  Regional studies in California (Frerichs et al.
1984), New Mexico (Kattnpong and Becker 199X), and
Texas (Stern and Gaskill 1978) provide further evidence
that Hispanics have a lower risk of death from
cerebrovascular disease than do \\`hites and African

Smoking and Pregnancy

  Smoking has long been known to be associated
with poor outcomes for the infants of mothers who
smoke. Mean infant birth weight and low birth weight
(LBW) (~2,500 grams or ~5.5 pounds) are often stud-
ied as measures of fetal morbidity because birth weight
is easy to measure. LBW can result either from preterm
delivery (~37 weeks' gestation) or from intrauterine

Americans. Frerichs and colleagues (1984) compared
1980 death rates among the different racial/ethnic
groups in Los Angeles County. The age- and gender-
adjusted cerebrovascular disease death rates per
100,000 were 64 for Hispanics compared with 76
for whites (death rate ratio, 0.84) and 94 for African
Americans (death rate ratio, 0.68).

  After reviewing New Mexico vital statistics data
for 1958-l 987, Ka ttapong and Becker (1993) described
time trends in deaths from cerebrovascular disease
among Hispanics, whites, and American Indians. Ex-
cept for the period 1983-1987, Hispanic men had lower
death rates than white men. From 1983 to 1987, the
ratio of death rates among Hispanic men (45.8 per
100,000) compared with the rate among white men
(36.1 per 100,000) was 1.27. For women, the pattern of
death rates was less consistent. From 1958 through
1972, Hispanic women had higher death rates than
white women; between 1973 and 1982, they had lower
rates; and from 1983 through 1987, Hispanic women
had slightly higher death rates (43.1 per 100,000) than
white women (39.3 per 100,000).

  Stern and Gaskill (1978) examined temporal
trends in stroke deaths from 1970 through 1976 among
Hispanics and whites living in Bexar County, Texas,
which includes San Antonio. Stroke deaths were gen-
erally lower among Hispanic women, but no signifi-
cant difference was observed between the rates among
men of either racial/ethnic group. Furthermore, no
temporal trends in stroke deaths were evident for
either gender or racial/ethnic group.

  Cigarette smoking probably explains some of the
risk of stroke among Hispanics. However, data to as-
sess the strength of this relationship are not available.
Because the data presented here suggest that stroke is
a leading cause of morbidity and death among His-
panics (NCHS 19931, future studies should examine
the specific role that cigarette smoking plays.

growth retardation, but the distinction may be diffi-
cult to make. Smoking has been associated with an
average decrease in birth weight of about 200 grams
as well as LBW, preterm birth, perinatal mortality, and
infant mortality (USDHHS 1980, 1989b; Malloy et al.
1988; English and Eskenazi 1992).


Tobacco Use Anmg U.S. Racial/Ethm'c Minority Groups

  Evidence that the relationship between smoking
and poor infant outcomes is causal has been strength-
ened by recent studies that used biomarkers of tobacco
exposure, such as saliva and serum cotinine (Bardy et
al. 1993; Li et al. 1993; English et al. 1994). Bardy and
colleagues (1993) demonstrated a dose-response rela-
tionship between serum cotinine and decreased ges-
tational age, decreased birth weight, and decreased
crown-heel length.

  The exact mechanisms whereby smoke exposure
affects the fetus are poorly understood. Carbon mon-
oxide, which impairs oxygen delivery to the fetus, and
nicotine, which impairs placental blood flow, have
been implicated as the causative substances in tobacco
smoke (USDHHS 19801.

   The infant outcomes most often studied have
been LBW and infant mortality. Sudden infant death
syndrome (SIDS) is an important component of infant
mortality because it is the most common cause of death
among infants older than one month of age. Available
data show that LBW, infant mortality, and SIDS occur
differentially in different racial/ethnic groups in the
United States (Table 10) (Kleinman 1990; NCHS 1994).
In general, whites have lower rates of these conditions
and other racial/ethnic groups tend to have higher
rates, but considerable variation exists.

  Several studies have reported different effects
of smoking on LBW, infant mortality, and SIDS
across racial/ethnic minority groups. This section
focuses only on those studies that have investigated
potential racial/ethnic group differences in the rela-
tionship between smoking and infant outcomes.

Studies of Low Birth Weight

  Nearly 25 years ago, the possibility was raised
that smoking might have a differential effect on repro-
ductive outcomes in different racial/ethnic groups
(Lubs 1973). In a study of all singleton live births at
Yale-New Haven Hospital in 1972, Lubs reported a dif-
ference in the effect of maternal smoking on LBW
among 783 African American and 3,415 white women.
A strong dose-response relationship was observed be-
tween the number of cigarettes smoked during preg-
nancy and infant LBW (defined as 52,500 grams for
whites and 12,350 grams for African Americans).
Among African American women, smoking 20 or more
cigarettes per day was associated with a threefold in-
crease in LBW, compared with only a twofold increase
among white women. These racial/ethnic group dif-
ferences were not explained by differences in age,
prepregnancy weight, education, or marital status.

  Several more recent studies also provide evidence
for the possibility of a differential effect of smoking
on LBW among white and African American women.
English and colleagues (1994) used interview data from
the Child Health and Development Studies, conducted
from 1959 through 1966 in California. Stored serum
samples were analyzed for cotinine, and the levels
were compared with self-reported cigarette consump-
tion and infant birth weight for 374 African American
and 829 white pregnant smokers separately. African
American pregnant smokers were found to have
higher serum cotinine levels than white pregnant
smokers after the data were controlled for smoking
dose and demographic confounders. No racial/
ethnic minority group difference was found in the
rate of decrease in mean birth weight per given amount
of cotinine in the serum of women who smoked. These
data suggest that cigarette smoking may have a greater
effect on birth weight among African Americans than
among whites because higher cotinine levels are
present in African American women than in white
women who smoke the same amount; the higher
cotinine levels may result from a greater intake of to-
bacco smoke per cigarette by African American women
than by white women.

  Li and colleagues (1993) found a differential ef-
fect of smoking reduction during pregnancy on infant
birth weights among African American and white
women. Study subjects were 803 participants in an
experimental trial of smoking cessation for pregnant
women in Alabama; self-reported smoking was vali-
dated with saliva cotinine. Reduction was defined as
a minimum drop in saliva cotinine values between the
baseline (early pregnancy) visit and the late pregnancy
visit. Smoking reduction increased the birth weight
of infants of both African American and white women,
but racial/ethnic group differences were present.
Among white women, a reduction in smoking in-
creased infant birth weight regardless of the baseline
cotinine value. However, among African American
women with high baseline cotinine values, a reduc-
tion in smoking had no effect on infant birth weights.
The authors suggested that high levels of cigarette
smoking (as detected by high cotinine levels) early
in pregnancy may have irreversible effects on African
American infants.

  Another recent study reported a differential ef-
fect of smoking on LBW (~2,500 grams) among multi-
parous African American and white women, but in the
opposite direction (Neggers et al. 1994). Among Afri-
can American women, the investigators found no sig-
nificant difference in birth weight between smokers

Health Comxquences 267


Table 10.  Rates of selected infant outcomes, by mother's race/ethnicity,* United States

African

American
Indian and

Asian American and Pacific Islander

Reference

Outcome/years   American  Alaska Native Total Chinese Japanese Filipino Other

NCHS, public Low-birth-weight
use data tapes,  (~2,500 grams)
1992s      rate per 100 live
         births, 1992       13.4

NCHS
19945

Infant mortality
rate per 1,000
live births, 1987

17.8

6.2       6.6     5.2     7.5      7.4    6.9

13.0       7.3     6.2     6.6     6.6 7.9

Kleinman 1990 Sudden infant
       death syndrome
       rate per 1,000
        live births,
          1983-1984

2.41        3.44      0.95    NA     NA     NA    NA

*The categories African American and white include persons of Hispanic and non-Hispanic origin. Conversely
persons of Hispanic origin may be included in other categories as well.
`Reported for selected states only; reporting areas for Hispanic origin vary by year.

and nonsmokers, whereas among white women, the
infants of smokers weighed significantly less than
those of nonsmokers. However, no information was
available on the number or type of cigarettes smoked
or the biomarker of exposure; these results were ad-
justed only for the mother's parity, age, height, and
alcohol consumption as well as the infant's gender and
gestational age at birth. In addition, the study was
not designed to study the relationship between smok-
ing and LBW but to determine whether the relation-
ship between maternal triceps skinfold thickness and
infant birth weight was modified by smoking and
race/ethnicity.

  Two studies have reported that smoking is re-
lated to an elevated risk of LBW among both African
American and white women, but neither study found
significant racial/ethnic group differences. In a popu-
lation-based, case-control study of African American
and white women delivering singleton infants with-
out congenital anomalies in a large urban county of
California, the Alameda County Low Birth Weight
Study Group (1990) found that the risk of LBW associ-
ated with regular smoking throughout pregnancy was
3.0 (95 percent confidence interval ICI], 1.7-5.3)
for white women and 3.6 (95 percent CI, 2.4-5.6) for

African American women (adjusted for age, parity,
prepregnancy weight, socioeconomic status, alcohol
use, prior LBW birth, and prenatal care). Unfortu-
nately, the authors were unable to adjust the data for
the number of cigarettes smoked.

  Castro and colleagues (1993) reported a study of
maternal smoking and substance abuse during preg-
nancy and found similar associations between smok-
ing during pregnancy and small size for gestational
age (birth weight of less than the 10th percentile for
gestational age) for African American and white
women (odds ratio [OR] for African American women,
2.0 [95 percent CI, 1.3-3.11; OR for white women,
2.4 [95 percent CI, 1.7-3.01). These results were
adjusted for maternal age, parity, marital status, in-
surance status, alcohol use, marijuana use, and other
drug use; however, no information was available on
the number of cigarettes smoked or the biomarker of
exposure.

  Few studies have examined the relationship be-
tween smoking and LBW among Hispanic popula-
tions. Cohen and colleagues (1993) analyzed birth
weight data on 19,571 Hispanic infants and 206,973
white infants (those whose mothers did not indicate
they were of Hispanic origin) born in Massachusetts


Total

Mexican
American

     Hispanic+


Puerto Rican      Cuban

Central and
South American

OtherJ    White

6.4          6.0           8.8          6.0           5.6          7.5       5.9

8.2          8.0           9.9          7.1           7.8          8.7       8.2

IiA          0.x-l           1.38

%~~ludes persons of unknown Hispanic origin.
`Data calculated to one significant digit.
NA = data not available.

between 1987 and 1989 and found that the incidence
of LBW ranged from a high of 73 per 1,000 Puerto Rican
infants to a low of 32.2 per 1,000 Cuban infants. The
crude percentage of LBW was higher for smokers than
for nonsmokers in each racial/ethnic group; however,
multivariate adjusted risks were not presented for
racial/ethnic groups separately.

   Several studies have demonstrated associations
between smoking and LBW in specific racial/ethnic
minority groups, including Puerto Ricans (Becerra and
Smith 19881, Mexican Americans (Wolff et al. 19931,
North American Indians (Godel et al. 19921, and Afri-
can Americans (Jacobson et al. 1994; Johnson et al.
1994). In each instance, smoking was shown to be re-
lated to lower birth weight; however, these studies did
not provide data on other racial/ethnic groups, which
might have allowed comparisons.

  The percentage of LBW (~2,500 grams) in
the United States in 1993 was higher overall for smok-
ers (11.8 percent) than for nonsmokers (6.6 percent)
(NCHS 1996b). Although a higher percentage of white
mothers (16.8) smoked during pregnancy than did
African American mothers (12.7), African American
women had a higher percentage (13.3) of LBW live
births than white women (6.0) did in 1993. Age- and

0.83          0.53         1.52      1.21

racial/ethnic-specific analyses of population data may
be more revealing. Land and Stockbauer (1993), for
example, found that the teenage-specific LBW rate
for African Americans in Missouri dropped by 13.6
percent from 1978-1990, concomitant with a drop in
cigarette smoking prevalence among young African
American mothers. Analyses of individual data sta-
tistically controlled for confounding factors such as
preterm deliveries and maternal parity, weight, and
access to health care (USDHHS 1989a) would be pref-
erable. The studies of individuals that are reported in
this section provide more useful data than do popula-
tion-based ecological comparisons on the relationship
between cigarette smoking and the increased occur-
rence of LBW in various racial/ethnic groups.

Studies of Infant Mortality and Sudden
Infant Death Syndrome

  Only one study has examined the risks of smok-
ing associated with overall fetal and infant mortality
in specific racial/ethnic groups (Kleinman et al. 1988).
The authors used data from Missouri live birth, fetal
death, and infant death certificates for births during


Table 11.  Risk of sudden infant death syndrome associated with smoking, by race/ethnicity, selected
      studies, United States

Reference     Exposure/years

Li and Daling   Active smoking
1991$         1984-1989

African American

OR"     c1+



3.1     1.7-5.9

American Indian
and Alaska Native

OR      CI



1.4     0.9-2.4

Asian American
and Pacific Islander

  OR     CI



  2.7   1.1-6.6

Schoendorf
and Kiely
1992$

Passive exposure
1988

Combined exposure
1988

1.8    1 .o-3.0      NA     NA        NA     NA




3.1     2.3-4.2      NA     NA        NA     NA

Klonoff-Cohen  Passive exposure
et al.A 1995     1989-1992
                 .~~~
*OR = odds ratio.
`CI = 95% confidence interval.

5.0    1 .l-22.8      NA      NA        NA     NA

SLi and Daling assessed the risk, by mother's ethnicity, associated with active maternal smoking during
pregnancy; ORs are adjusted for maternal age, marital status, prenatal care, parity, and birth weight.
"Schoendorf and Kiely assessed the risk, by mother's ethnicity, associated with (1) passive smoking (maternal
smoking after birth but not during pregnancy) and (21 combined exposure (maternal smoking during
pregnancy and after birth); ORs are adjusted for maternal age, education, and marital status.
`Klonoff-Cohen et al. assessed the risk, by infant's ethnicity, associated with total passive smoke exposure from
all adults (mother, father, live-in adults, and day-care providers); ORs are adjusted for birth weight, routine
sleep position, medical conditions at birth, breast-feeding, prenatal care, and maternal smoking during
pregnancy.
NA = data not available.

1979-1983 to examine the risk of mortality associated
with smoking during pregnancy. They found no sig-
nificant variation in the effects of smoking on African
American and white women, with adjusted ORs rang-
ing from 1.3 to 1.6, depending on parity and the
amount smoked.

   Three studies have examined the effects of smok-
ing on SIDS in specific racial/ethnic minority groups
(Table 11) (Li and Daling 1991; Schoendorf and Kiely
1992; Klonoff-Cohen et al. 1995). Li and Daling (1991)
used data from Washington State birth records from
1984 through 1989, linked with infant death records.
After adjusting the data for maternal age, marital sta-
tus, prenatal care, parity, and birth weight, they found
a statistically significant increased risk of SIDS associ-
ated with maternal smoking during pregnancy in all
racial/ethnic groups except American Indians (Table

11). The ORs were not significantly different between
groups, except between African Americans and Ameri-
can Indians. No information was available on the num-
ber of cigarettes smoked or the biomarker of exposure.

  Schoendorf and Kiely (1992) used data from the
1988 National Maternal and Infant Health Survey to
study the association between SIDS and maternal
smoking (either passive [only after birth] or combined
[during pregnancy and after birth]) among infants of
normal birth weight. They found similar increased
risks of SIDS among African American and white in-
fants exposed to maternal smoking (Table 111, after
adjusting the data for maternal age, education, and
marital status. Although white mothers reported
heavier smoking than African American mothers, the
authors did not adjust their findings for the number
of cigarettes smoked.


Implications

Hispanic              White

OR     CI          OR     CI

5.5    1.4-22.0         2.2    1.8-2.6

NA     NA           3.1    234.2

NA     NA          1.8    1 .o-3.1)

2.6    0.9-7.3          3.4    1.6-7.2

  Klonoff-Cohen and colleagues (1995) conducted
a 1989-1992 case-control study of passive smoking and
SIDS in five counties in southern California. The OR
for SIDS associated with all types of passive smoke
exposure combined was 3.50 (95 percent CI, 1.81-6.75),
after adjustment for birth weight, routine sleep posi-
tion, medical conditions at birth, breast-feeding, pre-
natal care, and maternal smoking during pregnancy.
The evidence suggested a dose-response relationship,
with an increased risk of SIDS associated with in-
creased passive exposure to smoke. The authors also
stratified the data by racial/ethnic group and found
similar effects across groups (Table ll), although the
results were not adjusted for the number of cigarettes
smoked.

Health Problems Affecting
Pregnant Women

  Smoking is related to a variety of health prob-
lems affecting pregnant women, ranging from ectopic
pregnancy to abruptio placentae (LJSDHHS 1980;
Rosenberg 1987), but race- and ethnic-specific data are
not generally available. In addition to exploring
smoking's effects on fetuses and infants, future re-
search should focus on the race- and ethnic-specific
effects of smoking on the pregnant woman herself.

  The question of whether race- and ethnic-specific
differences exist in the relationship between smoking
and infant outcomes has not been satisfactorily
resolved. Many intriguing questions have been raised,
but investigators have not yet determined the exact
nature of such differences or what factors mediate
them.

  Comparative studies have been hampered by
inconsistent and inadequate measurement of exposure.
For example, fe\v investigators have fully explored is-
sues of dose of smoking such as the number of ciga-
rettes smoked or the levels of biomarkers, although
the amount of smoking during pregnancy does differ
among racial/ethnic minority groups (see Chapter 2).
Moreover, even though the timing of smoking during
pregnancv may plav a critical role in the development
of LBW (Lieberman et al. 1994), few studies of LBW
ha\re separately assessed the effects of smoking dur-
ing each trimester of pregnancy. Patterns of quitting
and reducing smoking during pregnancy may in fact
differ by race/ethnicity.

  Racial/ethnic group differences in nicotine me-
tdbolisni may also be important (Wagenknecht et al.
1990; English et al. 1994). African American pregnant
smokers appear to have higher serum cotinine levels
than white pregnant smokers when the data are con-
trolled for nicotine dose (English et al. 1994). Thus,
fetal exposure may be higher among African Ameri-
cans than among whites for a given number of ciga-
rettes smoked.

  Racial/ethnic group differences in oxygen-
carrying capacity may also play a role in mediating the
effects of smoking. In 1973, Lubs suggested that the
increased effects of smoking on birth weight among Af-
rican American women might in part be explained by
higher rates of sickle cell trait or glucose-6-phosphate
dehydrogenase (G6PD) deficiency, which impair oxy-
gen-carrying capacity (Lubs 1973). No published re-
ports have examined Lubs's hypothesis. In addition,
anemia, which is more prevalent among African Ameri-
can women, may be a risk factor for preterm delivery
(Hague and Yip 1989).

  Future studies of smoking and pregnancy
outcomes should consider racial/ethnic group differ-
ences in the timing of smoking during pregnancy,
nicotine metabolism, and factors that affect oxygen-
carrying capacity, such as sickle cell trait, G6PD defi-
ciency, and anemia.


Summary of Health Consequences from Active Cigarette Smoking

  Attempts to predict racial- and ethnic-specific
rates of disease incidence and mortality from racial- and
ethnic-specific cigarette smoking prevalences are of
limited value, because other factors can also influence
disease rates. When studies of individuals are con-
ducted, the data lead to the conclusion that cigarette
smoking is a major cause of disease and death in each
of the four U.S. racial/ethnic minority groups studied
in this report. These studies reveal few major differ-
ences in the risk ratios for various diseases. Limited
epidemiological and biological data suggest that Afri-

can Americans may be at an especially high level of
risk for lung cancer. Although further research could
clarify the nature of the interrelationships between
cigarette smoking, other risk factors, potential modi-
fying factors, racial/ethnic group membership, and
various disease outcomes, it is clear that reducing to-
bacco use in each of the nation's racial/ethnic groups
will reduce the incidence and mortality from several
of the nation's leading causes of death and is a major
public health goal to pursue.

Effects of Exposure to Environmental Tobacco Smoke

   Environmental tobacco smoke (ETS) is the mix-
ture of sidestream smoke and exhaled mainstream
smoke that is produced by acti\re smokers and then
involuntarily inhaled by nonsmokers. Over the past
decade, the ad\rerse effects of ETS have been reported
in the literature. The 1986 Surgeon General's report
on smoking and health (USDHHS 1986a) concluded
that the inhalation of ETS (labeled "in\~oIuntarv smok-
ing" in that report) is a cause of diseases, including
lung cancer, in healthy nonsmokers and that the chil-
dren of parents who smoke are more likely than the
children of nonsmoking parents to ha\,e respirators
infections, respiratory symptoms, and abnormal matu-
ration of lung function. Similar conclusions Lvere also
reached in 1986 by a committee of the National Re-
search Council (1986). More recently, the U.S. Eniri-
ronmental Protection Agency (1992) assessed the risks
associated with ETS, and the results reaffirmed that
ETS is carcinogenic and that it exacerbates and may
even cause childhood asthma. To date, racial/ethnic
group differences in the adverse effects of ETS ha\re not
been investigated, although a number of studies have
investigated racial/ethnic group differences in the level
of exposure to ETS and in people's reactions to ETS.

  O\rerpeck and Moss (1991) examined patterns of
exposure to ETS among children five years of age and
younger included in the 1988 NHIS and found that
exposure varied by race/ethnicit)l and socioeconomic
status (Table 12). African American children M'ere the
most likely to be exposed to ETS, tvhereas Hispanic

children were the least likely to be exposed to ETS.
Moreover, in the CARDIA (Coronary Artery Risk De-
velopment in [Young] Adults) study, the prevalence
of exposure to ETS was significantly higher among
African Americans (32 percent) than among whites (24
percent) (Wagenknecht et al. 1993). OveraIl, 28 per-
cent of individuals 18-30 years of age were exposed
to ETS, as detected by a serum cotinine level of 2-13
ng/mL. Adult sur\re\i data from the 1992 California
Tobacco Survey sho\iT that Hispanics (21.3 percent)
i\rere most likelv to report working around a cigarette
smoker within the two Lveeks before the survey (Pierce
et al. 1993). Asian Americans (13.2 percent) and Afri-
can Americans (12.8 percent) reported being exposed
to ETS at M'ork in lolver proportions than whites
(17.9 percent). Data from the 1988 NHIS (CDC 1992)
sho\~ that 40.3 percent of employed adults reported
that cigarette smoking was allowed in their place of
employment. The percentages of persons who
reported experiencing discomfort caused by ETS ex-
posure at work did not differ significantly by racial/
ethnic group. In a 1992-1993 study of U.S. adults who
worked indoors, Asian Americans and Pacific Island-
ers (51.4 percent) were the most likely and African
Americans (43.3 percent) were the least likely to work
under a completely smoke-free ETS policy (Gerlach et
al. 1997). Since most studies suggest that differences
exist in the ETS exposure of various racial/ethnic
groups, studies to monitor the health effects of this
exposure are needed.


7hbm-c) Usr Amug U.S. Racid/Efhnic Minority Groups

Table 12.  Exposure to household smoke among children 5 years of age and younger and percentage
    distribution, by level of exposure since birth and selected characteristics, United States, 1988

Characteristic

                Percentage distribution*
                     Exposed since birth
Number of                          Current     Former
  children                          smoker in   smoker in
(in thousands)+ Total  Not exposed
                since birth   Totali   household   household

All children+             19,019

Ethnicity
African American
White

Hispanic origin
Non-Hispanic
Hispanic
   Mexican American

Annual household income
<s10,000
$lO,OOO-$24,999
$25,000-$39,999
2 $40,000

Poverty status'
In poverty
Not in poverty

Mother's education
< 12 years
12 years
> 12 years

Place of residence
Metropolitan statistical area
  Central city
  Not central city
Not metropolitan statistical area

2,759
15,575

16,923
2,096
1,006

2,685
5,436
4,871
4,149

3,376
14,582

3,279
8,014
7,505

14,550
5,994
8,556
4,469

100.0    51.1 (0.9)   48.9 (0.9)   42.4 (0.9)    6.1 (0.4)



100.0    41.5 (2.4)   58.5 (2.4)   51.3 (2.4)    6.7 (1.2)
100.0    51.9 (1.0)   48.1 (1.0)   41.6 (1.0)    6.1 (0.4)



100.0    50.4 (1.0)   49.6 (1.0)   43.2 (1.0)    6.0 (0.4)
100.0    56.4 (2.6)   43.6 (2.6)   35.8 (2.5)    6.9 (1.2)
100.0    60.7 (4.1)   39.3 (4.1)   31.8 (3.8)    6.5 (1.5)



100.0    33.4 (2.1)   66.6 (2.1)   57.7 (2.3)    8.7 (1.1)
100.0    44.3 (1.5)   55.7 (1.5)   48.8 (1.6)    6.3 (0.7)
100.0    55.9 (1.7)   44.1 (1.7)   38.3 (1.6)    5.4 (0.7)
100.0    63.7 (1.8)   34.3 (1.8)   29.5 (1.5)    4.6 (0.9)




100.0    36.4 (2.1)   63.6 (2.1)   55.7 (2.3)    7.6 (1.0)
100.0    54.8 (1.0)   45.2 (1.0)   39.2 (1.0)    5.6 (0.4)



100.0    33.3 (2.2)   66.7 (2.2)   61.2 (2.1)    5.1 (0.8)
100.0    44.5 (1.4)   55.5 (1.4)   47.9 (1.4)    7.3 (0.6)
100.0    66.3 (1.2)   33.7 (1.2)   27.6 (1.1)    5.4 (0.6)




100.0    51.5 (1.0)   48.5 (1.0)   42.2 (1.1)    5.9 (0.4)
100.0    49.4 (1.4)   50.6 (1.4)   43.6 (1.5)    6.3 (0.6)
100.0    52.9 (1.4)   47.1 (1.4)   41.1 (1.4)    5.6 (0.6)
100.0    49.7 (1.9)   50.3 (1.9)   43.1 (1.7)    6.8 (0.8)

*Figures in parentheses are standard errors of estimates.
`Excludes children whose exposure status is unknown.
*Includes children exposed since birth whose period of exposure is unknown.
`Includes all other ethnicities, unknown household income, unknown poverty status, unknown education of mother,
and unknown assessed health status.
Poverty status determined in the National Health Interview Survey by family size, number of children, and
household income by using 1987 poverty levels defined by the U.S. Bureau of the Census.
Source: Adapted from Overpeck and Moss 1991.


Effects of Smokeless Tobacco Use

  Smokeless tobacco refers to moist oral snuff, dry
oral and nasal snuff, and chewing tobacco. Smokeless
tobacco is commonly used by youths, particularly
those in rural areas, and it is highly addictive
(USDHHS 1986b; Boyd and Glover 1989). Among the
adverse health effects of smokeless tobacco use are oral
cancer, oral leukoplakia (white mouth lesions that may
be precancerous), gingival recession, periodontal dis-
eases, elevated blood pressure, and increased risk for
cardiovascular disease (NC1 1992; USDHHS 1994;
Bolinder et al. 1994).

   Few studies have examined the adverse health
effects of smokeless tobacco use in racial/ethnic
minority populations, and the research that has been
conducted has been limited in several ways: (1) popu-
lation-based, case-control studies rarely have sufficient
numbers of racial/ethnic group members to allow
group-specific analyses for groups other than African
Americans (Blot et al. 1988; Day et al. 1993); (2) be-
cause the use of smokeless tobacco and associated
health effects are relatively rare in most racial/ethnic
groups, the feasibility of conducting prospective in-
vestigations is limited; and (3) smokeless tobacco us-
ers often report current or past use of other substances,
such as cigarettes and alcohol, that are risk factors for
health effects also associated with smokeless tobacco
use, such as oral cancer (Blot et al. 1988; Mattson and
Winn 1989). These multiple risk factors complicate or
preclude analysis of the independent effects of smoke-
less tobacco use.

  The valid data that are available, however, indi-
cate that for men, the prevalence of smokeless tobacco
use is highest among American Indians, Alaska
Natives, and whites; for women, the prevalence is
highest among American Indians, Alaska Natives, and
African Americans (CDC 1993~). Data for 1989-1991
show that rates of death from cancers of the lip, oral
cavity, and pharynx have been higher among African
American men (7.8 per 100,000) than among Puerto
Rican men (3.9 per lOO,OOO), Asian American and Pa-
cific Islander men (3.4 per lOO,OOO), and white men (3.2
per 100,000) (Table 2) (NCHS, public use data tapes,
1989-1991; U.S. Bureau of the Census 1993).

  In a case-control study, Winn and colleagues
(1981) examined the estimated relative risk of oral and
pharyngeal cancer associated with snuff-dipping
among African American and white women in the
southern United States. Although the relative risk was

higher among white women (4.2) than among African
American women (1.51, white women had dipped
snuff for significantly longer periods and had con-
sumed more snuff per week than African American
women had. The relative risk for cancers of the gum
and buccal mucosa increased with longer duration of
snuff use, but this analysis was not conducted sepa-
rately for African Americans and for whites.

   A few studies of the health effects associated with
smokeless tobacco use have been conducted among
American Indian and Alaska Native populations. In a
study of Navajo youths aged 14-19 years in New
Mexico (Wolfe and Carlos 1987), 64 percent of the teen-
agers used smokeless tobacco products. Oral leuko-
plakia was found in 26 percent of smokeless tobacco
users, representing a ninefold increase in risk when
these youths were compared with those who did not
use smokeless tobacco. The estimated relative risk of
leukoplakia increased with duration and frequency of
smokeless tobacco use. The investigators observed no
apparent differences between users and nonusers of
smokeless tobacco regarding gingival bleeding, calcu-
lus accumulation, or the extent or severity of gingival
recession or loss of periodontal attachment.

  In a survey of students in grades 7-12 attending
schools on the Rosebud Sioux Reservation in South
Dakota, more than one-third of the students reported
regularly using smokeless tobacco (CDC 1988). Of
these regular users, 37 percent had oral lesions (i.e.,
any white or red wrinkled area in the mouth or buccal
mucosa). The students with oral lesions had used
smokeless tobacco for a mean of 3.4 years, 6.6 times
per day, and they had held each dip or chew for an
average of 40 minutes. Students who used smokeless
tobacco but did not have lesions had used the product
for a mean of 2.3 years, 2.9 times per day, and they
had held each dip or chew for an average of 30 min-
utes. This suggests a possible relationship between
duration and intensity of smokeless tobacco use and
the occurrence of oral lesions. The prevalence of oral
lesions among nonusers of smokeless tobacco was not
reported.

  The 1986-1987 National Survey of Oral Health
in U.S. School Children conducted oral clinical exami-
nations on 17,027 children aged 12-17 years who
provided information on their use of various tobacco
products (Tomar et al. 1997). Smokeless tobacco
lesions (defined by the authors as slight to heavy


wrinkling of the oral mucosa) were more common   chewing tobacco use.  Lesions were more common
among white (2.0 percent) than among African Ameri-   with increasing duration and frequency of smokeless
can (0.2 percent) or Hispanic (0.8 percent) school chil-   tobacco use. Because of small sample sizes, analyses
dren. In white males, the strongest correlates of le-    were not conducted on data for other racial/ethnic
sions were, in order, current snuff use and current    groups.

Nicotine Addiction and Racial/Ethnic Differences

  Most smokers have difficulty quitting because
they are addicted to nicotine (USDHHS 1988). An un-
derstanding of the role of nicotine addiction in deter-
mining smoking behavior could help clarify racial/
ethnic differences in tobacco use and facilitate smok-
ing cessation treatment.  Nicotine addiction was
                       _
reviewed extensivelv in the 1988 Surgeon General's
report on smoking and health (USDHHS 1988). Con-
cepts of addiction also ha\,e been relriewed in subse-
quent Surgeon General's reports (USDHHS 1989b,
1994). However, relati\rely little research has been con-
ducted on racial/ethnic minority differences in nico-
tine addiction. This section provides a brief revie\\r of
nicotine addiction and discusses the limited data on
racial/ethnic differences and nicotine addiction.

Nature of Addiction

  In the broadest sense, addiction (often used in-
terchangeably with dependence) indicates a loss of
control over drug-taking behavior. The World Health
Organization describes drug dependence as "a behav-
ioral pattern in which the use of a given psychoactive
drug is given a sharply higher priority over other be-
haviors which once had a significantly higher value"
(Edwards et al. 1982). In other words, drug use con-
trols one's behavior to an extent considered detrimen-
tal to the individual or to society.

  The criteria for drug dependence, described in
the 1988 Surgeon General's report on smoking and
health (Table 13) (USDHHS 19881, include highly con-
trolled or compulsive use of a drug, the use of a drug
that produces psychoactive effects, and evidence that
drug-taking behavior is reinforced by the effects of the
drug. Other criteria for drug dependence have been
developed by the American Psychiatric Association
[APA] (1994) for the fourth edition of the Diagr~ostic
and Sfafistical Mnnunl r$Melztal Disonfers lDSM-Wr"J
(Table 14). These criteria are quite specific and useful
in diagnosing drug dependence in individual patients.

Pharmacologic Factors in Nicotine Addiction

  Nicotine addiction, like all drug addictions, is a
complex process involving the interplay of pharma-
cology, learned or conditioned factors, personality,
social setting, and genetics (USDHHS 1988, 1994;
Benowitz 1992a). The pharmacologic reasons for drug
use include an enhancement of one's mood or func-
tioning. Drugs produce such effects either directly or
by relieving withdrawal symptoms. The pharmaco-
logic factors involved in nicotine addiction work in
selFera ways. For example, positive effects reported
after smoking tobacco include pleasure, arousal, and
relaxation as well as improved attention, reaction time,
and performance of certain tasks. In addition, ciga-
rette smoking has been cited as effective in relieving
aversive emotional states, including reducing anxiety
or stress, relieving hunger and preventing weight gain,
and relieving nicotine withdrawal symptoms (Table
15) (Benowitz 1992a).

  The pharmacology of nicotine addiction can be
discussed in relation to several processes: (1) absorp-
tion, distribution, and elimination of nicotine in the
body (pharmacokinetics); (2) pharmacologic effects of
nicotine on target organs (pharmacodynamics); and
(3) translation of pharmacologic effects into behavior.
These processes are reviewed in the following sections,
and racial/ethnic differences are discussed when
information is available.

Absorption, Distribution, and Elimination of
Nicotine in the Body

  Nicotine from tobacco smoke is absorbed rapidly
across the lungs' alveolar membranes and into the sys-
temic circulation (Benowitz 1990). Following absorp-
tion from the lung, concentrations of nicotine in
the blood rise quickly and peak at the completion of
smoking. Concentrations of nicotine in arterial blood
leaving the lungs and heart are several times higher
than those measured in venous blood (Henningfield


Table 13.  Criteria for drug dependence
Primary criteria
Highly controlled or compulsive use
Psychoactive effects
Drug-reinforced behavior

Additional criteria
Addictive behavior often involves-
  stereotypic patterns of use
  use despite harmful effects
  relapse following abstinence
  recurrent drug cravings

Dependence-producing drugs often produce-
tolerance
physical dependence
pleasant (euphoric) effects

Source: Adapted from U.S. Department of Health
and Human Services 1988.

et al. 1993). Within 10 to 19 seconds after the start of a
puff, nicotine is delivered to the brain. Rapid delivery
of high concentrations of nicotine to the brain provides
the possibility for rapid behavioral reinforcement from
smoking and allows the smoker to control the concen-
tration of nicotine in the brain and, hence, to modu-
late the pharmacologic effects of nicotine.

  In contrast, the absorption of nicotine from
smokeless tobacco is gradual, with blood levels peak-
ing at the end of chewing tobacco or using snuff
(Benowitz et al. 1988). Buccal-oral absorption results
in a gradual increase in concentrations of nicotine in
the brain, with relatively little arterial-\renous disequi-
librium, This pattern of absorption may provide a less
intense pharmacologic reinforcement than that pro-
duced by smoke inhalation but is sufficient to produce
addiction.

  The level of nicotine in the body is determined
by the balance of nicotine intake from tobacco and the
rate of nicotine elimination from the body. Nicotine is
eliminated primarilv by hepatic metabolism, with a
small amount (5-14 percent) excreted unchanged in
the urine. The primary metabolite of nicotine is
cotinine, which has been used as a measure of nicotine
exposure (Benowitz 1996). Keenan and colleagues
(1994, 1995) recently published preliminary data
consistent with the hypothesis that cotinine has some

psychoactive properties. These effects do not appear
to be mediated by nicotine receptor agonism, but could
play some role in nicotine addiction, The rate of me-
tabolizing nicotine varies considerably from person to
person (Benowitz et al. 1982). A person who metabo-
lizes nicotine slowly would not need to take in as much
nicotine to achieve a particular level of nicotine in the
body as a person who metabolizes nicotine more rap-
idly. The level of nicotine in the body appears to be
positively correlated with the degree of nicotine de-
pendence and negatively correlated with the likelihood
of successful cessation therapy (USDHHS 1988;
Pomerleau et al. 1990; Sutherland et al. 1992).

Theoretically, racial/ethnic differences in the ab-
sorption, distribution, or elimination of nicotine could
influence the likelihood of developing nicotine depen-
dence (see Racial/Ethnic Differences in Nicotine Me-
tabolites later in this chapter for further discussion
of this topic).

Pharmacodynamics of Nicotine

  Nicotine acts on nicotinic cholinergic receptors
in the brain and other organs of the body, enhancing
the release of neurotransmitters such as acetylcholine,
norepinephrine, dopamine, beta-endorphin, and sero-
tonin (USDHHS 1988). The physiologic consequences
of nicotine intake include behavioral arousal and sym-
pathetic neural activation (Table 15) (Benowitz 1992a).
The release of specific neurotransmitters has been
speculatively linked to the various reinforcing effects
of nicotine (Pomerleau and Pomerleau 1984). For ex-
ample, the enhanced release of dopamine and norepi-
nephrine may be associated with pleasure as well as
appetite suppression, the latter of which may contrib-
ute to lolver body weight. The release of acetylcho-
line may be associated with improved performance of
beha\rioral tasks and improved memory, whereas the
release of beta-endorphin may be associated with re-
duced anxiety and tension.

  Although smokers give different explanations for
smoking, most agree that smoking produces arousal,
particularly with the first few cigarettes of the day, and
paradoxically, smoking can also be calming or relax-
ing, especially in stressful situations (Pomerleau and
Pomerleau 1984; Benowitz 1992a). Consistent with
reports of arousal, the smoking of cigarettes or
the administration of nicotine is followed by
electroencephalographic desvnchronization, with an
upward shift in the brain's dominant alpha frequency
and decreased total alpha and theta power (Pickworth
et al. 1989).


Table 14. American Psychiatric Association diagnostic criteria for substance dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested
by three or more of the following consequences, occurring at any time in the same 12-month period:

Tolerance, as defined by either-

need for markedly increased amounts of the substance to achieve intoxication or desired effect or
markedly diminished effect with continued use of the same amount of the substance.

Withdrawal, as manifested by either-

the characteristic withdralval syndrome* for the substance or
the same (or a closely related) substance being taken to relieve or avoid writhdrawal symptoms.

Consumption of the substance in larger amounts or over a longer period than was intended.

Having a persistent desire to cut down or control substance use or unsuccessfully trying to do so.

Spending a great deal of time in activities necessary to obtain the substance (e.g., visiting multiple doctors or
driving long distances), use the substance (e.g., chain-smoking), or recover from its effects.

Giving up or reducing important social, occupational, or recreational activrities because of substance use.

Continuing to use the substance, despite the knowledge that one has a persistent or recurrent physical or
psychological problem likely caused or exacerbated by the substance (e.g., current cocaine use despite
recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was
worsened by alcohol consumption).
*The characteristic withdra\yal syndrome for nicotine refers to the daily use of nicotine for at least several
weeks and abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24
hours by four or more of the following signs: dysphoric or depressed mood; insomnia; irritability, frustration,
or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; increased appetite or weight gain.
Source: Adapted from American Psychiatric Association 1994.

   Several researchers have studied the effects of
cigarette smoking and nicotine administration on the
behavior of smokers who have abstained from tobacco
use (abstinent smokers) (USDHHS 1988; Hughes et al.
1990; Warburton 1990; Le Houezec and Benowitz 1991;
Heishman et al. 1994). Many of these studies have
shown that nicotine restores tobacco-abstinence-
related deficits in attention and short-term memory
and decreases reaction time (Peeke and Peeke 1984;
USDHHS 1988; Snyder et al. 1989; Snyder and
Henningfield 1989; Warburton 1990; Levin 1992;
Pritchard et al. 1992). Nicotine also may increase a
person's vigilance in performing repetitive tasks and
increase selective attention in abstinent smokers. The
effects of nicotine on the cognitive functioning of non-
smokers have not been clearly identified (USDHHS

1988; Heishman et al. 1994). Smokers commonly re-
port pleasure, mental stimulation, and reduction of
stress after smoking a cigarette (McKennell 1970;
Russell et al. 1974).

  Cigarette smoking and nicotine also have sym-
pathomimetic action, producing brief increases in
blood pressure, heart rate, and cardiac output with
cutaneous vasoconstriction (Benowitz 1988). Nicotine
causes muscle relaxation by stimulating discharge of
the Renshaw cells and pulmonary afferent nerves,
which inhibit motor neuron activity and relax certain
muscles. However, not all muscles are relaxed;
increased electromyographic activity and tonicity
of the large upper-back muscles (trapezius) have been
observed after smoking (Fagerstrom and Gotestam
1977).


Table 15.  Human pharmacology of nicotine
Primary effects*

Withdrawal symptoms

Pleasure
Arousal, enhanced vigilance
Improved task performance
Relief of anxiety
Reduced hunger
Body weight reduction

Electroencephalogram desynchronization
Increased circulating levels of catecholamines,
vasopressin, growth hormone, adreno-
corticotropic hormone (ACTH), cortisol,
prolactin, beta-endorphin
Increased metabolic rate
Lipolysis, increased free fatty acids

Heart rate acceleration
Cutaneous and coronary vasoconstriction
Increased cardiac output
Increased blood pressure

Irritability, restlessness
Drowsiness

Difficulty concentrating, impaired task performance
Anxiety
Hunger
Weight gain
Sleep disturbance
Cravings or strong urges for nicotine

Decreased catecholamine excretion+

Heart rate slowing'

Skeletal muscle relaxation

*Some of these effects are related in part to relief of withdrawal symptoms.
`May represent a return to baseline rather than true withdrawal.
Source: Benowitz 1992a.

   Genetic differences in the number of nicotinic
receptors and pharmacologic responses to nicotine
have been well demonstrated in animals (Marks et al.
1991). Genetic differences in pharmacologic responses
to nicotine could underlie different susceptibilities to
nicotine addiction, as appears to be the case for cer-
tain types of alcohol addiction (Hughes 1986;
Cloninger 1987; Carmelli et al. 1992). Genetic suscep-
tibility may vary by ancestry of origin (for example,
sickle cell disease and African American ancestry).
Genetic differences in nicotine responsiveness associ-
ated with ancestry of origin remain to be explored.

Tolerance, Withdrawal, and Addictive Tobacco Use

  With prolonged or repeated exposure to nicotine,
neurologic changes (neuroadaptation) occur. In ani-
mals, chronic nicotine exposure results in an increased
number of nicotinic receptors in the brain (Marks et
al. 1985). During the course of these changes, the

smoker develops more brain nicotinic receptors and
an increased tolerance to the various effects of nico-
tine. For example, previous studies have shown that
at autopsy, the number of nicotinic receptors was
greater in the brains of cigarette smokers than in those
of nonsmokers (Benwell et al. 1988). Smokers develop
substantial tolerance to the behavioral arousal and
cardiovascular effects of nicotine in the course of a
single day (Benowitz et al. 1989b). They can regain
sensitivity to the effects of nicotine, at least in part,
after overnight abstinence from smoking.

  As a consequence of these neurologic changes,
nicotine withdrawal symptoms appear when nicotine
use is abruptly stopped (Table 16) (Hughes and
Hatsukami 1992). Withdrawal symptoms include rest-
lessness, irritability, anxiety, drowsiness, impatience,
confusion, impaired concentration, and depression
(Hughes et al. 1990). Some abstaining smokers
gain weight, and others have impaired performance
measures, such as reaction time. Many abstaining

178 Chapter 3

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

Table 16.  Incidence* of nicotine withdrawal
     symptoms, United States

Symptom

Clinic      Self-
attendees   quitters
(%)       (%)

Anxiety              87        49
Irritability            80        38
Difficulty concentrating     73        43

Restlessness            71         46
Hunger               67        53
Craving              62        37
Nocturnal awakenings     24         39
Depression            NA        31

*Percentage of subjects with postcessation ratings
greater than precessation ratings 2 days after they
quit smoking.

NA = data not available.

Sources: Hughes 1992; Hughes and Hatsukami
1992. Adapted from Hughes and Hatsukami 1992.

smokers have a strong craving to smoke a cigarette.
Most of the withdrawal symptoms reach maximal in-
tensity 24 to 48 hours after cessation and gradually
diminish in intensity within three to four weeks (Gross
and Stitzer 1989; Hughes et al. 1990), although some
individuals experience longer lasting symptoms
(USDHHS 1988). These symptoms, which also appear
after quitting the use of smokeless tobacco (CDC 1994)
or nicotine gum, are relieved following the adminis-
tration of nicotine-a strong indication that the with-
drawal symptoms are related to the effects of nicotine.

  The degree of nicotine dependence is determined
in part by the level of nicotine that accumulates in
smokers. In general, the level of accumulated nicotine
is proportional to the number of cigarettes smoked per
day. Consistent with the concept of a daily tolerance-
withdrawal cycle, a short duration of time between
awakening and smoking the first cigarette is associ-
ated with a high degree of nicotine dependence
(Heatherton et al. 1989). This presumably reflects an
effort to reIieve nicotine withdrawal symptoms. These
two factors-the number of cigarettes smoked per day
and the amount of time from awakening to smoking
the first cigarette-are commonly used to assess the
severity of nicotine dependence (FagerstrGm and
Schneider 1989).

Level of Addiction

   Assessments of the level of nicotine addiction
help predict responses to nicotine and serve as a
potential guideline for therapeutic approaches to
smoking cessation. The professionals who design strat-
egies to prevent tobacco use and treat persons with
nicotine addiction need to understand the high level
of addiction among cigarette smokers and to appreci-
ate the group-specific cultural characteristics of the be-
havior and smokers' individual reasons for initiating,
continuing, and quitting tobacco use (Krasnegor 1979;
Grunberg and Acri 1991). The most widely used in-
dexes of addiction levels are the number of cigarettes
smoked per day, the serum nicotine or cotinine level,
the Fagerstrijm dependence questionnaire (Fagerstriim
and Schneider 1989), and the diagnostic criteria of the
DSM-IV>' (APA 1994). The FagerstrGm dependence
questionnaire incorporates questions about the num-
ber of cigarettes smoked per day, the time between
awakening and smoking the first cigarette of the day,
as well as episodes in which the smoker lost control of
smoking behavior (such as smoking at inappropriate
times or in inappropriate places). The prevalence of
smoking cessation-and conversely, the number of
unsuccessful quit attempts-also reflects the level of
addiction, at least in part. The brand of cigarette
smoked might be expected to correlate with a person's
level of dependence because high-yield cigarettes
nominally deliver more nicotine per cigarette. How-
ever, in large surveys of smokers, only a modest rela-
tionship was found between yield (measured by a
smoking machine) and levels of nicotine or cotinine in
the body (Benowitz et al. 1986; Coultas et al. 1993).
This is because people smoke differently than ma-
chines that are set to a standardized testing protocol-
that is, they are able to take more frequent or deeper
puffs, to smoke each cigarette more completely, to
smoke more cigarettes per day, and to block ventila-
tion holes in the cigarettes (Henningfield et al. 1994;
NC1 1996a).

Racial/Ethnic Differences in Nicotine Metabolites

  Evidence suggests that African Americans have
higher cotinine levels per reported number of ciga-
rettes smoked per day than whites (Wagenknecht et
al. 1990; English et al. 1994; Clark et al. 1996a) (Figure
5). In Figure 5, the racial/ethnic minority group com-
parisons among those who smoked 25 or more ciga-
rettes per day may be somewhat biased, because the
average daily consumption for whites was substantially
higher than that for African Americans and Mexican

Health Consequences 179


Surgeon General's Report

Figure 5.  Serum cotinine levels by number of cigarettes smoked daily for African Americans,
    Mexican Americans, and whites, National Health and Nutrition Examination Survey,
     United States, 1988-1991

350 1 .  African
300          American

  250 -
=i
6
-&  200-
6
2
:s  150-
3

  loo-

&l  Mexican
   American

O White

15-~25

Average number of cigarettes smoked per day (past 5 days)

Note: N = 2,136.
Source: National Center for Health Statistics, public use data tape, 1997.

Americans. Clark and colleagues (1996b) found no
evidence that underreporting of daily cigarette con-
sumption occurred more often in African American
than in white smokers.

  One possible explanation for the higher cotinine
level among African Americans is that African Ameri-
cans may absorb more nicotine from their cigarettes
than whites (Benowitz et al. 1995). Greater absorp-
tion could result from several factors, including group-
specific patterns of smoking behavior (i.e., more and
deeper puffs per cigarette or longer retention of tobacco
smoke in the lungs) (Benowitz et al. 1995). Addition-
ally, menthol in cigarettes may facilitate absorption of
cigarette smoke constituents (Jarvik et al. 1994;
McCarthy et al. 1995; Clark et al. 1996a). However,
the fact that African Americans smoke menthol ciga-
rettes more commonly than whites do explains only a
small percentage of their higher levels of cigarette

25+

smoke constituents (Wagenknecht et al. 1992;
Ahijevych et al. 1996; Clark et al. 1996a).

  Racial/ethnic differences in nicotine metabolism
could influence the development of nicotine addiction.
Several researchers have suggested that African Ameri-
cans might metabolize cotinine differently than whites
(Pattishall et al. 1985; Wagenknecht et al. 1990; English
et al. 1994; Benowitz et al. 1995). Results of studies of
nonsmokers support this hypothesis (Pattishall et al.
1985; Wagenknecht et al. 1993; Crawford et al. 1994;
Knight et al. 1996; Pirkle et al. 1996). Most of these
investigations (Pattishall et al. 1985; Crawford et al.
1994; Knight et al. 1996; Pirkle et al. 1996) reported that
African Americans had higher cotinine levels than
whites, even after ETS exposure and other factors were
taken into account. These findings may be limited by
the fact that no measures of tobacco smoke or nicotine
concentrations in the air were obtained.

180 Chapter 3

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

  Based on a preliminary report of data for 40 Af-
rican Americans and 39 white controls matched for age,
gender, and cigarette consumption, Benowitz and col-
leagues (1995) reported that the disposition kinetics
of nicotine were similar for both groups. For example,
the percentage conversion of nicotine to cotinine was
similar across groups.  However, the clearance of
cotinine was significantly lower for African Americans
than for whites. Additionally, the average estimated
intake of nicotine per cigarette smoked was 1.41 mg in
African Americans and 1.09 mg in whites. This differ-
ence is of borderline statistical significance (p = 0.07)
(Benowitz et al. 1995). African Americans took in 28
percent more nicotine per cigarette than would have
been expected based on FTC yields; whites took in 9
percent more nicotine per cigarette than would have
been expected based on FTC yields (Pkrez-Stable et
al., unpublished data).

  Investigators have also found cotinine levels in
African Americans that were higher than expected for
the number of cigarettes smoked. Ahijevych and
Wewers (1993) found an average salivary cotinine level
of 402 ng/mL in African American women who
smoked an average of 15 cigarettes per day. This level
is much higher than the expected level found in other
persons who smoked the same number of cigarettes.
Clark and colleagues (1996b) reported that African
American smokers smoked longer cigarettes and more
of each cigarette than white smokers. However, be-
cause they smoked fewer cigarettes each day, African
Americans smoked fewer total daily millimeters of
cigarettes. Among young adults in the CARDIA study,
African Americans (48 percent) were more likely than
whites (36 percent) to report that a substantial amount
of their cigarette burned without their smoking it
(Wagenknecht et al. 1992). Also, in a study of 33 Afri-
can American and white women, Ahijevych and
colleagues (1996) did not find a racial/ethnic differ-
ence in total puff volume (per cigarette).

  PQez-Stable and colleagues (1990) reported that
among Mexican Americans who were part of the
1982-l 984 HHANES, cotinine levels were unexpect-
edly high in smokers reporting low levels of cigarette
consumption. Higher-than-expected cotinine levels
may reflect underreporting of smoking by Hispanics,
but the possibility also exists that Hispanics absorb
or metabolize nicotine differently than whites
(Henningfield et al. 1990). However, recent data from
NHANES III (Figure 5) indicate that, among persons
who smoked at least one cigarette daily, Mexican
American smokers had lower serum cotinine levels in
each consumption category than African American and
white smokers.

Racial/Ethnic Differences in Self-Reported
Nicotine Dependence

  The use of questionnaires to systematically in-
vestigate racial/ethnic differences in nicotine depen-
dence has been limited. Data from the 1987 NHIS
(Table 17) show that African Americans were more
likely than whites and Hispanics to report smoking
their first cigarette of the day within 10 minutes of
awakening, although these differences tended to dis-
appear among those who reported smoking 25 or more
cigarettes per day (NCHS, public use data tapes, 1987).
Telephone survey data on smoking, collected as part
of the Community Intervention Trial (COMMIT) for
Smoking Cessation, also indicate that African Ameri-
cans were more likely than whites to smoke within 10
minutes of awakening (an indicator of nicotine depen-
dence [USDHHS 19881), even after the researchers con-
trolled for the number of cigarettes smoked per day
(Royce et al. 1993). Conversely, Andreski and Breslau
(1993) conducted a study that used the dependence
criteria of the DSM-IIITM and found that, compared
with African Americans, greater proportions of whites
had symptoms of nicotine dependence. The research-
ers randomly selected 1,200 adults aged 21-30 years
from the members of a health maintenance organiza-
tion in southeast Michigan. Overall, 22.6 percent of
the whites who smoked met the criteria for nicotine
dependence, compared with 9.3 percent of the Afri-
can Americans who smoked. Nicotine dependence
was found to have a significant association with
psychological distress, as measured by the Brief Symp-
tom Inventory for smokers in both groups. Poor
physical health was also associated with nicotine de-
pendence, and this relationship was stronger among
African Americans than among whites.

  Kandel and colleagues (1997) used questions
from the 1991, 1992, and 1993 (combined) National
Household Surveys on Drug Abuse (NHSDAs) to de-
velop a proxy measure of DSM-IVTM (APA 1994) de-
pendence on various substances (including nicotine).
Respondents were asked, for example, if they felt un-
able to reduce their use when they tried to cut down,
experienced withdrawal symptoms (described in this
survey as feeling sick because they stopped or cut
down), felt that they needed or were dependent on
the substance, and felt the need for larger amounts to
obtain the same effect. This study used responses from
87,915 persons aged 12 years and older. Among per-
sons who smoked during the previous year, whites
were more likely than African Americans, Hispanics,
and other racial/ethnic minority group members to
be rated as dependent on nicotine. The authors

Health Consequences 181


Surgeon General's Report

Table 17. Percentage of adult smokers* who reported that they smoked their first cigarette within
    10 minutes and within 30 minutes of awakening, by race/ethnicity and number of cigarettes
    smoked per day, National Health Interview Survey, United States, 1987

Characteristic

1-14 cigarettes
510 minutes
130 minutes

African Americans        Hispanics

%    KI+             %     WI



21.9      4.9            11.3     5.3
39.2     5.5            26.2      7.3

  Whites

%     WI



11.1     2.1
27.1     3.0

15-24 cigarettes
110 minutes           51.7     8.4            32.7     10.3          36.9     2.4
530 minutes           77.6      5.9            61.3     10.3           68.4     2.5

2 25 cigarettes
110 minutes           69.0     18.0           63.3     17.2          61.9     3.0
130 minutes           95.6      3.6           93.4      8.2          88.8     1.8
*Persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that
they currently smoked.
`95% confidence interval.
Source: National Center for Health Statistics, public use data tapes, 1987.

acknowledged that their study was limited somewhat
because the NHSDA indicators of dependence were
not based on diagnostic interviews designed specifi-
cally to assess DSM-IVTM criteria. Nevertheless, the
finding that whites were more likely to exhibit indica-
tors of dependence than African Americans was con-
sistent with that of Andreski and Breslau (1993). Fur-
ther research is needed to resolve the apparent dis-
crepancy for African Americans between studies that
are based on the number of minutes to the first ciga-
rette of the day and those that are based on DSM-IIP
or DSM-IVTM criteria for dependence.

  Navarro (1996) used population-based data from
the 1990 California Tobacco Survey on white (n =
70,997) and Hispanic (n = 28,000) adults. Her analy-
ses indicated that whites were significantly more likely
than Hispanics to smoke on a daily basis and to smoke
at least 15 cigarettes each day. Furthermore, among
the daily smokers, whites were more likely than
Hispanics to smoke a cigarette within 30 minutes of
awakening. Among Hispanics, those who were less
acculturated (i.e., who came from households where
the language spoken in the household was not English)
were significantly less likely than those who were more
acculturated (i.e., who came from households where
English was the language spoken) to be daily smokers
and to smoke at least 15 cigarettes each day. Among

Hispanics who were daily smokers, the percentage
who smoked within 30 minutes of awakening did not
differ significantly by level of acculturation.

  Smoking to maintain a lower body weight is be-
lieved to contribute to tobacco dependence. In a sur-
vey of high school students in Memphis, Tennessee,
Camp and colleagues (1993) found that more whites
than African Americans believed that cigarette smok-
ing could help them control their body weight. Among
the high school students who smoked, 39 percent of
white females and 12 percent of white males reported
smoking to control their body weight, compared with
none of the African American students.

  A few studies have analyzed the perceptions that
members of racial/ethnic groups have regarding the
addictive nature of tobacco. In a San Francisco area
study of 2,835 primary care patients who smoked,
Vander Martin and colleagues (1990) found that whites
smoked more cigarettes per day and were more likely
to consider themselves addicted to cigarettes than Af-
rican American, Asian American, and Hispanic smok-
ers. Smoking within 15 minutes of awakening was
least likely among Hispanic smokers but equally com-
mon among smokers in the other groups. In addition,
African Americans and Hispanics were less likely than
the others to believe that quitting smoking would lead
to weight gain.

182 Chapter 3

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

   Most Americans of all races and ethnicities real-
ize that cigarette smoking is addictive. In a survey of
2,092 adults in St. Louis and Kansas City, Missouri,
Brownson and colleagues (1992) found that a similar
number of whites (90.3 percent) and African Ameri-
cans (88.5 percent) believed cigarette smoking was
addictive. Results from the 1992-1993 CPS (see Chap-
ter 5, Research and Development Limitations) showed
that most members of the four racial/ethnic groups as
well as whites agreed with the statements that ciga-
rette smoking was an addiction or both a habit and an
addiction (Table 18) (U.S. Bureau of the Census, NC1
Tobacco Use Supplement, public use data tapes, 1992-
1993). Minor differences across gender were observed,
although smokers were somewhat less likely to agree
with the statements. Approximately 5 percent of the
Asian American and Hispanic smokers indicated that
cigarette smoking was neither a habit nor an addic-
tion, compared with 1.9 percent of white smokers.

Racial/Ethnic Differences in Quitting Smoking

  Because nicotine is addictive, highly addicted
smokers have great difficulty in quitting. Differences
in quitting can be used as another measure of the level
of dependence. Some studies have found that although
a similar percentage of whites and African Americans
have ever been smokers, the percentage of former
smokers has been greater among whites (26.4 percent)
than among African Americans (17.2 percent)
(Novotny et al. 1988) (see also Chapter 2). Data for
1989 from the BRFSS indicate that the standardized
prevalence of smoking cessation was 47 percent among
whites vs. 39.1 percent among African Americans
(prevalence of cessation was defined as the percent-
age of ever smokers who were former smokers) (CDC
1990). Similar findings were reported by Kabat and
Wynder (19871, Hahn and colleagues (19901, and
Geronimus and colleagues (1993). The 1991 NHIS
Health Promotion and Disease Prevention supplement
collected data on smokers who had quit for at least
one day at the time of survey and for at least one month
in the previous year (CDC 1993b). Hispanics (52.1
percent) and African Americans (48.7 percent) were
more likely than whites (40.3 percent) to have quit
smoking for one day. However, data on abstinence
from smoking in the previous year showed that His-
panics (16.3 percent) and whites (14.0 percent) were
more likely than African Americans (7.9 percent) to
have quit smoking for one month or longer. Thus,
African Americans were less likely than whites to

maintain abstinence. This effect remained after the
findings were controlled for socioeconomic status. In
an unadjusted analysis of data from the Current Popu-
lation Survey NC1 Supplement, a similar pattern
was observed, although the differences between Afri-
can Americans and whites were slight (see Table 2 and
African Americans, Quitting Behavior in Chapter 2).

  The lower smoking cessation rates among Afri-
can Americans do not appear to result from a lack of
desire to quit (Royce et al. 1993). In the COMMIT tele-
phone survey, 46.0 percent of African American
women and 44.4 percent of African American men
stated that they wanted to quit smoking "a lot," com-
pared with 35.0 percent of white women and 33.3 per-
cent of white men. Thus, the lower prevalence of
cessation among African Americans may be related
to factors other than the desire to quit, such as the
absence of culturally appropriate smoking cessation
interventions, difficulties in accessing community
resources for quitting smoking, and possibly a higher
level of nicotine dependence as indicated by compara-
tively higher levels of cotinine when the data are con-
trolled for the number of cigarettes smoked.

Addiction to Smokeless Tobacco

   Considerable nicotine is absorbed from smoke-
less tobacco. An average systemic dose of nicotine is
3.6 mg for snuff, 4.6 mg for chewing tobacco, and 1.8
mg for cigarettes (Benowitz et al. 1988). Blood nic-
otine concentrations throughout the day are similar
among smokers and those who use smokeless tobacco
(Benowitz et al. 1989a). Plasma cotinine levels in regu-
lar smokeless tobacco users are often similar to the lev-
els in cigarette smokers (Holm et al. 1992). Abstinence
from smokeless tobacco use results in signs and symp-
toms of nicotine deprivation that are similar to those
seen in smokers after they stop smoking (Hatsukami
et al. 1987; CDC 1994). These symptoms are reversed
by the use of tobacco or administration of nicotine
gum. In a study of Swedish oral snuff users, many of
the participants considered themselves addicted to
snuff, and they reported having as much difficulty giv-
ing up smokeless tobacco use as was reported by ciga-
rette smokers trying to quit smoking (Helm et al. 1992).
Evidence also suggests that when regular snuff users
are deprived of snuff, they will smoke cigarettes to
satisfy their need for nicotine (Benowitz 1992b). How-
ever, no data are available on racial or ethnic differ-
ences in the level of addiction to smokeless tobacco.

Health Consequences 183


Surgeon General's Report

Table 18.  Percentage of men and women who considered smoking a habit or addiction,* overall and by
    smoking status, Current Population Survey, United States, 1992-1993

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

Characteristic     %+  %I*      %    XI       %    XI      %    KI     %   4cI

Overall
Habit
Addiction
Both

Men
Habit
Addiction
Both
Women
Habit
Addiction
Both

Nonsmokers
Habit
Addiction
Both

Men
Habit
Addiction
Both
Women
Habit
Addiction
Both

Smokers
Habit
Addiction
Both

Men
Habit
Addiction
Both
Women
Habit
Addiction
Both

31.7    0.7     19.6    2.6      23.9    1.4     25.1   0.8    17.8   0.2
19.8    0.6      19.6    2.6      17.8    1.2     26.3   0.8    21.9   0.2
41.3   0.7     54.6    3.3      46.4    1.6     38.4   0.9    57.0   0.3

32.3    1.1      19.5    3.9      25.5    2.0     26.4   1.2    19.3   0.3
20.4    0.9     21.4    4.0      18.4    1.8     26.7   1.2    22.0   0.3
39.5    1.1     52.6    4.9      45.8    2.3     36.7   1.3    55.2   0.4

31.3    0.9     19.6    3.5      22.5    1.9     24.0   1.0    16.5   0.3
19.5    0.8      18.1    3.4      17.2    1.7     25.9   1.1    21.9   0.3
42.5    0.9     56.2    4.4      46.9    2.2     39.8   1.2    58.6   0.4

29.8    0.8      18.3    3.3      21.7    1.4     23.5   0.8    16.4   0.2
20.4   0.7     21 .l    3.5      18.9    1.4     27.1   0.9    23.0   0.3
42.9    0.8     54.6    4.2      47.5    1.8     39.4   1.0    57.7   0.3

30.3
20.5
41.6

1.3
1.1
1.4


1.0
0.9
1.1




1.4
1.1
1.4



2.0
1.7
2.0


1.9
1.5
1.9

19.8    5.3      22.2    2.2     24.6   1.3    18.0   0.4
22.4    5.5      20.2    2.1     27.9   1.4    22.8   0.4
51.4    6.6      48.1    2.6     38.0   1.5    56.1   0.5

29.6
20.3
43.7

17.3    4.2      21.3    1.9     22.7   1.1    15.0   0.3
20.2    4.5      17.8    1.8     26.5   1.1    23.1   0.4
56.8    5.5      47.0    2.4     40.4   1.3    59.0   0.4

36.6
18.6
37.2

21.5    4.4      36.0    3.9     32.7   2.0    22.1   0.5
17.5    4.0      12.3    2.7     22.6   1.7    18.9   0.4
54.4    5.3      40.9    4.0     34.1   2.0    55.2   0.6

36.4
20.2
35.1

19.4    5.9      36.6    4.7     32.3   2.5    22.9   0.7
20.5    6.1      12.6    3.2     23.3   2.3    19.7   0.6
53.6    7.5      38.3    4.7     32.8   2.5    53.0   0.8

36.7
17.2
39.0

23.7    6.4      34.6    7.1     33.2   3.1    21.2   0.7
14.4    5.3      11.5    4.8     21.4   2.7    18.1   0.6
55.2    7.5      47.0    7.5     36.1   3.2    57.3   0.8

*In response to the question, "Do you think smoking is a habit, an addiction, neither, or both?"
`Percentages in this table do not include all categories of responses and thus may not equal 100%.
*95% confidence interval.
Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
1992-1993.

I84 Chapter 3

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

Conclusions

1.  Cigarette smoking is a major cause of disease and
death in each of the four racial/ethnic groups stud-
ied in this report. African Americans currently
bear the greatest health burden. Differences in the
magnitude of disease risk are directly related to
differences in patterns of smoking.

2.  Although lung cancer incidence and death rates
vary widely among the nation's racial/ethnic
groups, lung cancer is the leading cause of cancer
death for each of the racial/ethnic groups studied
in this report. Before 1990, death rates from malig-
nant neoplasms of the respiratory system increased
among African American, Hispanic, and American
  Indian and Alaska Native men and women. From
1990 through 1995 death rates from respiratory can-
cers decreased substantially among African Ameri-
can men, leveled off among African American
women, decreased slightly among Hispanic men
and women, and increased among American Indian
  and Alaska Native men and women.

3.  Rates of tobacco-related cancers (other than lung
cancer) vary widely among members of racial/
ethnic groups, and they are particularly high
among African American men.

4.  The effect of cigarette smoking (as reflected by
biomarkers of tobacco exposure) on infant birth
weight appears to be the same in African American
and white women. As reported in previous Sur-
geon General's reports, cigarette smoking increases
the risk of delivering a low-birth-weight infant.

Appendix. Methodological Issues

5.

6.

7.

8.

No significant racial/ethnic group differences have
been consistently demonstrated in the relationship
between smoking and infant mortality or sudden
infant death syndrome (SIDS); cigarette smoking
has been associated with increased risk of SIDS
and remains a probable cause of infant mortality.

Future research is needed and should focus on how
tobacco use affects coronary heart disease, stroke,
cancer, chronic obstructive pulmonary disease, and
other respiratory diseases among members of
racial/ethnic groups. Studies also are needed to
determine how the health effects of smokeless to-
bacco use and exposure to environmental tobacco
smoke vary across racial/ethnic minority groups.

Persons of all racial/ethnic backgrounds are vul-
nerable to becoming addicted to nicotine, and no
consistent differences exist in the overall severity
of addiction or symptoms of addiction across
racial/ethnic groups.

Levels of serum cotinine (a biomarker of tobacco
exposure) are higher in African American smok-
ers than in white smokers for similar levels of daily
cigarette consumption. Further research is needed
to clarify the relationship between smoking prac-
tices and serum cotinine levels in U.S. racial/
ethnic groups. Variables such as group-specific
patterns of smoking behavior (e.g., number of
puffs per cigarette, retention time of tobacco smoke
in the lungs), rates of nicotine metabolism, and
brand mentholation could be explored.

  It is important to review some methodological
issues involved in collecting the data discussed in
this chapter. These methodological problems affect
the quality of the data and the type of conclusions
that can be reached from studies conducted to date.
Also, because cigarette smoking tends to be associated
with other lifestyle risk factors that impact on health
(e.g., Wingard et al. 1982; Vickers et al. 1990; Perez-
Stable et al. 19941, there is a need to control their
co-occurrence in order to better understand the
health effects of tobacco use.

Classification of Smoking Status

  In investigating the health effects of smoking
cigarettes and using other tobacco products, research-
ers typically obtain information from the subjects or
surrogate respondents on the use of such products.
Questionnaires usually cover cigarette smoking sta-
tus (i.e., never, former, and current smoker), number
of years of smoking and age at initiation of smoking,
number of cigarettes smoked per day, and use of other
tobacco products (e.g., pipes, cigars, and smokeless

Health Consequences 185


Surgeon Gerzeral `s Report

tobacco). However, this information may not be fully
valid, resulting in misclassification of exposure to ciga-
rette smoking. A previous report of the Surgeon Gen-
eral reviewed the classification of cigarette smoking
status and the consequences of misclassification
(USDHHS 1990).

  Misclassification of smoking information merits
consideration in investigating tobacco use among
racial/ethnic populations, because of the potential for
bias in comparing the effects of smoking across racial/
ethnic groups. To date, such bias has not been identi-
fied, although several studies show that Hispanics may
underreport cigarette smoking. In a population-based
survey in New Mexico, Coultas and colleagues (1988)
compared self-reports of smoking against salivary
cotinine level (a product of nicotine that has been used
as a measure of exposure to nicotine) and end-tidal car-
bon monoxide concentration. Based on the question-
naire results, the age-standardized prevalence rates of
current smoking were 30.9 and 27.1 percent for His-
panic men and women, respectively After adjusting
for cotinine and carbon monoxide levels, these percent-
ages were 39.1 and 33.2. The rate of misclassification
was greater in self-reported former smokers than in
never smokers, but self-reported never smokers also
had levels of cotinine and carbon monoxide indicative
of active smoking.

  Using information from the Hispanic Health and
Nutrition Examination Survey (HHANES), Perez-
Stable and colleagues (1992) documented the
misclassification of smoking status through compari-
sons of self-reports with serum cotinine levels. Among
65 Mexican American former smokers participating in
the HHANES in 1982 through 1983, 7 (10.8 percent)
had a cotinine level indicative of active smoking;
among 124 reported never smokers, 5 (4 percent) were
probably active smokers based on their cotinine lev-
els. In a number of surveys, Hispanics, particularly
Latin0 groups in the southwestern and western United
States, have been found to smoke about one-half pack
of cigarettes per day, compared with non-Hispanic
whites who typically report smoking one pack per day
(Coultas et al. 1994). Perez-Stable and colleagues (1992)
used data from 547 Mexican American participants in
the HHANES to examine underreporting of cigarette
consumption using the ratio of serum cotinine to
self-reports of the number of cigarettes smoked per
day as the "gold standard." This study found that
among Mexican Americans, 20.4 percent of men
and 24.7 percent of women who were self-reported
smokers underreported smoking between one and
nine cigarettes per day. Self-reported Mexican Ameri-
can smokers who reported smoking greater numbers
of cigarettes per day underreported less frequently.

  An analysis of the data from the Coronary
Artery Risk Development in (Young) Adults Study
(CARDIA) showed that there were higher rates of
misclassification in terms of self-reported nonsmok-
ers who had serum cotinine levels of at least 14 ng/
mL among African Americans (5.7 percent) than
among non-Hispanic whites (2.8 percent) (Wagen-
knecht et al. 1992). Alternative explanations for
underreporting, such as more efficient smoking and
differences in cotinine metabolism, could not be
excluded.

   Two additional studies examined the relation-
ship between ancestry of origin and levels of biochemi-
cal markers in smokers. In a study of participants in
CARDIA, African American smokers demonstrated
higher cotinine levels than non-Hispanic white smok-
ers after controlling for several dimensions of cigarette-
smoking behavior (Wagenknecht et al. 1990). Lactose
intolerance, which elevates breath hydrogen concen-
tration, may increase the apparent level of expired air
carbon monoxide, a readily measured marker of ac-
tive smoking (McNeil1 et al. 1990). Lactose intolerance
is common in a number of racial/ethnic groups, in-
cluding Asian Americans and African Americans.

Classification of Race/Ethnicity

  The data included in this chapter are derived
from diverse sources, including vital statistics, cancer
registries, and epidemiological studies on smoking.
Race/ethnicity has been classified in these studies us-
ing various techniques, including designation on death
certificate, classification according to cancer registry
protocols, self-reports, birthplace, language use, and
surname. The validity of each of these approaches is
undoubtedly imperfect; moreover, validity varies
across regions and over time. However, comprehen-
sive assessments of the validity of racial/ethnic mi-
nority classification in various types of health data
have not been reported.

   The limited information available indicates some
potential for misclassification. For example, Frost
and colleagues (1992) compared the classification of
"Native American," as recorded by the Seattle-Puget
Sound registry of the Surveillance, Epidemiology, and
End Results (SEER) Program against an Indian Health
Service (IHS) registry of patients eligible for services.
A substantial portion of patients with invasive cancer
in the IHS registry were not similarly classified
by the Seattle-Puget Sound cancer registry. Similarly,
an injury registry for the state of Oregon under-
counted those with injuries (Sugarman et al.
1993). Using data from the National Longitudinal
Mortality Study Sorlie and colleagues (1992) compared
demographic characteristics reported on the CI'S of the

186 Chapter 3

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

U.S. Bureau of the Census with those characteristics
reported on the death certificates for persons who died
(during a seven-year follow-up period). Among 216
persons identified as American Indians or Alaska
Natives by the CPS, only 159 (73.6 percent) were so
classified on the death certificate. Similarly, the con-
cordance rate for 272 persons classified by the CPS as
Asian Americans or Pacific Islanders was 82.4 percent.
Such disagreement suggests that current estimates of
mortality rates for selected racial/ethnic groups are
underestimated. However, in New Mexico, the classi-
fication of "American Indian" by the New Mexico Tu-
mor Registry, also a participant in the SEER Program,
closely corresponded with the classification by the
state's Bureau of Vital Statistics (Eidson et al. 1994).

  Another study in New Mexico also showed a
high concordance between self-reported Hispanic
race/ethnicity and the designation by the Bureau of
Vital Statistics (Samet et al. 1988bl. In the report by
Sorlie and colleagues (1993), 10.3 percent (n = 62) of
persons identified as Hispanics by the CPS were not
classified as Hispanics on the death certificate. Sur-
names also have been used to classify Hispanic
ethnicity, using either surname lists developed by the
U.S. Bureau of the Census or name recognition algo-
rithms (Howard et al. 1983; Wiggins and Samet 1993).
Although studies in parts of the southwestern United
States have shown a generally high validity for sur-
name-based approaches for identifying Hispanic
ethnicity, the sensitivity and specificity of the various
Census Bureau lists have varied over time, and data
from the Southwest cannot be readily generalized to
other locales. In addition, surname lists tend to ex-
clude women who marry non-Hispanic whites and
who take their husband's last name and to exclude as
well their children when given the father's non-
Hispanic last name (Marin and Marin 1991).

  These studies suggest that the validity of classi-
fication of race/ethnicity is likely to vary across loca-
tions and possibly by type of data. In interpreting
health data for racial/ethnic populations, consideration
should be given to the potential for misclassification
of race/ethnicity and the consequences of any result-
ing bias.

Classification of Health Outcomes

  Comparisons of disease occurrence among
racial/ethnic groups also may be biased by differen-
tial patterns of disease diagnosis and labeling by race
and ethnicity. Such differences may have multiple
causes that reflect the complex sequence that begins
with the development of symptoms and signs and ex-
tends to the labeling of an illness by a clinician or the
statement of cause-of-death on a death certificate.

Health beliefs and knowledge, ability to access and
pay for medical care, the quality of care available, and
differential patterns of care by race/ethnicity may all
affect diagnoses of illnesses. A full review of these top-
ics is beyond the scope of this report, but several ex-
amples are offered to illustrate the potential for differ-
ential patterns of classification of health outcomes by
race/ethnicity.

  Becker and colleagues (19901 examined the assign-
ment of underlying cause of death to the category
"symptoms, signs, and ill-defined conditions" in the
Mnnual of the International Classification of Diseases, Inju-
ries and Causes of Death (ICD). In the nation, the crude
death rate for this non-specific category has paralleled
the mortality rate in this category for African Ameri-
cans. Becker and colleagues (1990) analyzed vital statis-
tics data for New Mexico for 1958 through 1982 and
calculated mortality rates for "symptoms, signs, and
ill-defined conditions" by racial/ethnic group. The
state mortality rates for Hispanics, non-Hispanic
whites, and American Indians for this category ex-
ceeded the nationwide rates. Among the racial/ethnic
minority groups in New Mexico, American Indians had
particularly high mortality rates; for men, 8.4 percent
of American Indian deaths were in this category ver-
sus 5.9 percent of Hispanic deaths and 5.0 percent of
non-Hispanic white deaths. Similarly, mortality rates
for cancers of ill-defined and unknown primary sites
tend to be much higher in American Indians in several
areas of the country than for all racial/ethnic groups
combined (Valway 1992).

  Recent comparisons of the evaluation and man-
agement of chest pain and coronary artery disease in
African Americans and non-Hispanic whites further
illustrate the potential for bias by race/ethnicity in di-
agnostic classification. In a study of patients present-
ing to an emergency room with chest pain, African
Americans were less likely to be admitted and less
likely to be sent to a coronary care unit once they were
admitted (Johnson et al. 1993). The study also found
that African Americans were as likely as non-Hispanic
whites to have cardiac catheterization. In contrast,
other studies, using Department of Veterans' Affairs,
Medicare, and other large data bases, have shown that
African Americans are less likely than non-Hispanic
whites to have cardiac catheterization and invasive
interventions for coronary artery disease (Wenneker
and Epstein 1989; Udvarhelyi et al. 1992; Ayanian et
al. 1993; Franks et al. 1993; Whittle et al. 1993; Peterson
et al. 1994). These differential patterns of evaluation
by race/ethnicity could introduce bias in investigations
of tobacco smoking and coronary artery disease among
African Americans and non-Hispanic whites by
underestimating the effects of cigarette smoking on
coronary artery disease.

Health Consequences 187


Surgeon General's Report

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204 Chapter 3

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

Introduction 207

Historical Context of Tobacco  208

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

Economic Influences 213

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

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

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

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

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

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

Chapter Summary 239

Conclusions 240

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

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

References 245

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

Introduction

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

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

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

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

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

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

Factors That Inflllelrce Tobacco Use  207


Surgeon General's Repot9

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

Historical Context of Tobacco

African Americans

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

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

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

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

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

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

208 Cl1f7ptcr 4

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

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

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

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

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

American Indians and Alaska Natives

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

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

Factors That I~zflueme Tobacco Use  209


Surgeon General's Report

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

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

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

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

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

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

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

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

210 Clznpter 4

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

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

Asian Americans and Pacific Islanders

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

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

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

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

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

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

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

Factors That Influence Tobacco Use  211


Surgeon General's Report

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

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

Hispanics

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

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

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

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

212 Chapter 4

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

Economic Influences

Tobacco Industry Support for Racial/Ethnic
Minority Communities

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

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

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

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

Employment Opportunities

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

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

Factors That Influence Tobacco Use  213


Surgeon General's Report

discrimination and other factors (Northrup and Ash
1970).

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

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

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

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

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

Advertising Revenues

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

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

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

214 Chapter 4

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

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

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

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

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

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

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

Funding of Community Agencies and
Organizations

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

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

Factors That I@uence Tobacco Use  215


Surgeon General's Report

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

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

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

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

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

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

216 Chapter 4

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

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

Support for Education

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

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

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

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

Support for Political, Civic, and
Community Campaigns

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

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

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

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

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

Factors That Irzflr~e~zce Tobacco Use  217


Surgeolz General's Report

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

Support for Cultural Activities

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

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

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

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

218 Chapter 4

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

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

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

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

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

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

Support for Sports Events

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

Factors That Influence Tobacco Use  219


Surgeon General's Report

Advertising and Promotion

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

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

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

220 Chapter 4

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

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

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

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

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

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

Magazine Advertisements

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

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

Outdoor Advertisements

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

Factors That Inflllence Tobacco Use  221

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

In-Store Promotions

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

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

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

Racial/Ethnic Symbols, Names, and Events

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

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

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

222 Chapter 4

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

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

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

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

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

Targeted Products

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

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

Frzctors That Influence Tobacco Use  223


Surgeon General's Report

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

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

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

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

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

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

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

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

224 Chapter 4

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

Psychosocial Determinants

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

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

Initiation and Early Use of Tobacco

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

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

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

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

Factors That Influence Tobacco Use  225


Surgeon General's Report

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

African Americans

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

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

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

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

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

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

226 Chapter 4

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

American Indians and Alaska Natives

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

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

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

Asian Americans and Pacific Islanders

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

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

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

Factors That Influence Tobacco Use  227


Sllrgeon Genernl's Report

Hispanics

  Research on why Hispanics begin to smoke of-
ten is narrowly focused on subgroups, such as those
from a specific city or with a particular national back-
ground. Smith and colleagues (1991), using a cross-
sectional design, examined numerous potential factors
affecting cigarette smoking and intentions to smoke
among Puerto Rican teenagers in Boston, Massachu-
setts, and Hartford, Connecticut. Few statistically sig-
nificant associations were found. Among Puerto Rican
male adolescents, current cigarette smoking was asso-
ciated with greater acculturation, more close friends
who smoked, older age, and greater exposure to smok-
ing at recreational activities. Among female Puerto
Rican teenagers, the only factor associated with smok-
ing was having close friends who smoked. In this
study, the smoking status of parents had no effect on
teenagers' smoking behavior.

  Three studies have analyzed possible factors
associated with tobacco use among Hispanic youths
in the New York City area. Among Puerto Rican and
Dominican seventh graders (Bettes et al. 1990), the
researchers found that tobacco use was unrelated
to language use (a possible proxy variable for accul-
turation) but was significantly associated with nega-
tive self-esteem, lower psychological well-being,
higher psychological distress, and risk-taking. In a
subsequent study, Dusenbury and colleagues (1992)
examined possible factors associated with smoking
experimentation and current cigarette use among
New York City Hispanic youths aged lo-18 years. The
researchers found an almost identical set of significant
factors for both experimental and current use of ciga-
rettes. These predictors included being older; having
poor academic performance; having friends, parents,
and siblings who smoked; believing that smoking was
highly normative; and having parents with neutral or
favorable attitudes toward cigarette smoking. More
recently, Dusenbury and colleagues (1994) found that
among Hispanic sixth- and seventh-grade students in
New York City, those who smoked cigarettes tended
to be older and to have a greater proportion of friends
and relatives who smoked. They also found that
speaking both English and Spanish at home and with
friends (a behavior related to biculturalism) increased
these students' probability of smoking cigarettes.
Separate analyses for boys and for girls showed that
boys from bilingual homes were more likely to smoke;
however, this was not true among girls. Data from
two Southwestern cities indicate that a low level of
maternal education and low grades obtained in school
were associated with cigarette smoking among His-
panic youths (Schinke et al. 1992).

  Cowdery and colleagues (1997) analyzed cohort
data collected in the 1989 and 1993 Teenage Attitudes
and Practices Survey (TAPS) from a nationally repre-
sentative sample of Hispanic adolescents aged 15-22
years in 1993. They found that among Hispanic ado-
lescents, the most strongly associated risk factor for
smoking initiation was peer smoking. Additionally,
not reporting a dislike for being around smokers
and believing that smoking helps people relax and re-
duces stress were associated with an increased risk of
smoking among males and females. The belief that
smoking helps keep weight down was significantly
associated with smoking among females. Among
males, believing that there was no harm in an occa-
sional cigarette, that smoking reduces boredom, and
that smoking helps ease nervousness at social events
were all associated with an increased risk of smoking.
  School participation may be an important pre-
dictor of tobacco use among Hispanics because they
have the highest high school dropout rates of the ma-
jor racial/ethnic groups in the United States (Kaufman
and Frase 1990; Tomas Rivera Center 1993). Among
white youths, dropping out of high school is a distinct
correlate of cigarette use (Weng et al. 1988), but the
results are not as clear for Hispanics. Chavez and col-
leagues (1989) studied three groups of Mexican Ameri-
can respondents-a group of youths who had dropped
out of school, a group of youths at serious academic
risk of dropping out of school, and a control group-
from three Southwestern U.S. locations that varied in
population size. Among Mexican American male
youths, those at risk of dropping out of school and
those who had dropped out of school had a higher
prevalence of cigarette use but a lower prevalence of
smokeless tobacco use than the control group. No sig-
nificant differences in tobacco use were found among
the three groups of Mexican American female youths.
Watts and Wright (1990) compared Mexican Ameri-
can adolescents in Texas who were incarcerated with
those who were attending high school and found that
both minor delinquency and violent delinquency were
significantly associated with tobacco use.
  The results from a recent study by Felix-Ortiz and
Newcomb (1992) provide additional insights into the
variables related to smoking among Hispanic adoles-
cents.  The researchers assessed risk factors and
protective factors as predictors of both the frequency
of cigarette smoking and the quantity of cigarettes
smoked. Multiple regression analyses showed that
among Hispanic boys (but not among girls), risk
factors such as low academic achievement, low law
abidance, low religiousness, and high level of depres-
sion significantly predicted both the quantity of

228 Chapter 4

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

cigarettes smoked and the frequency of smoking. In a
more recent study, Felix-Ortiz and Newcomb (1995)
found that neither familiarity with Hispanic culture
nor familiarity with the larger U.S. culture was directly
associated with tobacco use among boys and girls.
Among Hispanic boys, cigarette use was associated
with less respeto-a cultural value that grants preroga-
tives to adults and others with social power and that
refers to a sense of personal self-worth. Among
Hispanic girls, cigarette use was related to more in-
volvement in Hispanic groups and political activities.
A significant interaction was found between English-
and Spanish-language proficiency (usually considered
a proxy measure of acculturation) and frequency of
cigarette smoking among both boys and girls. For
example, Hispanic youths with poor English- and
Spanish-language skills had the highest frequency of
cigarette use, whereas those with poor English-
language skills but strong Spanish-language skills re-
ported the lowest frequency of cigarette use. Hispanic
youths with strong English-language skills had mod-
erate levels of cigarette smoking frequency, regardless
of their degree of Spanish-language proficiency.

  Another study of 1,411 females of Latin0 origin
(Latinas) found differences in knowledge and percep-
tions about cigarette smoking between Spanish-
language and English-language/bilingual young
women (Campbell and Kaplan 1997). In this study,
Latinas who either spoke English or were bilingual
were less likely than their counterparts who spoke only
Spanish to acknowledge the danger associated with
smoking an occasional cigarette or to recognize the
difficulty in quitting smoking, were more likely to
identify beneficial aspects of smoking, and were more
likely to consider smoking socially.

  For many Hispanic youths, adaptation to life in
the United States may produce psychological stress and
anxiety. Whether these factors are directly associated
with smoking among Hispanic youth is not known. In
a recent study of migrant adolescents in the San Diego,
California, area, Lovato and colleagues (1994) reported
that respondents' level of acculturation was not related
to cigarette smoking or alcohol use, even though the
more acculturated adolescents were more likely to en-
gage in binge drinking. Acculturation remains a strong
theoretical consideration in smoking initiation, but
current findings are limited by the methodological
issues previously cited. In addition, a variety of accul-
turation measures have been used, and these have
intrinsic limitations for assessing the cultural learning
process (Marin 1992). Interpretation is particularly
problematic when researchers use proxy measures such
as language proficiency to measure complex psycho-

social processes like acculturation. The existence of
multiple cultures within Hispanic communities adds
to the complexity of this issue, as is also the case in
Asian American communities.

Multiple Group Studies

   Several studies have examined initiation and
early use of tobacco among more than one racial/eth-
nic group and have compared data within and among
these groups. Some of these studies have concentrated
on analyzing the prevalence of perceived risk factors
commonly associated with tobacco use, and other stud-
ies have addressed the question of what differentiates
smokers from nonsmokers.

   CDC and 13 universities conducted research in a
collaborative partnership that involved a series of
focus groups and in-depth interviews among African
American, American Indian, Asian American and
Pacific Islander, Hispanic, and white teenagers. The
purpose of the research was to assess differences in
the functional value of smoking, the images associated
with and social norms that surround smoking, and the
messages that youths report receiving about smoking.
The universities used common methodologies, proto-
cols, definitions, and coding schemes for transcripts
of focus groups and interviews. Preliminary findings
of this research are that (1) young smokers know about
the addictive nature of nicotine; (2) smoking is viewed
as "cool" and "grown up"; (3) smoking derives func-
tional value from group belonging and stress
management; (4) among girls, notions of "respect" and
"reputation" are influential for nonsmoking in some
groups; and (51 parental messages about smoking vary
by race/ethnicity, but African American and Hispanic
parents give clearer messages about not smoking than
parents in other groups. Other emerging issues noted
in this analysis are that (1) smoking is not seen as im-
age enhancing among African American girls;
(2) African Americans were more likely to pair ciga-
rette smoking with marijuana to maintain a "high";
(31 parental smoking is a negative influence, particu-
larly among American Indian families; and (4) varia-
tion exists among the racial/ethnic groups with regard
to the media channels through which messages are
received (Mermelstein et al. 1996).

Prevalence of Risk Factors for Cigarette Use

  Several studies have analyzed how possible risk
factors for tobacco use differ among youths in various
racial/ethnic groups. For instance, in a study of Los
Angeles County students in grades seven through

Factors That I@uence Tobacco Use  229


Surgeon General's Report

nine, Maddahian and colleagues (1986) found that
African American adolescents reported having the
highest number of friends who provided cigarettes,
followed by white, Hispanic, and Asian American ado-
lescents. Perceived ease in acquiring cigarettes was
highest among white adolescents and lowest among
Asian American adolescents; Hispanic and African
American adolescents reported moderate ease in ac-
quiring cigarettes. In assessing how earned income
vs. allowance income related to cigarette use, the re-
searchers found that Asian American and white ado-
lescents reported having a higher earned income than
adolescents in the other two racial/ethnic groups; in
comparison, Hispanic and African American adoles-

cents reported receiving more allowance income than
Asian American or white adolescents. Maddahian and
colleagues (1988) subsequently found that African
American and Hispanic youths reported greater inten-
tion to use cigarettes than white and Asian American
youths. In a more recent study, involving northeast-
ern U.S. youths in grades six through eight,
Vanderschmidt and colleagues (1993) found that physi-
cal violence and sexual activity were the risk behav-
iors most highly associated with smoking among
African American, Hispanic, and white students.

  Smoking-related perceptions and risk factors
also differ among older youths of different racial/
ethnic backgrounds. In a study of high school seniors

Table 1.  High school seniors' perceptions about the risks associated with cigarette smoking, Monitoring the
    Future surveys, United States, 1980-1989

Perceived risks                    Gender

African
Americans

%    N*

American
Indians

%    N*

Percentage who believe that people
take a great risk of harming them-
selves if they smoke one or more
packs of cigarettes per day

Male        68.4 1,586          52.5    221
Female       71.0 1,901          63.5    181

Percentage who believe that people
disapprove or strongly disapprove
of people aged 18 years and older
smoking one or more packs of
cigarettes per day

Male        77.6 1,717          64.1    220
Female       80.4 2,076          63.1    210

Percentage who think their close
friends disapprove or strongly
disapprove of their smoking one
or more packs of cigarettes per day

Male        75.4 1,193          65.2    179
Female        80.5  1,610          69.1    155

Percentage who report that none vs.
most or all of their friends smoke
cigarettes

None                         Male          17.1  1,340          12.8   200
                           Female        19.9  1,807          11.0   184

Most or all                     Male          19.0  1,340          30.0    200
                           Female        18.7  1,807         36.8    184

*The number of respondents (N) varied for each question. Each of the numbers (N) reported represents the
total number of students who were asked a particular question, not the number of students who responded
affirmatively.

230 Chapter 4

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

participating in the MTF between 1980 and 1989,
Wallace and Bachman (1993) found that American In-
dians, both males and females, were less likely than
students in other racial/ethnic groups to perceive that
smoking one or more packs of cigarettes per day posed
a great risk to their health (Table 1). The perception
that friends and people in general disapproved of
smoking one or more packs of cigarettes per day was
least prevalent among male and female American
Indian high school seniors and most prevalent among
female Asian American seniors. Finally, the percent-
age of students who reported that most or all of their
friends smoked cigarettes was highest among Ameri-
can Indian seniors and lowest among Asian American
seniors.

Factors Associated with Initiation of Cigarette Use

  Numerous researchers have assessed patterns of
cigarette use initiation among young people of vari-
ous races/ethnicities. For example, Botvin and col-
leagues (1994) studied potential predictors of cigarette
smoking onset among seventh graders in six New York
schools within low-socioeconomic communities. Ap-
proximately 50 percent of the children were African
American, and 36 percent were Hispanic. Statistically
significant predictors for ever smoking included the
absence of one or both parents, low grades in school,
high prevalence of smoking among friends, and a sense
of hopelessness. The data were not analyzed sepa-
rately by race/ethnic@.

Asian             Mexican          Puerto Ricans and
Americans          Americans          Latin Americans

%    N*           %    N+            %      N*

Whites

%     N*

67.6   309          69.7   456          66.2     228          64.0   11,266
71.8   307          67.1   477          64.2     241          66.6   11,764

80.4   350          77.3   486          82.7     280          77.1   11,970
85.6   311          81.2   477          82.2     258          70.0   12,459

77.0   277          76.3   335          77.1     163          73.1   10,346
81.7   270          80.2   414          79.0     165          73.6   11,163

19.1   298          14.3   429          10.9     185          11.6   11,226
29.6   274          17.2   439          12.4      213           9.9   11,760

12.8   298          16.9   429          19.5     185          19.3   11,226
11.4   274          17.4   439          21.9     213          25.4   11,760

Source: Adapted from Wallace and Bachman 1993.

Factors That Influence Tobacco Use  231


Surgeon General's Report

  In assessing differences among racial/ethnic
groups, Koepke and colleagues (1990) compared 14 po-
tential predictors of cigarette smoking onset among
seventh- through ninth-grade African Americans, Asian
Americans and Pacific Islanders, Hispanics, and whites
from Los Angeles and San Diego, California. The re-
searchers found that most variables were not related to
smoking onset among any of the racial/ethnic groups,
and no single factor was a statistically significant pre-
dictor among all four groups. Greater anger increased
the likelihood of smoking onset for African American
and Hispanic youths but was unrelated to smoking on-
set for Asian American, Pacific Islander, and white
youths. The number of close friends who had tried ciga-
rettes was a significant predictor of smoking onset for
Hispanic, Asian American, and Pacific Islander youths
but not for African American or white youths. These
studies underscore the variability of predictors among
groups.

  Peer influences also were identified in a study of
sixth and seventh graders in San Diego. Elder and
colleagues (1988) found that white girls, African Ameri-
can boys, and Asian American boys who believed that
a large number of their peers smoked cigarettes were
more likely to experiment with smoking. When ac-
tual continued use of cigarettes was considered, the
normative belief (that a large proportion of their peers
smoked) predicted cigarette smoking for Hispanic
boys and for white boys and girls. These normative
perceptions were most strongly associated with experi-
menting with chewing tobacco among white boys and
girls and Asian American boys. Other studies also
have found that peer smoking had a significant effect
on cigarette smoking initiation. Sussman and col-
leagues (1987), for example, examined predictors of
cigarette smoking among Southern California adoles-
cents in Los Angeles and Orange Counties and found
that peer pressure to smoke was not a predictor of
smoking, although peer cigarette use was a critical
predictor for Asian Americans, Hispanics, and whites
(but not for African Americans). In this same study,
parental pressure to smoke and knowledge of the
health consequences of smoking were not associated
with smoking for any group. On the other hand, three
variables were statistically significant predictors for
all four groups-general availability of cigarettes,
difficulty in refusing offers to smoke, and intent to start
smoking. The strongest predictors of cigarette smok-
ing were different for each racial/ethnic group: for
white youths, adult and peer models of smoking
were the strongest predictors; for Hispanic youths, self-
image as a smoker and adult or peer approval of
smoking were the strongest predictors; for African

American youths, preference for risk-taking was the
strongest predictor; and for Asian American youths,
low self-esteem and poor achievement in school were
the strongest predictors.

  Castro and colleagues (1987) also found that peer
smoking behaviors were significantly correlated with
cigarette smoking among African American, Asian
American, Pacific Islander, Hispanic, and white teen-
agers in Los Angeles County. Disruptive family events
(e.g., number of relocations) were significantly corre-
lated with cigarette smoking among Asian American,
Pacific Islander, and white youths but not among
African American and Hispanic youths. In addition,
law abidance, liberalism, and religiousness were sig-
nificantly associated with less frequent cigarette smok-
ing among African American, Asian American, Pacific
Islander, and white youths but were associated with
more frequent cigarette smoking among Hispanics. A
more recent study (Landrine et al. 1994) has found that
although cigarette smoking among peers is a good pre-
dictor of cigarette smoking among white adolescents, it
is a less powerful predictor of cigarette smoking among
African Americans, Asian Americans, and Hispanics.

  The role of personal psychological characteris-
tics in predicting cigarette smoking has also been stud-
ied in a multiracial/multiethnic setting. Among
seventh graders in New York City, Bettes and
colleagues (1990) found that certain psychosocial
variables-negative self-esteem, positive self-esteem,
psychological distress, psychological well-being, and
risk-taking-had no differential effect on tobacco use,
except that psychological well-being and high risk-
taking were found to be particularly protective for
African American seventh graders.

Factors Associated with Initiation of Smokeless
Tobacco Use

  Riley and colleagues (1991) found that among
African Americans, American Indians, and whites, self-
reported use of smokeless tobacco was associated with
the perceived consequences of use, the use of alcoholic
beverages and cigarettes, peers' use of smokeless to-
bacco, beliefs about the health consequences of smoke-
less tobacco use, and level of perceived control over
one's own health. The strongest predictors for all
groups were previous use of alcoholic beverages and
tobacco and peers' use of smokeless tobacco. Perceived
negative consequences were considered most impor-
tant among American Indians and whites. For Afri-
can Americans and American Indians, the strongest
predictor of the amount of smokeless tobacco used was
previous use of alcoholic beverages and cigarettes. For

232 Chapter 4

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

whites, the strongest predictor of the amount of smoke-
less tobacco used was peers' use of smokeless tobacco.

Summary, Initiation and Early Use of Tobacco

  The limited number of studies renders the results
fragmentary, but some general findings emerge.
Certain categories of variables-sociodemographic,
environmental, behavioral, personal, and psychologi-
cal-may be related to tobacco use initiation and con-
tinued use among youths of various racial/ethnic
minority groups. Some of these categories of variables
may predict initiation of tobacco use for all people,
regardless of their race/ethnicity (USDHHS 19941, but
the predictive strength of these variables likely differs
across racial/ethnic groups. Because of the method-
ological problems previously mentioned, the summa-
rized findings are not comparable across racial/
ethnic groups; these findings are meant to suggest a
pattern rather than to convey a body of evidence.
Future research must establish the strength of various
predictors by using comparable and culturally appro-
priate measurements. In addition, several important
predictors of tobacco use among racial/ethnic youth
and the environmental factors surrounding it have not
been thoroughly researched. One such example is the
role of tobacco advertising, which has been shown to
affect a number of risk factors related to smoking ini-
tiation, such as perceptions about the pervasiveness
of cigarette smoking, its social acceptability, its dan-
ger, and its function in social situations (USDHHS
1994). Finally, the relative strength of a community's
tobacco control infrastructure may influence behav-
iors and policies about tobacco and the tobacco indus-
try. Robinson and colleagues (1995) suggested that this
fact should be considered in assessments of initiation
and early use of tobacco products.

Tobacco Use Among Adults

  The factors associated with tobacco use among
adult members of racial/ethnic groups have been stud-
ied even less than those among young people. Few
studies have analyzed tobacco use among adult Ameri-
can Indians, Alaska Natives, Asian Americans, or
Pacific Islanders, and only limited information is avail-
able on predictors of continued tobacco use among
African Americans and Hispanics.

and stress in a sample of adult African Americans in
the San Francisco and Oakland areas of California.
African American men and women who reported high
levels of stress were more likely to smoke than those
reporting fewer stressful conditions. The role of stress
in cigarette smoking among adult African Americans
also has been supported by the findings of Feigelman
and Gorman (1989) and Ahijevych and Wewers (1993).
In a national sample of adults interviewed for the 1987
General Social Survey, Feigelman and Gorman (1989)
found that the highest proportion of smokers were
African Americans who were exposed to high levels
of stress and who had a low level of occupational pres-
tige. In comparison, whites with low stress and high
occupational prestige had the lowest proportion of
smokers. African American women with underdevel-
oped social networks were also more likely to smoke
than those with strong social support. The role of so-
cial support was not statistically significant for Afri-
can American men. In fact, African American men who
appeared to have little emotional support from friends
or family were less likely to smoke than African Ameri-
can men who had such support.

American Indians and Alaska Natives

  Hodge and colleagues (1996) studied adult
American Indian patients in Northern California. The
sample included members of the Hupa, Maidu, Pit
River, Porno, and Yurok Tribes of California as well as
a number of Sioux Indians. The researchers found few
differences in the type and amount of social support
experienced by American Indian smokers and non-
smokers. In the urban areas of San Francisco and San
Jose, American Indians who reported high levels of
stress were more likely to be current smokers than
those who reported lower levels of stress. American
Indians living in urban areas also reported being more
motivated to quit than those in rural areas.

  In a study of 614 American Indian women (East-
ern Band Cherokee) in western North Carolina,
Spangler and colleagues (1997) found several corre-
lates with higher prevalence of current smoking, in-
cluding younger age, alcohol use, no yearly physical
examination, marital status of separated or divorced,
lack of friends, and lack of church participation.
Having a lower level of education and having con-
sulted an Indian healer were correlated with higher
smokeless tobacco use.

African Americans

  Roman0 and colleagues (1991) examined the
association between cigarette smoking, social support,

Factors That Influence Tobacco Use  233


Asian Americans and Pacific Islanders

  In a study of adult male Vietnamese refugees liv-
ing in the San Francisco area, Jenkins and colleagues
(1990) found that cigarette smoking was significantly
related to having immigrated to the United States
within the previous nine years, not knowing that smok-
ing causes cancer, having an income below the federal
poverty level, and having limited proficiency in
English. No significant associations were found
between men's cigarette smoking and education,
alcohol use, marital or employment status, health con-
dition, or age. In another study, conducted between
1989 and 1991 (CDC 1992), cigarette smoking among
Chinese, Vietnamese, and Hispanics in California was
associated with an annual income of less than $25,000,
a high school education or less, recent immigration to
the United States, and limited proficiency in English.
  In a survey of Southeast Asian men-primarily
Cambodian, Laotian, and Vietnamese-Chen and col-
leagues (1993) found that compared with former smok-
ers and persons who had never smoked, smokers were
more likely to have limited proficiency in English, to
be more traditional (less acculturated), and to report
that almost all of their five best friends were smokers.
Only about one-third of the men surveyed had heard
that cigarette smoking may cause heart disease. In
addition, Chen and colleagues observed no statistically
significant differences in the knowledge of smoking
danger reported by smokers, former smokers, or per-
sons who had never smoked.

  In a survey of 832 Cambodian, Vietnamese, and
Laotian men in Ohio, Moeschberger and colleagues
(1997) found that the odds of never smoking and of
being a former smoker were significantly higher
among men who were employed than among those
unemployed. In addition, current smokers were more
likely than nonsmokers to be traditional or bicultural,
whereas men who had assimilated into U.S. culture
were four times as likely to have quit.

Hispanics

  The literature on correlates of cigarette smoking
among Hispanic adults is more substantive than that
for the other racial/ethnic minority groups. These
studies permit exploration of the interaction of cultural
pride and acculturation with other correlates of ciga-
rette smoking (Marin et al. 1989a; Castro et al. 1991)
and drug use among Hispanics (see Chapter 2).

The possible relationship between symptoms of
depression and cigarette smoking was investigated by
Perez-Stable and colleagues (1990), who examined the
association between smoking status (i.e., current smok-

ers, former smokers, and those who had never smoked)
and depressive symptoms in a random sample of 551
Hispanics in San Francisco. After controlling for gen-
der, acculturation, age, education, and employment
status, significant differences in depression (as mea-
sured by the Center for Epidemiological Studies De-
pression [CES-Dl Scale) remained between current
smokers and nonsmokers (both former smokers and
lifetime abstainers). Current smokers had a 70 per-
cent greater risk for having depressive symptoms than
persons who had never smoked. A recent study that
used data from the HHANES identified an association
between patterns of smoking initiation and depressed
mood, a history of major depression, or both (Escobedo
et al. 1996). The belief that cigarette smoking reduces
tension has been identified as a potent reason for smok-
ing, according to researchers studying Hispanics from
South America and the Caribbean who live in the New
York City area (Larino et al. 19931, as well as Mexican
Americans in San Francisco (Marin et al. 1989a).
  To identify additional correlates of tobacco use
among adult Hispanics, Lee and Markides (1991) com-
pared three age groups of adults in a sample of Mexi-
can Americans in the Southwestern United States who
were interviewed between 1982 and 1984 as part of
the HHANES. Among Mexican Americans aged
20-39 years, being a smoker was associated with the
increased consumption of alcohol for both men and
women, with poorer health for men, and with more
depressive symptoms for women. Among Mexican
American men aged 40-59 years, those who smoked
cigarettes also consumed more alcohol than those who
did not smoke. Among Mexican American women
aged 40-59 years, those who smoked cigarettes also
consumed more alcohol and had lower diastolic blood
pressure, lower body mass, and more depressive
symptoms than those who did not smoke. Among
Mexican Americans aged 60-74 years, men who
smoked were more likely to consume alcohol and cof-
fee and to have lower body mass than men who did
not smoke; women who smoked were also more likely
to consume coffee and alcohol than those who did not
smoke. A Mexican American subsample of the
HHANES showed that cigarette smoking was associ-
ated with the presence of other smokers at home or at
the workplace and with the respondent's level of
acculturation (Coreil et al. 1991). These data also
showed that cigarette smoking status was not related
to educational level or to employment status but that
age was positively associated with the number of
cigarettes smoked per day among younger men and
women aged 20-39 years. A study of Hispanic
adults in New Mexico (Samet et al. 19921 found a rela-
tionship between low levels of formal education and

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

prevalence of cigarette smoking. Low socioeconomic
status, often indicated by education, was also related
to cigarette smoking in that study.

   A number of studies conducted in San Francisco
have compared the psychosocial characteristics of His-
panic smokers with those of white smokers. These
studies provided an understanding of culture-specific
differences in attitudes, norms, and expectancies of
smokers and served as the basis for developing a
culturally appropriate smoking cessation interven-
tion-Programa Latin0 Para Dejar de Fumar (Hispanic
Program to Quit Smoking) (see Chapter 5). In one such
study (Marin et al. 1990a), Hispanic smokers were sig-
nificantly more concerned than white smokers about
harming their children's health. White smokers,
on the other hand, were significantly more con-
cerned than Hispanic smokers about burning holes in
their clothes and feeling controlled by the need to
smoke. White smokers were more likely than Hispanic
smokers to view other smokers as friendlier and more
sociable, aggressive, attractive, and feminine than non-
smokers (Marin et al. 1989b). More acculturated
Hispanics provided responses that more closely
resembled the responses of whites than the responses
of less acculturated Hispanics (Marin et al. 1989b).
Acculturation also was found to affect an individual's
willingness to quit smoking on the basis of advice from
his or her parents and physicians. Similarly, in a New
York City area survey of 88 Hispanics who expressed
interest in quitting cigarette smoking, Mahony and
colleagues (1993) found that their reasons for smok-
ing differed by their level of acculturation.

Summary, Tobacco Use Among Adults

   A few variables have been associated with the
continued use of cigarettes among adults from racial/
ethnic groups. Cigarette smoking among members of
the four racial/ethnic groups seems to be associated
with depression, psychological stress, and environ-
mental factors such as tobacco advertising and pro-
motion and the influence of peers who smoke. The
high levels of stress among members of the four
racial/ethnic groups may be the product of such fac-
tors as low-prestige jobs; poverty; difficulties associ-
ated with living in a new environment or culture;
limited proficiency in English; prejudice and discrimi-
nation; pressures to acculturate; limited free time; and
multiple demands on time related to jobs, substandard
housing, and the care of small children. Smoking ces-
sation programs directed at members of these racial/
ethnic groups should address stress reduction in
the same way that tobacco prevention and control strat-

egies should consider the historical context of tobacco
and the tobacco industry in the community and
cultural differences among racial/ethnic minority
communities.

  These data also indicate that Hispanic smokers
have expectations and attitudes related to cigarette
smoking that differ from those of white smokers-a
finding that supports the need for culturally appro-
priate cessation interventions. Future studies should
determine if similar differences in expectancies and
attitudes exist among smokers of the other three
racial/ethnic groups considered in this report. The
limited data available support the need for more and
better designed studies of tobacco use among mem-
bers of the various racial/ethnic groups.

Smoking Cessation

  Little is known about the psychosocial factors
that influence cigarette smoking cessation among
members of racial/ethnic groups. Although people's
level of addiction is an important determinant of
whether they will successfully stop smoking, limited
information is available on patterns of addiction
among members of various racial/ethnic groups. (For
more information on patterns of addiction, see Chap-
ter 3. For details about other variables that affect smok-
ing cessation, such as smoking patterns and access to
culturally appropriate cessation services, see Chapters
2 and 5.)

African Americans

  Knowledge about the damaging effects of smok-
ing can be an important motivator of smoking cessa-
tion (Orleans et al. 1989; Jepson et al. 1991; also see
Chapter 5). Studies of African Americans' knowledge
about the health consequences of tobacco smoking
have produced contradictory findings. Klesges and
colleagues (1988), for example, interviewed African
American and white adults in Fargo, North Dakota,
and Memphis, Tennessee, and found that proportion-
ately more whites than African Americans knew that
cigarette smoking was related to heart attacks, emphy-
sema, premature births, and skin wrinkles. Similarly,
Vander Martin and colleagues (1990) found that Afri-
can Americans from the San Francisco Bay area who
smoked cigarettes were less concerned about the health
effects of cigarette smoking than were whites who
smoked. African Americans also were less likely to
believe that cigarettes were addictive, produced harm-
ful health effects, or caused heart attacks.

Factors That Influence Tobacco Use  235


Surgeon General's Report

  Conversely, in a 1990 study in St. Louis and Kan-
sas City, Missouri, Brownson and colleagues (1992)
found that about the same percentage of AfricanAmeri-
cans and whites believed that smoking was harmful
to people's health. Although African Americans
recognized the harmful effects of environmental to-
bacco smoke (ETS), they tended to minimize some of
the health effects of smoking, particularly its link with
heart disease. Similarly, an ABC News/The Washing-
ton Posf survey conducted in February 1993 found that
a large proportion of African American and white
adults perceived ETS to be a health risk (Roper Center
for Public Opinion Research 1993). In that poll, how-
ever, a greater proportion of African Americans than
whites reported that they worried a great deal about
ETS. In studies limited to African Americans, research-
ers have reported differences based on smoking sta-
tus. Warnecke and colleagues (1978) interviewed Afri-
can American women in Buffalo, New York, and found
that current smokers were less likely to say they be-
lieved that cigarette smoking was related to a variety
of conditions, including cancer and heart disease, than
were former smokers or persons who had never
smoked.

  Most African American smokers want to quit,
and many have tried. In a 1986 study of African Ameri-
can smokers who were policyholders of the North
Carolina Mutual Life Insurance Company, Orleans and
colleagues (1989) found that 79.3 percent of respon-
dents had tried to quit smoking at least once in their
lifetime. Hoffman and colleagues (1989) found that
most of the patients in a general community hospital
in Chicago who smoked reported previous attempts
to quit on their own, and 65 percent wanted to stop
smoking immediately. More than two-thirds of these
African American smokers indicated that they would
like a formal program to help them quit smoking. In a
more recent survey, Ahluwalia and McNagny (1993)
found that among all African American patients visit-
ing a county-operated health facility in Atlanta, Geor-
gia during a three-week period, 86 percent of the
smokers wished to quit. Ninety-nine percent of those
who wanted to quit smoking indicated they would par-
ticipate in a smoking cessation program even if it in-
volved visits to the hospital. According to data from
the 1993 NHIS (CDC 1994b), 71.4 percent of African
Americans aged 18 years or older who currently
smoked were interested in quitting.

  Royce and colleagues (1993) used a sample
drawn from metropolitan communities in California,
New Jersey, New York, and North Carolina as part of
the Community Intervention Trial for Smoking Ces-
sation (COMMIT) project and found that more Afri-
can Americans than whites reported a strong desire to

quit smoking and more attempts to quit in the past
year. These researchers also observed that a larger
percentage of African Americans than whites reported
a need to smoke within 10 minutes of awakening (a
behavioral symptom of nicotine dependence), even
after the analysis controlled for age, education, and
gender. In the San Francisco Bay area study by Vander
Martin and colleagues (1990), African American adult
smokers were more interested in quitting smoking than
were white adult smokers and were also more confi-
dent that they could successfully quit.

  When smoking cessation trends are compared, a
different pattern emerges by gender. Hahn and col-
leagues (1990) found a slightly higher proportion of
white women in Minneapolis and St. Paul (33 percent)
than of African American women (29 percent) who
reported trying cigarettes with lower levels of tar and
nicotine in the previous year, and a higher proportion
of white men (63 percent) than African American
men (52 percent1 reporting that they had tried to quit
smoking.

  In their study of African American women in
Buffalo, New York, Warnecke and colleagues (1978)
found that many women who had quit smoking
attributed their quitting to the fact that cigarette smok-
ing causes cancer (44 percent) or other diseases
(45 percent); to physical side effects such as coughing
or headaches (36 percent); or to negative cosmetic ef-
fects such as bad breath, stained teeth, or bad smell
(34 percent). More recently, in a series of eight focus
group discussions with African American women
smokers residing in Chicago public housing develop-
ments, respondents said that quitting was difficult for
them because they lived in a highly stressful environ-
ment that made it difficult to manage their personal
lives (Lacey et al. 19931. Cigarette smoking was one of
the few pleasures available to them in such an envi-
ronment, and the women had few if any sources of
information on how to quit smoking. In addition, these
women tended to believe that cigarette smoking posed
minimal health risks, that the behavior was quite com-
mon among other adults, and that all that was needed
to quit was the willingness to do it. In a study of ur-
ban pregnant women, O'Campo and colleagues (1992)
found that the only predictor of quitting smoking
during pregnancy for African American women was
intention to breast-feed, whereas among white women,
the best predictors were educational level, age, and
parity About 46 percent of African American women
who quit smoking during pregnancy relapsed within
6-12 weeks after delivery Formula feeding of the in-
fant was the best predictor of postpartum smoking
relapse for both African American and white mothers.

236 Chapter 4

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

American Indians and Alaska Natives

  Few studies have focused on smoking cessation
among American Indians, and no studies have ad-
dressed smoking cessation trends among Alaska Na-
tives. In a survey of American Indians in Northern
California, respondents were found to have fairly high
levels of information regarding the health effects of
cigarette smoking (Hodge et al. 1994). For example, a
similar proportion of urban (94 percent) and rural (91
percent) American Indian smokers knew that smok-
ing during pregnancy would harm the fetus. Although
American Indian smokers were as knowledgeable as
nonsmokers regarding the health effects of cigarette
smoking, attitudes about smoking differed between the
two groups. American Indian smokers were more
likely than nonsmokers to think that it is acceptable to
smoke and chew tobacco, to permit the advertising of
tobacco products, to let visitors smoke in one's home,
and to allow smoking in restaurants. In addition,
American Indian women who smoked reported a
greater number of depressive symptoms (as measured
by the CES-D) than nonsmoking women. However,
researchers observed no differences in the number of
depressive symptoms among men who smoked com-
pared with men who did not smoke. A fairly large
number of American Indians reported that they were
not interested in quitting (45 percent of residents in
urban areas and 55 percent of residents in rural areas).
In the 1993 NHIS, however, 65.0 percent of American
Indian or Alaska Native smokers aged 18 years or over
reported that they wanted to quit smoking cigarettes
completely (CDC 199413). In another study of current
smokers who were patients at Indian health clinics,
Lando and colleagues (1992) found that the most com-
monly mentioned reasons for relapse were cravings,
stress, nervousness, and the pressure to smoke in so-
cial situations.

Asian Americans and Pacific Islanders

  Little has been published about smoking cessa-
tion among Asian Americans and Pacific Islanders. In
one study that addressed this issue, Jenkins and
colleagues (1990) found that among adult Vietnamese
refugees living in the San Francisco area, 82 percent of
smokers wanted to quit, but 71 percent of them felt
that quitting would be difficult. About 69 percent of
the Vietnamese smokers had been advised by their
physicians to reduce or quit smoking. Lack of infor-
mation about the health consequences of cigarette
smoking is a problem among some Asian American
groups. In a study of Chinese Americans in Oakland,

California, Lew (1992) found that 53 percent of the re-
spondents did not know that heart disease was asso-
ciated with cigarette smoking, and 26 percent of them
said they did not know that lung cancer was related to
cigarette smoking.  Of current Asian American or
Pacific Islander smokers aged 18 years or more in the
1993 NHIS, 60.2 percent reported being interested in
quitting smoking completely (CDC 1994b).

Hispanics

  Several studies have examined what motivates
adult Hispanic smokers to quit. Marin and colleagues
(1990b) found that family-related consequences and
concerns (e.g., to set a good example for one's chil-
dren) contributed more to Hispanics' desire to quit
smoking than to whites' desire to quit. Hispanic smok-
ers who intended to quit believed that by doing so they
would improve family relations, breathe more easily,
and have a better taste in their mouths. They also be-
lieved that they would gain weight. In an earlier study,
Hispanic smokers who subjectively considered them-
selves to be highly addicted to tobacco had the lowest
levels of perceived self-efficacy to avoid cigarette
smoking (Sabogal et al. 1989). The level of perceived
self-efficacy to avoid smoking also declined as the re-
ported number of cigarettes smoked per day increased.
In the 1993 NHIS, 68.7 percent of Hispanic smokers
aged 18 years or over said they wanted to quit smok-
ing cigarettes entirely (CDC 1994b). Research with
Hispanic adults has shown that their expectancies for
quitting and for continued cigarette smoking differ in
terms of their level of acculturation so that those
Hispanics who have acculturated more tend to re-
semble whites in their expectations (Marin et al. 1989a,
199Ob).

Summary, Smoking Cessation

  Although the literature on predictors or corre-
lates of smoking cessation among members of these
four racial/ethnic minority groups is limited, an
important theme emerges from the studies reviewed
in this section. Some studies, primarily those of Afri-
can Americans (see also Chapter 5), have shown that
smokers tend to report having little knowledge of the
health effects of smoking or techniques to quit smok-
ing. Smokers' lack of information about cessation
techniques available in the community is consistent
with underdeveloped tobacco control infrastructures
and the low levels of resources for research and
program delivery (Robinson et al. 1995; Shelton et al.
1995). Information alone is not enough to produce a

Factors That influence Tobacco Use  237


Surgeon General's Report

behavior change as complex as quitting, but informa-
tion on the health consequences of smoking is still
perceived by some researchers as necessary to develop
the motivation to quit. Information on resources and
techniques for quitting may also be essential for the
success of a smoking cessation program. The lack of
information may appear surprising in view of the
decades-long smoking education campaigns conducted
by federal and state agencies and voluntary associations,
but it is consistent with the thesis that resources allo-
cated for tobacco control research and programs have
been proportionately lower in racial/ethnic communi-
ties than in white communities (Robinson et al. 1995).
Equally important, information may not have been
presented through appropriate channels, and the
motivational messages may not have been culturally
appropriate (see Chapter 51.

  This literature review has identified several ar-
eas for which more appropriate approaches are
needed. First, the effects of stress and depression on
attempts to quit smoking are particularly important
among members of racial/ethnic groups. Culturally
appropriate cessation interventions need to identify
the sources of stress and then present stress-reduction
techniques that are perceived as appropriate and ef-
fective by members of racial/ethnic groups. Second,
group-specific motivations and attitudes predict a
person's interest in and success at quitting smoking.
Future research should focus on group-specific
attitudes and expectancies as well as those that are
shared by racial/ethnic groups. The effects of accul-
turation and group identification also need to be
addressed, particularly because research involving
Hispanics has shown that acculturation plays an im-
portant role in shaping the attitudes and expectancies
held by Hispanic smokers (Marin et al. 1989a; 1990a,b).

  In summary, the distinctive psychosocial envi-
ronment of disparate racial/ethnic minority, groups
requires that additional tailored intervention materi-
als be designed. Existing smoking cessation programs
and strategies currently designed for the general popu-
lation cannot simply be adapted or translated for use
with a particular racial/ethnic group (see Chapter 5
for more discussion of cessation).

Methodological Limitations of
the Literature

  The content of the literature must be interpreted
in light of its methodological limitations. The weak-
nesses of the studies demand caution, but on a more
positive note, they suggest appropriate directions for,

future research. These limitations fall into four main
categories: (1) nongeneralizability, (2) noncompar-
ability, (3) sample size and aggregation problems, and
(4) nonreporting.

  Nongeneralizubility. Most studies of psychosocial
factors in racial/ethnic groups have been conducted
in big cities such as Chicago, Los Angeles, New York,
and San Francisco. Some of the findings may not ap-
ply to persons residing in smaller cities or rural areas
where the psychosocial environment that influences
tobacco use may differ from that in large urban areas
or racial/ethnic enclaves in large cities.

  Similarly, primary prevention research in this
field has relied heavily on urban school populations.
Most studies have excluded school dropouts; students
attending alternative, parochial, or private schools;
those housed in detention facilities; those living
and working in rural environments; and other
at-risk youths, and therefore may have limited
generalizability.

  Noncomparability. Many studies have used dif-
ferent variables to measure the same phenomenon, or
they have measured the same variables differently.
Differential instrumentation (Cook and Campbell
1979) is a problem because a construct may not only
differ in meaning from one culture to another, but its
appropriate measurement (operationalization) may
also differ (Berry 1969; Triandis and Marin 1983; Marin
and Marin 1991). For example, if a risk factor survey
initially developed for a white population is adminis-
tered unchanged to African Americans or Hispanics,
it may prove to be culturally inappropriate and invalid.
Instead, researchers should consider what meanings
the survey terms or constructs have for the group
members (Brislin et al. 1973). Few researchers have
conducted the basic ethnographic and psychosocial
research needed to identify these culture-specific con-
structs. With the exception of some investigators who
have studied smoking cessation among Hispanics
(discussed earlier in this chapter), most researchers
have ignored a central assumption of cross-cultural
research-that equivalent and culturally appropriate
instrumentation must first be developed and used.

  Another difficulty in analyzing and comparing
studies of tobacco use among young respondents is
that the studies rarely measure comparable behaviors.
For example, some researchers attempt to predict the
first instance when a person uses a tobacco product.
Other researchers, primarily in cross-sectional
studies, use their data to predict current reported to-
bacco use and assume that those variables may help
explain initiation of tobacco use.

238 Chapter 4

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

  Aggregation problems. A common problem with
some of the studies reviewed in this chapter is that
racial/ethnic populations have not been assessed
separately from larger populations. For example, some
studies of African Americans and whites have failed to
separate these groups when reporting the results. Other
studies, particularly those with small sample sizes, have
not separated subgroups within racial/ethnic minor-
ity groups-for example, distinguishing Chinese from
Vietnamese-even when such separation is essential to
properly understanding the results. Such results would
be difficult to reproduce without knowledge of the
population mix.

  Nonreporting. The data summarized in this
chapter are further limited by a bias in the reporting
of results. Some researchers report only significant re-
sults and fail to indicate the equally important obser-

Chapter Summary

vation that some associations are not significant. This
limitation can negatively affect the design of cultur-
ally appropriate prevention strategies. In addition, few
of the studies reviewed in this chapter adequately de-
scribe the procedures followed or the data collected.
Properly understanding the meaning and measure-
ment of many of the variables included in these
research reports is difficult because of the paucity of
detail. Finally, few of these studies have reported on
issues of statistical power in their designs, which fre-
quently are characterized by a small sample and a large
number of variables.

  Despite such limitations in the quality and com-
parability of data, these studies identify the variables
that should be the focus of future research and
variables that need to be considered in culturally
appropriate prevention programs (see Chapter 5).

  Tobacco use patterns are influenced by many
factors. In addition, the factors themselves and their
importance in influencing tobacco use vary among ra-
cial and racial/ethnic groups. Some common experi-
ences and themes, however, emerge: the targeted
advertising and promotions through racial/ethnic-
specific media channels, the influence of peers who
smoke on initiation of tobacco use, the association of
depression and stress with cigarette smoking and ces-
sation among adults from different racial/ethnic
groups, and the influence of acculturation. Psycho-
social variables help explain individual tobacco use
behavior. Tobacco advertising and promotion are

influential because they appear to affect the perceived
sense of pervasiveness, function, and image of tobacco
use, which in turn affect these psychosocial variables.
Another possible influence is the historical relation-
ship between racial/ethnic minority communities and
the tobacco industry. Most likely, it is not any one
single factor but the interplay or convergence of these
factors that significantly influences both a person's de-
cision to use tobacco and the resulting tobacco use pat-
terns. The effects of each factor have so far eluded
quantification by researchers based on available evi-
dence; more research is needed to better understand
the etiology, exposure, and effects of these factors.

Factors That Influence Tobacco Use  239


Surgeon General's Report

Conclusions

1.  The close association of tobacco with significant
events and rituals in the history of many racial/
ethnic communities and the tobacco industry's
long history of providing economic support to
some racial/ethnic groups-including employ-
ment opportunities and contributions to commu-
nity groups and leaders-may undermine
prevention and control efforts.

2.  The tobacco industry's targeted advertising and
promotion of tobacco products among members
of these four U.S. racial/ethnic groups may un-
dermine prevention and control efforts and thus
lead to serious health consequences.

3. The high level of tobacco product advertising
in racial/ethnic publications is problematic be-
cause the editors and publishers of these publica-
tions may omit stories dealing with the damaging
  effects of tobacco or limit the level of tobacco-use
prevention and health promotion information in-
cluded in their publications.

4. Although much of the original research on psy-
  chosocial factors that influence tobacco use reflects
general processes that may apply to racial/ethnic
populations, documenting such generalizability
requires further research.

5.  The initiation of tobacco use and early tobacco use
among members of the various racial/ethnic mi-
nority groups seem to be related to numerous cat-
egories of variables-such as sociodemographic,
environmental, historical, behavioral, personal,
and psychological-although the predictive power
of these categories or of specific risk factors is not
known with certainty because of the paucity of
  research.

6. Cigarette smoking among members of the four
racial/ethnic groups is associated with depression,
psychological stress, and environmental factors
such as advertising and promotion and peers who
smoke, as is also the case in the general popula-
tion. The role of these factors in tobacco use among
members of these racial/ethnic groups deserves
attention by researchers and persons who develop
smoking prevention and cessation programs.

Appendix. A Brief History of Tobacco Advertising
Targeting African Americans

  A previous report of the Surgeon General
(USDHHS 1994) presented a brief historical perspec-
tive of cigarette advertising in the United States
focusing on advertising strategies targeting youths.
Because targeted marketing to other racial/ethnic
groups is a more recent phenomenon and because in-
formation about this practice with African Americans
is more available, this appendix focuses on advertis-
ing to African Americans. This appendix updates the
review in the 1994 Surgeon General's report, particu-
larly as it relates to African Americans.

Early Assumptions

  A significant proportion of cigarette advertising
targeting African Americans was based on the belief

that consumer behavior among African Americans
differs from that of whites. In the 195Os, a primary
belief of advertising agencies working on cigarette
advertising was that status-seeking was a central mo-
tivator of African Americans. A survey of Ebony read-
ers, published in Advertising Age (1950), showed that
"prestige and quality-not cost-are the most impor-
tant factors to stress when appealing to colored
buyers. Because of the psychological considerations
involved, Negroes are extremely desirous of being
identified as customers who recognize and demand
quality merchandise" (p. 17).

  Another early assumption of advertising agen-
cies targeting African Americans was that advertise-
ments featuring African American models were more
effective-or at least more appealing to African

240 Chapter 4

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

Americans-than advertisements portraying whites.
In a 1950 survey of the buying habits and motivations
of African Americans, Starch and colleagues found that
the majority of Ebony readers preferred advertisements
featuring African American models, although about
one-third of the African American respondents said
that it did not matter whether African American mod-
els were used (Advertising Age 1950). In a later study
of consumer reactions to the use of white or African
American models, 93 white and 88 African American
college freshmen in Houston were asked to react to
four cigarette advertisements, indicating whether the
models were ugly or beautiful, low class or high class,
and friendly or unfriendly (22 bipolar scales were pre-
sented) (Barban and Cundiff 1964). In general, the ciga-
rette advertisement with white models and the same
advertisement with African American models drew
similar reactions from whites and African Americans.
In a more recent study, however, African Americans
who strongly identified with their culture were more
likely to prefer African American models (Whittler
1989). Another recent study has shown that African
American college students preferred television com-
mercials for consumer products that included African
American models (Pitts et al. 1989). These findings
were replicated recently among African American
Chicago youths aged 12-14 years who perceived Afri-
can American models in cigarette advertisements as
more appealing (Huang et al. 1992).

  A central belief related to targeted advertising
and marketing is the assumption that members of ra-
cial/ethnic groups, particularly African Americans and
Hispanics, are brand-conscious and brand-loyal con-
sumers. This approach to purchasing is believed to
motivate consumers to spend extra money to purchase
a product with a recognized brand name or a product
that has been used by family members and neighbors
for a relatively long period of time. Large multina-
tional brand names often are associated with quality
in the immigrants' countries of origin, and purchas-
ing of those brands in the United States may serve as
an example of having "arrived" or achieved a sought-
after economic status. Other researchers hypothesize
that previous consumer experiences and an increase
in disposable income produce brand consciousness.
For example, Dallaire (19551 argued that "the Negro's
desire to improve his lot, his increasing income and
the fact that he's been burned so badly and so often in
the past with shoddy merchandise makes him a highly
brand-conscious consumer" (p. 58). Whether brand
loyalty is indeed a characteristic of certain racial/eth-
nic minority groups continues to be debated
(Deshpande et al. 1986; Donthu and Cherian 1992);

however, this assumption often has been invoked in
the design of advertising directed at members of
racial/ethnic groups.

  Promotional campaigns directed at African
Americans and members of other racial/ethnic groups
also operate under the assumption that these individu-
als are more likely than whites to trust advertising,
although most of the studies on which this perception
is based have been limited by methodological flaws
such as nonrandom sampling and a small sample size.
In a 1961 study of 1,106 African Americans and 537
whites, about twice as many whites as African Ameri-
cans had unfavorable attitudes toward all types of
advertising (Bullock 1961). In a 1968 study of 1,846
persons, the 77 African Americans interviewed had the
highest proportion (53 percent) of favorable responses
to the open-ended question "How do you yourself feel
about advertising?" compared with 1,707 whites (40
percent) (Bauer and Greyser 1968). Eleven years later,
Durand and colleagues (1979) interviewed 80 persons
and found that African Americans were consistently
more trusting of television and newspapers than
whites were, and they relied less on magazine adver-
tisements. Soley and Reid (1983) interviewed a ran-
dom sample of 185 Atlantans and found that African
Americans were more satisfied with the informational
value of magazine and television advertising than
whites were and that high-income respondents were
the least satisfied with advertising.

Early Targeted Advertising Efforts
(194Os-1960s)

  Turn-of-the-century advertisements for tobacco
products tended to include women, to emphasize fe-
male sexuality, and to portray women as dangerous
and delightful. Conversely, American Indians and
African Americans often were pictured as childlike and
unattractive (Mitchell 1992). Tobacco companies have
depicted African Americans in their advertisements
since the first Bull Durham advertisements appeared
at the turn of the century, but only since the 1940s have
they aggressively targeted African Americans as a dis-
tinct consumer market.

  In the decades that have followed, tobacco com-
panies have been described as "bold pioneers in both
their use of new media and their targeting of other
segments even when controversial" (Pollay et al. 1992,
p. 49). In 1942, the advertising agency of the Lorillard
Tobacco Company, J. Walter Thompson Company, be-
gan to monitor cigarette sales in African American
neighborhoods as part of an Old Gold cigarette
promotion (Pollay 1988). By 1948, Philip Morris was

Factors That Influence Tobrrcco Use  241


Surgeon General's Report

running its "no cigaret hangover" campaign in the
African American press and in daily newspapers pub-
lished in languages other than English (Tide 1948,
p. 18). By 1955, several cigarette companies, in-
cluding Philip Morris, were producing advertising ma-
terials targeting African Americans and Hispanics
(Printers' Ink 1955). Soon thereafter, Philip Morris
began placing point-of-sale materials in English as well
as Spanish for the newly repositioned Marlboro ciga-
rettes (Ullman Gravure, Inc. 1957). A decade after
tobacco firms first displayed an interest in African
American consumers, the firms were described as
"leaders among advertisers gunning for a bigger share
of the Negro market" (Dallaire 1955, p. 58).
  One of the earliest targeting efforts, conducted
on behalf of Liggett & Myers's Chesterfield cigarettes,
targeted African Americans via advertisements featur-
ing athletes' testimonials and placed in racial/ethnic
newspapers and magazines, such as Ebony, Our World,
and Tan. The company also launched an extensive
point-of-sale advertising campaign featuring African
American sports figures (Dallaire 1955). The campaign
included a series of six documentary films that pre-
sented African American achievements. Each film was
viewed by about 3 million people in 500 primarily
African American theaters. These films also were
shown at more than 100 African American colleges,
where free cigarette samples were distributed, reach-
ing an estimated 900,000 additional people. The suc-
cess of this effort led to the filming of 13 five-minute
films featuring interviews with African American
celebrities (Dallaire 1955).

  The 1950s also marked the introduction of men-
tholated cigarettes. Although a greater proportion of
African Americans now smoke mentholated cigarettes
compared with members of other racial/ethnic groups
(Chapter 21, no evidence exists that the menthol mar-
ket was initially conceived as having any special ap-
peal to African Americans or other racial/ethnic
groups. Mentholated cigarettes are relative newcom-
ers to the tobacco market, and they have been well re-
ceived by smokers. In 1956, Brown & Williamson's
mentholated and then unfiltered Kool cigarette
enjoyed an increasing market share that attracted its
competitors to introduce mentholated cigarettes with
filters. These competitors and their entries included
R.J. Reynolds's Salem, Philip Morris's Spud, Liggett
& Myers's Oasis, and Lorillard's Newport cigarettes.
By the end of 1957,5 percent of all cigarettes consumed
were mentholated, representing "a relatively sharp
gain for a fledgling cigarette movement exploring a
new taste" (Wootten 1957, p. 22).

  By 1959, The American Tobacco Company, the
only firm without a mentholated cigarette, was
preparing to market a cigarette tentatively called Rich-
mond. The campaign concept allegedly argued that
the Richmond cigarette "gives you all of smoking's
pleasure, with none of its penalties" Printers'Ink 1959a,
p. 12). Around the same time, Brown & Williamson
was ready to test market a second menthol brand,
Belair, and was introducing three other menthol brands
into the market-Riviera, Spring, and Alpine (Print-
ers' Ink 1959~). Tobacco companies also were begin-
ning to use technical jargon to market their menthol
products. For example, in 1959, advertising profession-
als described R.J. Reynolds's advertisements for Salem
as "breathlessly reporting `an amazing new develop-
ment' in copy that was both opaque and studded with
scientific jargon" to inform consumers about the highly
porous paper that "air softens every puff. There are,
obviously, just no limits to the company's tender regard
for the smoker" (Printers' Ink 1959b, p. 8).
  In a study of early cigarette advertisements
targeting African Americans, investigators compared
a complete set of cigarette advertisements from Ebony
for the years 1950-1965 with a matched set of adver-
tisements from Life (Pollay et al. 1992). The results,
which follow, are important in promoting a better un-
derstanding of the principles followed in advertising
targeted to African Americans.

  By 1965, all six major U.S. cigarette firms had
advertised in the pages of Ebony as well as Life. While
the cigarette advertising in Life increased over the
years, particularly between 1963 and 1965, the amount
of such advertising in Ebony more than tripled during
the same period. Ebony initially had fewer cigarette
advertisements (16 in 1950) than Life (31 in 19501, but
a dramatic increase in efforts targeting African Ameri-
cans soon led Ebony to have more than twice the num-
ber of cigarette advertisements (57 in 1962) as Life (28
in 1962) (Pollay 1990; Pollay et al. 1992). An analysis
of the page costs indicated that this pattern was not
related to the relative costs of the two magazines nor
was it likely related to cigarette firms' joining other
firms to offer their products to African Americans
through African American-owned media. Although
this was a period of general growth for Ebony, "ciga-
rette firms increased their spending and page acquisi-
tion even more than the average, keeping themselves
out in front of the pack" and making cigarette firms
the source of an estimated 6.5 percent of Ebony's total
advertising income in 1962 (Pollay et al. 1992, p. 54).

  The investigators also found that the manifest
race/ethnicity of the models portrayed in cigarette

242 Chapter 4

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

advertisements increased between 1950 and 1965. Out
of the 540 cigarette advertisements in Ebony, more than
84 percent featured identifiable human models, and
more than 90 percent of those used African American
models. In the early 195Os, the white endorsers who
occasionally appeared in Ebony included physicians
who claimed "more doctors smoke Camels" and tele-
vision and movie stars (Pollay et al. 1992). Since 1958,
virtually all models in Ebony's cigarette advertisements
have been African American. Yet none of the African
American cigarette endorsers appearing in Ebony ad-
vertisements have appeared in Life advertisements, not
even the widely popular sports stars and musicians.

  During the early years of targeted advertising,
professional athletes were most often featured in
cigarette advertisements. Sports stars were used in
advertisements even when the advertising copy was
inconsistent with athletics. A Lucky Strike cigarette
advertisement in Ebony, for example, referenced sci-
entific tests in 1950 but showed a picture of an African
American Olympic athlete. These advertisements
sometimes differed from advertisements appearing in
media targeting the general population. In 1960, Kent
cigarettes illustrated its "scientist's choice" campaign
in Ebony with another Olympic champion, not with a
scientist as was done in the advertisement placed in
Life. Although athletes also appeared in cigarette ap-
peals to the larger public, "cigarette ads aimed at black
readers of Ebony were significantly more likely to use
athletes than those aimed at white readers of Life. For
1950-1965, endorsements from athletes were about five
times more common in Ebony than in Life" (Pollay et
al. 1992, p. 51).

  Although most tobacco-producing companies
were targeting the African American market through
Ebony, these companies advertised significantly fewer
cigarette brands in Ebony than in Life (Pollay et al. 1992).
Advertising of new products seems to have lagged in
African American publications. Whereas advertise-
ments for filtered tobacco products first appeared in
Life in 1953 and made up one-half of all cigarette ad-
vertising in Life by 1955, advertisements for filtered
tobacco products did not appear in Ebony until 1955
and did not represent one-half of its cigarette adver-
tising until 1958, three years later than for Life.

Recent Targeted Advertising Efforts
(Late 196Os-1980s)

  By the late 196Os, with racial/ethnic pride en-
hanced by the success of the civil rights movement,
the nature and appeal of advertising began to change

to better tailor the contents of the advertisements
to targeted racial/ethnic groups. In an analysis of ad-
vertisements for all consumer products in selected is-
sues of Ebony and Life in 1960, Be&man (1963) found
that in about two-thirds of the advertisements featur-
ing models, African American models were substituted
for white models in advertisements placed in Ebony,
although the content of the advertisements was basi-
cally identical. The African American models initially
featured were predominantly light skinned, accord-
ing to Berkman (19631, but subsequent studies of all
Ebony advertisements between 1952 and 1968 showed
that the use of male models with more African Ameri-
can features and hair texture became more common
over time, whereas the advertisements continued to
use female African American models with Caucasian
features (Gitter et al. 1972; Weiss 1972).

  Cigarette advertising has changed in similar
ways. In the late 196Os, Lorillard's advertisements for
Kent cigarettes featured an African American model
wearing an Afro hairstyle and saying "that's where
it's at" (Advertising Age 1968, 1969). By 1971, Liggett
& Myers employed an advertising agency that special-
ized in targeting the African American market. The
agency's campaign for L&M cigarettes featured a slo-
gan that called the brand "super bad" (meaning excel-
lent), and research indicated the advertisement had
"great appeal among members of the black commu-
nity" (Advertising Age 1971a, p. 20).

  Not all cigarette advertisements aimed at Afri-
can Americans have been successful at employing
meaningful role models or at credibly using street or
popular language. One African American marketing
professional asserted that neither the Marlboro cow-
boy nor the Viceroy race car driver was meaningful to
most African Americans and that Winston's use of the
phrase "How good it is!" in a racial/ethnic advertise-
ment was a "white man's cliche that retired with Jackie
Gleason." In contrast, Kool's slogan, "Come all the
way up to Kool, America's #l selling menthol," was
lauded for astutely positioning the leader as a sign of
upward mobility (Wall 1973, p. 71).

  In the 197Os, Liggett & Myers began targeting
African American women with advertising for its "arty
female oriented" Eve cigarettes by running advertise-
ments with African American models in Black America
Magazine, Black Enterprise, Ebony, Essence, Jet, New Lady,
and Tuesday Magazine (Advertising Age 1971b, p. 24).
The next year, Liggett & Myers began promoting L&M
cigarettes to African American men and women via
advertisements in African American magazines, in-
cluding Contact, National Scene, and Soul Illustrated

Factors That Influence Tobacco Use  243


Surgeon General's Report

(Advertising Age 1971a). In 1974, Kool cigarette adver-
tisements in African American magazines featuring
African American models used the copy "Nobody
makes cool like Kool" (Advertising Age 1974, p. 76).

  During the mid-1970s, products targeted to Afri-
can Americans began to emerge. For example, R.J.
Reynolds created an extra-strong menthol product,
Salem Extra, which was advertised as offering "differ-
ent smokes for different folks." The cigarette was
market-tested in Birmingham and New Orleans
through outdoor advertisements as well as newspa-
per and regional magazine advertisements that were
supported by sampling. These efforts indicated to the
advertising trade that Salem Extra should be targeted
to African Americans, along with another extra-strong
menthol brand, Super M, which was being tested by
The American Tobacco Company in Pittsburgh
(O'Connor 1974).

  In the late 197Os, tobacco companies began us-
ing billboards to advertise cigarettes in racial/ethnic
minority communities. Over the past two decades,
billboards have appeared more frequently in commer-
cially zoned areas and in older, poorer, and otherwise
less desirable residential neighborhoods that border
major highways and mass transit systems. In surveys
of six cities in the late 198Os, Scenic America, a national
organization opposed to billboards, found far more
billboards advertising tobacco products in minority
neighborhoods than in other neighborhoods

(McMahon and Taylor 1990). For example, 76.7
percent of advertising messages on billboards in
one impoverished African American community in
Philadelphia were for alcoholic beverages and tobacco
products. In San Francisco, 62 percent of the billboards
in predominantly African American neighborhoods
advertised cigarettes, compared with 36 percent of all
billboards citywide (McMahon and Taylor 1990). Ac-
cording to the Outdoor Advertising Association of
America Marketing Division, tobacco companies are
the leading outdoor advertisers, accounting for ap-
proximately one-third of all billboards (McMahon and
Taylor 1990). Furthermore, data for 1988 show that
cigarettes are the most heavily advertised product in
outdoor media (CDC 1990a). A study conducted in
Columbia, South Carolina, confirmed that African
American communities have 2.6 times as many bill-
boards advertising cigarettes as white communities
have (Mayberry and Price 1993).

  In the late 197Os, cigarette producers and their
advertising agencies were becoming very aware of the
significance of the African American market, as exem-
plified by this quotation from a well-known advertis-
ing agency: "While Blacks represent only 10.3% of the
total U.S. population, they account for 18% of all smok-
ers and 31% of all menthol smokers" (Rosser Reeves
Inc. 1979, p. 12). As a result, tobacco companies have
heavily advertised and promoted cigarettes to racial/
ethnic minorities, particularly African Americans.

244 Chapter 4

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

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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


Surgeon General's Report

They may be unable to afford the high cost of some
group interventions.

They may perceive such efforts to be inconvenient
(e.g., requiring transportation and child care) and
time consuming.

They may prefer to deal with personal problems
alone or in the family rather than to seek profes-
sional or other help outside of the home.

They may lack access to linguistically appropriate
services.

They may distrust researchers and health care pro-
viders who are not members of their racial/ethnic
groups or who are unaware of their culture and
behavioral expectations and traditions.

If they have physically demanding jobs or heavy
caregiving responsibilities, they may be too ex-
hausted to attend program meetings.

  The difficulty in obtaining enough individuals
to participate in smoking cessation groups or even to
continue their participation after a few initial sessions
has been a problem for many ethnic smoking cessa-
tion programs, including those targeting Hispanics in
San Francisco, California (Perez-Stable et al. 1993) and
Queens, New York (Nevid and Javier 1992), African
Americans in Atlanta, Georgia (Ahluwalia and
McNagny 1993), and Chinese restaurant workers in
Boston, Massachusetts (Betty Lee Hawks, personal
communication, 1993). As a result, many programs
have stopped using cessation groups as a possible in-
tervention strategy and as a way to deliver informa-
tion personally.

  As an alternative to group approaches, interve-
nors in San Francisco began offering personal consulta-
tion over the telephone and face-to-face (Perez-Stable
et al. 1993). Trained individuals provide information
and support to smokers who want more information
than is provided in a self-help manual. This approach
(labeled consultas, or personal consultations), although
demanding in terms of time and personnel, is consid-
ered culturally appropriate among Hispanics, who tra-
ditionally value personal attention. This alternative also
allows telephone advisors to tailor the information to
each person's needs. Another alternative program,
which provides individual counseling to Southeast
Asian smokers in their homes rather than in clinics, has
been well received in Long Beach, California (Mary
Anne Foo, personal communication, 1994).

Community Approaches

  Most community smoking cessation programs
targeting members of racial/ethnic groups have been
conducted in fairly large urban communities and have
used self-help materials together with mass media and
outreach workers. In a recent overview of community-
wide programs targeting cardiovascular disease,
Winkleby (1994) noted the need to conduct focused
studies with populations that have not been reached
successfully in the past with large-scale projects, as is
the case with members of the four racial/ethnic
minority groups considered in this report.

  Because so many racial/ethnic groups place a
high value on the family and on the authority of older
relatives (Sabogal et al. 19871, some community pro-
grams have employed family-centered interventions,
working under the assumption that a smoker's chil-
dren and other relatives can effectively intervene and
that parents can be a child's best source of informa-
tion regarding smoking-prevention programs. In
Boston, the South Cove Community Health Center
involved more than 350 Chinese elementary school
children in a poster contest to depict the hazards of
tobacco. Many of these posters depicted the father
smoking at home and motivated children to discuss
cigarette smoking in their homes (Esther Lee, personal
communication, 19931. In a Vietnamese Saturday lan-
guage school program in Sacramento, California,
youths have been mobilized to carry antismoking
messages to their families and to encourage them to
avoid using tobacco (Debra Oto-Kent, personal com-
munication, 1993). In another project, Asian American
and Pacific Islander children were asked to compete in
a "letter to my parents" writing contest, asking them
not to smoke (Irene Linayao-Putman, personal commu-
nication, 1993). Anecdotal information about this and
similar programs indicates that the children enjoy these
activities and that their parents are seldom discomforted
by the letters, particularly when they perceive the pro-
grams to be sanctioned by the school system. Never-
theless, the usefulness of such an approach may be
limited in families that maintain strict patriarchal or ma-
triarchal structures in which children's interventions
may be perceived as a lack of respect toward adults or
as a challenge to the parents' authority.

  As mentioned previously, large-scale community
projects generally have used multiple strategies and
channels to disseminate smoking cessation informa-
tion and to motivate smokers to quit. A sample of pro-
grams targeting members of the four racial/ethnic
groups is presented below. This listing represents the

278 Chapter 5

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

variety of community approaches developed to help
racial/ethnic smokers quit but should not necessarily
be perceived as a list of model programs.

Stanford Five-City Multifactor Risk
Reduction Project

  Researchers at Stanford University developed the
Stanford Five-City Multifactor Risk Reduction Project
to examine cardiovascular disease and related risk fac-
tors over a nine-year period in five small communi-
ties in northern California. The project was based on
behavior-change models and social-learning theory
(Farquhar et al. 1985,199O) and used television, mass-
distributed print media, direct mailings, contests, cor-
respondence courses, and school-based programs for
youths. In the communities with very high concen-
trations of Hispanics, Spanish-language radio and
newspaper columns were chosen as the primary meth-
ods of disseminating information. The decline of
smoking rates was 13 percent greater in the treatment
cities than in the control cities (Farquhar et al. 1990).
Although researchers observed no differences in the
proportion of experimental or control respondents who
reported ever receiving advice from physicians on
quitting smoking, whites (51.1 percent) were much
more likely to report having received this advice than
Hispanics (32.6 percent) (Frank et al. 1991).

  Researchers found that the project was fairly suc-
cessful in promoting the use of self-help smoking ces-
sation materials among whites. A greater proportion
of smokers in the experimental communities (22.1 per-
cent) than in the control communities (15.0 percent)
reported using smoking cessation materials in the 12
months before the interview (Jackson et al. 19911. In
the experimental communities, Hispanics and whites
did not differ in their reported use of materials to re-
duce cardiovascular risk. When asked about their use
of tobacco control materials, 31 .O percent of Hispanic
women and no Hispanic men reported using smok-
ing cessation print materials during the previous 12
months, compared with 21.3 percent of white women
and 13.7 percent of white men.

  The project was less effective in promoting smok-
ing cessation programs; no Hispanic smokers reported
using such programs, compared with 6.3 percent of
white smokers. More recent analyses of and comment
on risk-reduction data from this and other community-
based interventions suggest that such interventions can
achieve more positive results by being coupled with
policy initiatives, developing more focused studies,
and broadening evaluation concepts (Winkleby et al.
1992; Fortmann et al. 1993; Winkleby 1994).

Programa Latin0 Para Dejar de Fumar (Hispanic
Program to Quit Smoking)

  The Programa Latin0 Para Dejar de Fumar was a
community-based, culturally appropriate intervention
designed specifically for Hispanic smokers in San Fran-
cisco (Perez-Stable et al. 1993; Marin and Perez-Stable
1995). Funded by the NC1 for 1985-1995, the program
was operated jointly by the University of California,
San Francisco, and the University of San Francisco. To
motivate Hispanic smokers to quit and to inform them
of strategies to stop smoking, the program used mass
media (primarily radio and television public service
announcements), outreach efforts, and distribution of
the Guia. Program planners developed the various
versions of the Guia, implemented the consultas ap-
proach to deal with individual needs for counseling,
and used a periodic raffle to reward individuals who
quit smoking within a given period of time (Perez-
Stable et al. 1993). Intervention messages were based
on research that identified the attitudes, norms, expect-
ancies, and values of Hispanic smokers (Marin et al.
1990a,b). The strategies incorporate significant cultural
values such as fmnilialism (the normative and behav-
ioral influence of relatives) (Sabogal et al. 1987) and
simpatia (a social mandate for positive social relation-
ships) (Triandis et al. 1984). For example, a key mes-
sage of the program was that smokers should quit to
protect the health of their children and to avoid set-
ting a bad example for children. To incorporate
simpatia into the program, planners developed inter-
vention materials that emphasized the positive aspects
of quitting and avoid confrontational approaches. This
latter approach was similar to that used in materials
developed for American Indians (American Indian
Cancer Control Project 1991).

  The Programa Latin0 Para Dejar de Fumar has
been evaluated through a number of cross-sectional
and longitudinal surveys as well as through smaller
scale studies that have examined the effectiveness of
specific strategies (Marin et al. 199Oc, 1994; Perez-Stable
et al. 1993; Marin and Perez-Stable 1995). The program
has significantly increased Hispanics' knowledge
about the dangers of smoking, awareness of the pro-
gram, and participation in the program. Most impor-
tant, the program has decreased the prevalence of
smoking among Hispanics in San Francisco (Marin and
Perez-Stable 1995). These changes have been observed
primarily among the less acculturated Hispanic smok-
ers who make up the targeted group. For example,
during the first year of the program, 24.9 percent of
the less acculturated Hispanics in San Francisco re-
ported awareness of the program; two years later, that

Tobacco Control and Education Efforts  279


Surgeon General's Report

proportion had increased to 48.5 percent (Marin et al.
1990b; Marin and Perez-Stable 1995). During the first
year in which the Guia was available, 23 percent of the
less acculturated Hispanic women and 12 percent of
the less acculturated Hispanic men in San Francisco
reported having a copy. One year later, the propor-
tion of the less acculturated Hispanics who reported
having a copy of the Guia had increased to 37.7 per-
cent of the women and 34.1 percent of the men.

Si Puedo (Yes, I Can)

  Si Puedo was an eight-week smoking cessation
program designed specifically for Hispanic smokers
in a largely Hispanic area of Queens, New York. The
program used the Guia and other print materials,
weekly bilingual group meetings, regular telephone
calls to offer support to participants, and videotaped
vignettes in which Hispanic actors conveyed smok-
ing cessation messages. Persons were recruited
through mass media advertising, direct mailings to
Hispanic physicians and clergy, and fliers posted
throughout the community. Most participants were
from South America (57 percent); the rest were from
the Caribbean (25.4 percent) or Central America
(9 percent). Some people participated in all aspects of
the program, whereas others used only the self-help
materials. Preliminary figures show that 55.6 percent
of the participants who took part in all components of
the Si Puedo smoking cessation program stopped
smoking by the end of the program (Nevid and Javier
1992). In comparison, 21.7 percent of those who used
only the self-help materials abstained from smoking.

Pathways to Freedom Community
Demonstration Project

  The American Cancer Society (ACS) used the
Pathways to Freedom manual and videotape as part of a
demonstration project to lower the prevalence of ciga-
rette smoking among African Americans (Robinson et
al. 1992; Robinson and Sutton, in press). During the
first phase (1992-1993), the ACS provided funds to
eight of its local units in Long Beach and central Los
Angeles, California; Philadelphia, Pennsylvania; Dela-
ware; the District of Columbia; Georgia; Kansas; and
Texas. The ACS units developed programs to recruit
African American smokers to quit smoking using the
Pathzuays to Freedom materials and to expand the ACS's
outreach into African American communities. Many
of them planned their projects to coincide with the
Great American Smokeout (GAS).

  In the second phase of the project (1993-1994),
the ACS provided funding to seven more local units

in Contra Costa and San Diego Counties, California;
Maryland; Nebraska; Chattanooga and Memphis, Ten-
nessee; and Utah. Cessation activities expanded to
include efforts to mobilize African American commu-
nities and to identify more individuals and groups
willing to become tobacco control advocates.

  The process evaluation of the first phase showed
that the program was easier to implement in commu-
nities with a previous history of community-based
outreach efforts (Robert G. Robinson et al., unpub-
lished data). Dissemination of the self-help manual
was most difficult in multiethnic communities and
areas of a city. Most ACS agencies used a variety of
distribution channels, including churches, health care
organizations, and recreation centers. The program
helped the ACS to approach African Americans and
to gain support from African American volunteers.
Even though the project emphasized self-help
approaches, several ACS units incorporated Pathways
to Freedom materials into smoking cessation groups
conducted in African American communities.

  The outcome evaluation of the first phase con-
sisted of telephone interviews with 763 smokers who
returned a screening postcard that was attached to each
Pathzuays to Freedom manual. Respondents reported a
favorable impression of the manual and a 10 percent
quit rate at 30 days. In addition, smokers who viewed
the Pafhzuays to Freedom videotape were significantly
more likely than others to accept and use the self-help
materials as well as to move from precontemplation
to contemplation in the process of changes involved
in smoking cessation.

Quit Today!

  A two-part study funded by the NC1 will evalu-
ate the effectiveness of the Pathzuays to Freedom manual
and videotape when incorporated into a community-
based campaign targeting adult African American
smokers.  In the first phase of the project, the
Pathways to Freedom videotape will be distributed
communitywide, and paid radio announcements will
be aired, encouraging smokers to call the CIS for help.
In the second phase of the project, callers to the CIS
will be randomly selected to receive either the Path-
zuays to Freedom manual and smoking cessation coun-
seling related to the manual or an NC1 manual and
standard CIS smoking cessation counseling. Results
of this study should produce important information
about the effectiveness of targeted self-help smoking
cessation materials for African Americans combined
with established services such as the CIS.

280 Chapter 5


Tobacco Use Among U.S. RnciallEthnic Minority Groups

Chicago Lung Association's Multifaceted Smoking
Cessation Intervention

  In 1985, Warnecke and colleagues (1991)
launched a multifaceted smoking cessation interven-
tion on behalf of the Chicago Lung Association. Like
a number of programs, this intervention used materi-
als originally produced for whites to target members
of other racial/ethnic minority groups. The program
used televised messages on techniques for quitting
smoking and avoiding relapse as well as the ALA self-
help manual and smoking cessation groups. More than
325,000 smokers in the targeted population viewed
televised messages featuring role models who encour-
aged them to obtain a self-help manual, Freedom from
Smoking in 20 Days, by mail or at one of three loca-
tions-a local hardware store, an HMO, or the Chi-
cago Lung Association. A total of 9,182 smokers (23
percent of whom were African American) registered
to participate in the study and were followed for 24
months. The results showed that African American
and white smokers responded differently to various
smoking cessation strategies. For example, African
Americans were more likely than whites to report see-
ing the televised messages on a daily basis and were
more likely to recall the messages. However, African
Americans were less likely than whites to attend smok-
ing cessation groups.

  As an adjunct to the Chicago Lung Association's
program, Jason and colleagues (1988) studied the ef-
fects of a television program in the West Garfield Park
neighborhood of Chicago, where 86 percent of the resi-
dents were African American. Before the television
program aired, individuals who reported smoking
were randomly assigned to a control group (91 per-
cent were African American) or to an experimental
group (96 percent were African American). Members
of the control group viewed the program or read the
self-help manual at their leisure, whereas members of
the experimental group received motivational calls
prompting them to view the television program and
inviting them to attend smoking cessation meetings
at a community health center three times during the
20-day program. Eight percent of the smokers in the
experimental group reported quitting at the end of the
program, compared with 1 percent of those in the con-
trol group. After four months, 20 percent of the smok-
ers in the experimental group had quit, compared with
9 percent of those in the control group.

Chicago Community-Based Interventions for
Low-Income African Americans

  In conjunction with the smoking cessation
television program sponsored by the Chicago Lung

Association, Lacey and colleagues (1991) designed
community-based interventions for low-income
African Americans living in four subsidized housing
projects in Chicago. Residents were trained as lay
health advisors to deliver smoking cessation messages
to their neighbors. They made weekly home visits
during the 20 days in which the television program
was aired, and they used reminder cards to support
the positive behaviors outlined in the program. A
subsample of women in the housing projects watched
the televised program and participated in six smok-
ing cessation classes, which used a curriculum similar
to the one presented in the television program. Health
educators gave the women supplemental materials ap-
propriate for them and tips on sources of social sup-
port for smoking cessation. Classes were held in the
housing projects. Of the 235 residents who preregis-
tered for the smoking cessation intervention, 141 at-
tended at least one class or accepted at least one home
visit. Of the 56 women who attended at least one class
session, 11 percent quit smoking. About one-half of
the 174 residents who registered for the home visita-
tion accepted such a visit, but none quit smoking.
Focus groups conducted in conjunction with the in-
tervention indicated that residents of the housing
projects perceived that they were not vulnerable to the
negative health consequences of smoking, that smok-
ing helped them to cope with stress, and that they had
few environmental supports for quitting smoking.

Freedom from Smoking@ for You and Your Family
on TVlPor Su Salud y Su Familia

  Like the Chicago Lung Association's interven-
tion, the Freedom from Smoking@ for You and Your
Family Project in California featured role models in
televised pieces and distributed self-help materials. In
1991, project planners produced special editions of the
ALA Freedom from Smoking@ for You and Your Family
self-help manual and the Guia and placed them in a
newspaper insert that was distributed throughout
seven English-language television markets-Eureka,
Fresno, Los Angeles, Sacramento, Santa Barbara, San
Diego, and the San Francisco Bay area-and four
Spanish-language television markets-Fresno, Los
Angeles, Sacramento, and the San Francisco Bay area.
In addition, locally produced television pieces in both
English and Spanish were shown for seven days as
part of the daily news. These news pieces included
interviews with Hispanic and white experts on
tobacco-use control and with four local residents who
had volunteered to use the self-help materials to quit
smoking. The program reached nearly 1.2 million


Surgeon General's Report

smokers (C. Anderson Johnson et al., unpublished
data). The newspaper insert was most frequently read
by white (22 percent), Asian American and Pacific Is-
lander (18 percent), and African American (16 percent)
smokers; smaller proportions of English-speaking His-
panics (14 percent) and Spanish-speaking Hispanics
(10 percent) read the insert. The television pieces were
viewed most frequently by Spanish-speaking Hispanics
(25 percent), followed by African Americans (14 per-
cent), Asian Americans and Pacific Islanders (9 per-
cent), whites (9 percent), and English-speaking
Hispanics (9 percent). A year after the intervention,
3.1 percent of the people who had read the English-
language newspaper insert and had viewed the tele-
vision piece were former smokers; this was true among
all racial/ethnic minority groups except Spanish-
speaking Hispanics. In comparison, 1.5 percent of the
people who did not participate in the program were
former smokers. By itself, neither the English-language
television piece nor the newspaper insert was effec-
tive in promoting smoking cessation. Viewers of the
Spanish-language television program, which used cul-
turally appropriate materials, were more successful; 9
percent of viewers were former smokers at 12 months,
compared with 2 percent of smokers who did not view
the program.

A Su Salud (To Your Health)

  A Su Salud was a mass media health promotion
program conducted from 1985 through 1990 to reduce
smoking among Mexican Americans residing along the
U.S.-Mexico border in Eagle Pass and Del Rio, Texas
(Ramirez and McAlister 1988; Amezcua et al. 1990).
This mass media campaign used role models, an ex-
tensive media campaign, community volunteers, and
behavioral modeling techniques grounded in the prin-
ciples of Bandura's (1977) Social Learning Theory. It
was modeled after a similar program implemented in
North Karelia, Finland (McAlister et al. 1982; Puska et
al. 1987). ASu Salud recruited individuals who wanted
to quit smoking, organized focus groups to determine
their needs and levels of awareness about tobacco use,
and then featured community role models in a series
of informational programs that were televised on
local Spanish-language stations. The media messages
were reinforced through a network of community vol-
unteers who personally contacted the targeted popu-
lation individually or in small groups. The volunteers
delivered calendars with community events and sto-
ries about the role models. The program also produced
fotonovelas-pictorial stories, presented in a comic-book
format, which depicted smoking cessation behaviors.

The program resulted in a modest but notable increase
in smoking cessation rates among community mem-
bers. Out of the 17 percent of smokers who reported
that they had quit smoking, 8 percent were verified
(McAlister et al. 1992).

University of North Carolina/North Carolina
Mutual Quit for Life Guide

  The Quit for Life program used lay leaders to pro-
mote smoking cessation messages. The Quit for Life
Guide was based on the ALA's Freedom from Smok-
ing@ for You and Your Family Project and targeted poli-
cyholders of the predominantly African American
North Carolina Mutual Life Insurance Company
(Schoenbach et al. 1988). The program was novel in
that it was delivered by the company's life insurance
sales agents, who discussed the health consequences of
smoking with their customers and provided social sup-
port for quitting and avoiding relapse (Orleans et al.
1989). The Quit for Life program was moderately ef-
fective in promoting smoking cessation among the
targeted low- to middle-income smokers. Over a
two-year period, 2,042 smokers enrolled in the program.
About 14.9 percent of the participants who received
self-help materials, telephone counseling, and agent
support quit smoking at 12 months, compared with 14.1
percent of the participants who received just self-help
materials and agent support, and 12.3 percent of the
control subjects, who received agent support only. Veri-
fying these self-reported quit rates was impossible, how-
ever, because few respondents agreed to provide saliva
samples for a cotinine test, which would have provided
biochemical verification (Schoenbach et al. 1988).

  In an eight-week follow-up study, the Quit for
Life program targeted the insurance company's cor-
porate employees in a large urban center. Preliminary
results regarding policyholders in one sales district and
lasting eight weeks showed that 8 of the 126 African
American smokers enrolled in the program (6 percent)
were nonsmokers six months after enrollment (Sandra
W. Headen et al., unpublished data).

Legends

  Beginning in 1993, the NMA and CDC began co-
sponsoring the Legends campaign. Legends is the only
national-level, mass media motivational campaign di-
rected at African Americans who want to quit smok-
ing. The campaign consists primarily of public service
television and radio announcements that use famous
African American leaders and historic figures, such as
Martin Luther King, Jr., and Malcolm X, to motivate

282 Chapter 5

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

smokers to quit. Individuals interested in quitting can
request the Pathways to Freedom cessation guide by call-
ing a toll-free telephone number; the Legends campaign
generated more than 7,500 calls for the Pathways to Free-
dom guide within the first 18 months. The NMA has
supported the campaign at the local level by promot-
ing media and community outreach activities, includ-
ing billboard advertisements, in 14 NMA-sponsored
"Healthy People 2000" cities across the country.

Great American Smokeout

  GAS is an annual ACS-sponsored event that en-
courages smokers to quit. The results of a 1991
Gallup poll indicated that smokers of various racial/
ethnic minority groups may respond favorably to the
GAS (CDC 1992). Fewer African Americans and His-
panics than whites reported being aware of the
Smokeout. However, 25 percent of African Americans
and Hispanics who were aware of the GAS reported
participating in the project, and 14 percent of those
who participated reported that they were not smok-
ing cigarettes one to three days after the GAS (CDC
1992). The same poll estimated that during the 1991
GAS, approximately one-third of smokers in the United
States participated, either by not smoking or by reduc-
ing the number of cigarettes they smoked (CDC 1992).
Lieberman Research Inc. (1993) found that 26 percent
of smokers from racial/ethnic communities (i.e.,
African Americans, Asian Americans, Hispanics, and
others) participated in the 1993 GAS, compared with
only 19 percent of white smokers. In interviews
conducted 1 to 10 days after the GAS, however, similar
proportions of racial/ethnic group members (18 per-
cent) and whites (17 percent) reported that they had quit
or that they were smoking less than before the GAS.

Sue Khoe La Vang! (Health is Gold!)

  From 1990 to 1992, Sue Khoe La Vang! (Health is
Gold!), the Vietnamese Community Health Promotion
Project, conducted media-led smoking reduction cam-
paigns targeting Vietnamese men in San Francisco and
Alameda Counties and in Santa Clara County, Cali-
fornia (McPhee et al. 1993, 1995; Jenkins et al. 1997).
Both interventions used materials that were produced
in Vietnamese. The programs included antitobacco
counteradvertising campaigns that used billboard,
print, and television advertisements; published articles
in Vietnamese-language newspapers; a videotape that
aired on Vietnamese-language television stations;
health education materials such as brochures, a quit
kit, posters, bumper stickers, and a calendar; a

continuing medical education course on smoking
cessation counseling methods for Vietnamese physi-
cians; and the distribution of printed "no smoking"
signs and ordinances.  Unlike the Santa Clara inter-
vention, the San Francisco campaign was preceded by
a 15-month pilot antitobacco media program and in-
cluded a component for students and their families.

  The evaluation of the programs showed that the
Santa Clara intervention did not influence cigarette
smoking prevalence or recent quitting status (quitting
during the prior two years) (McPhee et al. 1995). How-
ever, a program effect was observed in the San Fran-
cisco trial, such that the odds of being a smoker were
significantly lower and the odds of quitting recently
were significantly higher in San Francisco than in a
comparison community (Jenkins et al. 1997). The au-
thors explained the difference in two ways, the longer
duration of exposure to the antitobacco campaign in
San Francisco (39 months) than in Santa Clara (24
months) and the added school- and family-based
component of the San Francisco campaign.

Involvement of Health Care Providers

  A number of successful smoking cessation ap-
proaches use health care providers, primarily physi-
cians and dentists, to inform patients about the urgency
of quitting smoking and to suggest quitting strategies
(Health and Public Policy Committee 1986; Flay et al.
1992; Reid et al. 1992; NC1 1994; Fiore et al. 1996). Al-
though this approach may be effective with members
of the four racial/ethnic minority groups studied in
this report-particularly those groups that exhibit high
power distance (i.e., the respect for and deference to
authority figures such as physicians, teachers, and
older people) (Hofstede 19801-a number of structural
characteristics limit the usefulness of this approach.
The most important limitation is that a large propor-
tion of members of these racial/ethnic minority groups
lack access to primary care providers. This problem
has been widely documented among adult members
of racial/ethnic groups (Aday et al. 1993) and adoles-
cents (Lieu et al. 1993), such as among African Ameri-
cans (Hopkins 1993) and Hispanics (Treviiio et al. 1991;
GAO 1992; Pierce et al. 1994b).

  Data from the 1990 California Tobacco Survey
showed that 46.9 percent of Hispanic smokers had
not visited a physician in the 12 months before the
survey, compared with 42.0 percent of Asian Ameri-
cans and Pacific Islanders, 26.7 percent of African
Americans, and 33.4 percent of whites (Burns and
Pierce 1992). According to the 1992 NHIS data on

Tobacco Control and Education Efforts  283


Surgeon General's Report

cigarette smokers, 37.6 percent of Hispanics, 26.1 per-
cent of African Americans, and 29.2 percent of whites
had not visited a physician during the year preceding
the survey (Tomar et al. 1996). Data from the 1989 NHIS
on the number of annual visits per person to the dentist
showed that African American men (1.0 visits) and
women (1.4 visits) made fewer visits than Hispanic men
(1.5 visits) and women (1.7 visits) and white men (2.1
visits) and women (2.4 visits) (Bloom et al. 1992). Among
smokers, national data collected in 1992 showed that 42.6
percent of African Americans, 39.3 percent of Hispanics,
and 54.4 percent of whites had visited a dentist during
the preceding year (Tomar et al. 1996). In addition,
because many health care providers lack linguistic skills
and training in cultural sensitivity, they tend to be
ineffective advocates of smoking cessation among
members of ethnic groups. Equally problematic is the
fact that few physicians have the necessary training, feel
qualified and supported, or express interest in recom-
mending quitting to smokers (Kottke et al. 1994).

  Available data indicate that a large proportion
of health care providers, primarily physicians, do not
take advantage of office visits to encourage smokers
to quit. In general, members of racial/ethnic groups
are less likely than whites to receive advice on quit-
ting smoking from their physicians, and they are even
less likely to receive such advice from their dentists
(e.g., Kogan et al. 1994; Winkleby et al. 1995; Hymowitz
et al. 1996). According to data from the 1992-1993 CPS,
about 42.4 percent of Hispanics and 45.4 percent of
African Americans who had visited a physician dur-
ing the previous year reported that within that year
they had received a physician's advice on quitting
smoking, compared with 50.4 percent of whites (Table
5) (U.S. Bureau of the Census, NC1 Tobacco Use Supple-
ment, public use data tapes, 1992-1993). In general,
women reported receiving a physician's advice in
greater proportions than men. When asked if they had
ever received a physician`s advice on quitting smok-
ing, only 39.8 percent of Hispanics said they had, com-
pared with 47.2 percent of African Americans, 45.7
percent of Asian Americans and Pacific Islanders, 54.5
percent of American Indians and Alaska Natives, and
58.1 percent of whites. Results of the 1991 NHIS show
that whereas 38.2 percent of whites reported receiv-
ing advice to quit from a physician or other health care
professional at any visit during the preceding 12
months (CDC 1993a), a percentage significantly higher
than for Hispanics (30.6 percent), such advice was re-
ceived by 34.4 percent of African Americans, 41.4 per-
cent of American Indians and Alaska Natives, and 34.4
percent of Asian Americans and Pacific Islanders.
According to the 1992 NHIS data on cigarette smok-

ers who had visited a physician during the previous
year, 55.5 percent of whites, 50.2 percent of African
Americans, and 35.1 percent of Hispanics reported that
a physician had advised them to quit smoking during
the preceding year; among smokers who had visited a
dentist during the previous year, 23.4 percent of whites,
26.3 percent of African Americans, and 27.2 percent of
Hispanics reported that a dentist had advised them to
quit during the preceding year (Tomar et al. 1996). Be-
cause questions were worded differently about advice
from health care providers on quitting smoking, esti-
mates based on data from the 1991 NHIS and the 1992
NHIS are not directly comparable and cannot be in-
terpreted as indicating a secular trend. Findings from
other surveys show that among African Americans,
pregnant women are the most likely to receive smok-
ing cessation advice and services in a health care set-
ting (O'Campo et al. 1992; Tiedje et al. 1992).

  Results from the 1992 California Tobacco Survey
showed that among smokers who visited a physician
in the previous year, 60.9 percent of Hispanics did not
receive advice on quitting smoking, compared with
56.0 percent of African Americans and 47.8 percent
of whites (Pierce et al. 1994bl. These figures are
comparable to those found in the Stanford Five-City
Multifactor Risk Reduction Project, in which 63.4
percent of Hispanic smokers reported never being
advised to quit smoking by their physician, compared
with 45.9 percent of whites (Frank et al. 1991). These
differences seem to be particularly notable among less
educated Hispanics (Winkleby et al. 1995).

  Despite these limitations, the use of health care
providers to promote smoking cessation can have
promising results (Royce et al. 1995). The CDC has
funded the design of protocols that will prescribe strat-
egies health care providers can use when counseling
patients in smoking cessation, using the Guia for His-
panics and the Pathways to Freedom program for Afri-
can Americans. In addition, the NC1 has produced a
number of publications reviewing this approach (NC1
1994) as well as training materials to teach health care
personnel how to promote smoking cessation (Glynn
and Manley 19921, and a recent publication has evalu-
ated the effectiveness of various smoking cessation
approaches available to primary care clinicians (Fiore
et al. 1996).

For You and Your Family

  The For You and Your Family project provides
tobacco-use prevention services to racial/ethnic com-
munities in health care settings. The project, sponsored
by California's Department of Health Services, was

284 Clzapter 5

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

Table 5.  Percentage of adult smokers who have received advice to quit smoking from either a medical
    doctor or a dentist, by race/ethnicity and gender, Current Population Survey, United States,
      1992-1993

Characteristic

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

%   XI+      %     %I      %     -1     %    XI     %   KI

Received advice from a medical doctor in past year+

Total          45.4   1.7      48.3    6.2     49.6    5.3     42.4   2.6    50.4   0.7
Men           42.5   2.6      45.2    9.0      50.1     6.8     39.6   3.6    48.8   1.0
Women        47.3   2.2      51.0    8.5      48.8     8.6     45.5   3.8    51.7   0.9

Received advice from a medical doctor ever

Total          47.2   1.4      54.5    5.3      45.7     4.1     39.8   2.0    58.1   0.6
Men          40.5   2.1      50.4    7.5      43.7    4.8     33.2   2.5    53.1   0.8
Women        53.1   2.0      58.6    7.4      50.4    7.5     50.0   3.3    63.1   0.8

Received advice from a dentist in past yeart

Total          20.6   1.8      21.1    6.3      30.5     5.0     22.6   2.6     19.6   0.6
Men           22.0   2.8      28.5    10.1      36.3     6.4     23.3   3.6     21.4   0.9
Women         19.6   2.3      14.2    7.5      19.3    7.3     21.7   3.7    18.0   0.8

Received advice from a dentist ever

Total           14.7   1.0      18.2    4.1      24.9    3.5     16.7   1.6    18.6   0.4
Men          15.4   1.5      21.2    6.1      26.7    4.3     15.7   2.0    19.4   0.6
Women         14.1   1.4      15.2    5.4      20.8     6.1     18.2   2.6    17.8   0.6

*95% confidence interval.
`Among persons who visited a medical doctor during the past year.
SAmong persons who visited a dentist during the past year.
Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
1992-1993.

developed recently by a team of California research-
ers. This multicultural perinatal project seeks to re-
duce cigarette smoking among pregnant women and
to limit their exposure to ETS. The project includes a
trainer's guide, a health care provider's guide, and
targeted client education materials for African
Americans, American Indians, Hispanics, and Asian
Americans (i.e., Cambodians, Chinese, Koreans, and
Laotians). Materials for clients differ in their content
and format, depending on the racial/ethnic group be-
ing targeted; the materials range from a brochure for
African Americans entitled Hey, Girlfriend, Let's Talk
About Smoking and You to a four-color magazine
entitled La Mujer: La Familia y el Cigarrillo, which

motivates Hispanic women to quit and provides sug-
gestions and techniques for quitting and maintaining
abstinence (Otero-Sabogal and Sabogal1991).

  The importance of developing smoking cessation
programs for pregnant women of various races/
ethnicities has been documented recently among
American Indians (Bulterys et al. 1990). By using sta-
tistical models with information on the health status
of American Indians in the Aberdeen IHS area, Bulterys
and colleagues found that by quitting smoking, Ameri-
can Indian pregnant women would prevent 2.6 per-
cent of all infant deaths, 3.7 percent of postneonatal
deaths, and 1.2 percent of neonatal deaths.

Tobacco Control and Education Efforts  285


Surgeon General's Report

American Indian Cancer Control Project

  The American Indian Cancer Control Project in
California used self-help techniques, individual coun-
seling, and cultural interventions to help American
Indian smokers quit. Access to American Indians over
the age of 18 years was facilitated through 18 north-
ern California clinics owned and operated by Ameri-
can Indians. Fourteen rural clinics located on or near
reservations and four urban clinics participated in the
project. The project has been testing a clinic-based,
physician-initiated message enhanced by using Ameri-
can Indian community health representatives who also
provide outreach support. Recent data indicate that
the clinic-based procedures were an acceptable and
accessible means of reaching the American Indian
population in northern California (Hodge et al. 1995,
1996). Evidence from this project suggests the need
for culturally appropriate smoking cessation programs
(Hodge et al. 1995).

Involvement of Employers

  Employer-provided smoking cessation programs
could help to lower the prevalence of smoking, yet very
few individuals report having such programs avail-
able to them. Data from the 1992-1993 CPS showed
that 23.6 percent (95 percent confidence interval
[CI] = f 0.9 percent) of African Americans reported
having such services at work, compared with 22.4 per-
cent (CI + 0.3 percent) of whites, 21.8 percent (CI f 1.8
percent) of Asian Americans and Pacific Islanders, 18.8
percent (CI + 3.6 percent) of American Indians and
Alaska Natives, and 15.8 percent (CI + 0.9 percent) of
Hispanics (U.S. Bureau of the Census, NC1 Tobacco
Use Supplement, public use data tapes, 1992-1993).
Among smokers, 25.0 percent (CI f 1.8 percent) of Af-
rican Americans, 19.7 percent (CI + 0.6 percent) of
whites, 18.4 percent (CI f 4.1 percent) of Asian Ameri-
cans and Pacific Islanders, 17.7 percent (CI + 5.8 per-
cent) of American Indians and Alaska Natives, and 14.3
percent (CI f 1.9 percent) of Hispanics reported hav-
ing access to employer-provided smoking cessation
services (U.S. Bureau of the Census, NC1 Tobacco Use
Supplement, public use data tapes, 1992-1993).

Involvement of Nontraditional Providers

  Community members who traditionally have not
been perceived as health promoters also have become
involved in tobacco control efforts. For example, Af-
rican American religious leaders have been involved

in tobacco control efforts as well as in other health
promotion activities, such as the National High Blood
Pressure Education Program (1992). These ministers
and pastors carry great influence among African
Americans and are responsible for dictating social and
moral values. In addition, the church often has been
central in mobilizing African American communities
around issues of social justice. Examples of tobacco
control efforts involving community members, includ-
ing religious leaders, are presented in this section.
Unfortunately, little evidence is available about the
success or effectiveness of this type of intervenor.

  Heart, Body, and Soul is a church-based intervention
in east Baltimore, Maryland, a predominantly (88 per-
cent) African American community (Stillman et al. 1993;
Voorhees et al. 1996). Focus groups conducted before
the intervention revealed that African American smok-
ers were knowledgeable of the health risks of smoking
but knew few strategies beyond quitting cold turkey.
The smokers perceived little support for quitting from
their friends and family, with the exception of their
children, who tended to be strong motivators to quit
smoking. The smokers participating in the focus
groups did not approve of nicotine replacement and
viewed it as substituting one addiction for another. The
intervention phase of the study emphasized the impor-
tance of self-efficacy to promote behavior change and
social actions that promote large, systemic, social
changes as a strategy for affecting individual behav-
ior. The project was carried out through a partnership
with the local ministerial alliance. Of 130 churches in
the area, 22 participated in the intervention.

  After introductory activities, which included a
health fair, churches were randomly assigned to re-
ceive either an intensive smoking cessation interven-
tion or the minimal level of activity, which involved
distribution of the ALA educational brochure Don't Let
Your Dreams Go Up in Smoke (ALA 1990a). Churches
participating in the intervention received the same
brochure but also were involved in the following ac-
tivities: (1) training of smoking cessation specialists,
who conducted weekly support groups with a spiri-
tual overtone; (2) a kickoff service that included an
inspirational sermon, distribution of One Day at a Time
(a Scripture-based book of inspirational messages for
smokers), and an inspirational audiocassette on quit-
ting smoking; and (3) reinforcement of successful quit-
ting through recognition during church services and
the provision of certificates to volunteers participat-
ing in the program. The program is now being
extended to churches in 13 cities throughout the coun-
try. As a result of this program, a number of African
American clergy have formed a coalition, Black Clergy

286 Chapter 5

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

for Substance Abuse Prevention, to implement tobacco
control programs and other substance abuse preven-
tion efforts. The coalition is affiliated with the National
Association of African Americans for Positive
Imagery (NAAAPI). A recent study showed that
church-based programs can be effective in moving in-
dividuals along the continuum of change toward
quitting smoking (Schorling et al. 1997).

  Innovative programs are also under way in
California. In San Diego, the Union of Pan Asian Com-
munities of San Diego County delivers antismoking
messages through fortune cookies (Irene Linayao-
Putman, personal communication, 19931. The St. Mary
Medical Center and the United Cambodian Commu-
nity, Inc., in Long Beach, California, developed
audiocassettes that feature traditional Laotian and
Cambodian music as well as antismoking messages.
These audiocassettes are distributed through racial/

ethnic shops, health fairs, and other community events.
Barbers and beauty parlor operators also have been
trained to provide antismoking messages to their cli-
ents in small community programs in California and
other states.

  Although not all of these smoking cessation in-
terventions are culturally appropriate, preliminary
figures on the overall effectiveness of these massive
interventions show that progress is being made in a
number of areas. In California, for example, the over-
all prevalence of smoking has declined, more smok-
ing cessation services are available, people are more
aware of the dangers of cigarette smoking, and in-
creases in adolescent smoking appear to have stopped
(Breslow and Johnson 1993; Pierce et al. 1994b; Elder
et al. 1996). These results are true for members of
racial/ethnic minority groups as well as for whites.

Environmental Tobacco Smoke and Clean Indoor Air Policies

  A large number of individuals from racial/
ethnic groups work in the service industry (e.g., res-
taurants) and in blue-collar jobs (e.g., factories and
repair shops&areas of employment where cigarette
smoking usually is allowed. Thus, they are probably
heavily exposed to ETS.

  Although the data are incomplete, a few studies
indicate the extent to which nonsmokers, particularly
those who are members of racial/ethnic groups, are
exposed to ETS. Data from the 1993 California Tobacco
Survey showed that 32.0 percent of nonsmoking His-
panics were exposed to ETS at indoor workplaces,
compared with 19.1 percent of African Americans and
19.0 percent of whites (Pierce et al. 1994b).

  Exposure to ETS at home is also a concern among
members of racial/ethnic groups. Data from the 1992-
1993 CPS (Table 6) showed that a majority of Asian
Americans and Pacific Islanders (60.6 percent) and His-
panics (56.6 percent) did not allow cigarette smoking
in their homes (U.S. Bureau of the Census, NC1
Tobacco Use Supplement, public use data tapes, 1992-
1993). In comparison, smaller proportions of whites
(41.3 percent), African Americans (38.9 percent), and
American Indians and Alaska Natives (35.6 percent)
reported that they prohibited smoking at home. Mi-
nor gender differences were observed in the reporting

of such restrictions. Other surveys indicate that expo-
sure to tobacco smoke at home is a valid concern.

  An analysis of data from the Hispanic Health and
Nutrition Examination Survey indicates that 31 to 62
percent of Mexican American nonsmoking women had
household exposure to ETS (Pletsch 19941. In addi-
tion, 22 to 59 percent of Puerto Rican women and 40 to
53 percent of Cuban American women had such ex-
posure.

  In recent years, businesses and governments have
adopted policies, laws, and ordinances that limit ciga-
rette smoking in public places and in workplaces
(Rigotti and Pashos 1991). The effects of these policies
can be expected to benefit all U.S. residents, including
members of racial/ethnic minority groups. In addi-
tion, systemwide antismoking policies are being pro-
mulgated. For example, no-smoking policies have
been implemented in a number of federal workplaces,
including IHS hospitals and clinics and Department
of Defense installations. States have also been restrict-
ing smoking at a fairly rapid pace by banning smok-
ing on public transportation vehicles as well as in
health care offices and facilities, airports, other public
buildings, and elevators (O'Connor 1992). A number
of states also restrict smoking in indoor cultural and
recreational facilities, including libraries, museums,

Tobacco Control and Education Efforts  287


Surgeon General's Report

Table 6.  Percentage of adults who reported that no one is allowed to smoke anywhere inside the home,*
    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   Hispanics      Whites

%   x1+      %    XI      %     ?CI     %    KI     %   321

Overall
Total
Men
Women

Nonsmokers
Total
Men
Women

Smokers
Total
Men
Women

38.9   0.7      35.6 3.2      60.6     1.6    56.6 0.9    41.3 0.3
37.7 1.1      34.1     4.7     57.9     2.3    54.3 1.3    41.2 0.4
39.6 0.9      36.8 4.3      63.2     2.2    58.5 1.2    41.4 0.4

49.9 0.9      53.4 4.2     67.3     1.6    64.5 1.0    51.7 0.3
50.2   1.4      54.1     6.6     66.7     2.5    63.6 1.5    51.6 0.5
49.8   1.1      52.9 5.5     67.8     2.2    65.2    1.2    51.8 0.4

7.4 0.8       7.9     2.9     25.2     3.5    21.6 1.7    10.1 0.3
9.2 1.2      8.7 4.2     28.5     4.4    26.7 2.4    12.4 0.5
5.9 0.9       7.1     3.9     17.5     5.7    13.9 2.3     7.8 0.4

*Includes persons who reported having a rule that no one is allowed to smoke anywhere inside the home.
`95% confidence interval.
Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
1992-1993.

theaters, galleries, shopping malls, sports arenas, and
auditoriums. An ever-increasing number of states have
restricted smoking in schools and on school grounds
for students, school personnel, and other persons with
access to the school; 27 states restrict smoking in child
day-care centers. As of December 31, 1997, 41 states
have some kind of restriction on smoking in govern-
ment worksites, 21 have restrictions on smoking in pri-
vate worksites, and 31 restrict smoking in restaurants
(CDC, Office on Smoking and Health, State Tobacco Ac-
tivities Tracking and Evaluation System, unpublished
data).

  An increasing number of employers are also re-
stricting cigarette smoking. In the 1992-1993 CPS, a
substantial proportion of respondents reported that
their employers had policies prohibiting cigarette
smoking in work areas and in indoor public areas, such
as lobbies, rest rooms, and lunch rooms. Gerlach and
colleagues (1997) used data from the 1992-1993 NC1
Tobacco Use Supplement to the CPS to document the
prevalence and restrictiveness of workplace smoking
policies reported by African Americans, Asian Ameri-
cans and Pacific Islanders, Hispanics, and whites who
were employed in indoor workplaces. Their data

showed that 43.3 percent of African Americans, 51.4
percent of Asian Americans and Pacific Islanders, 45.1
percent of Hispanics, and 46.2 percent of whites
worked for employers who provided smoke-free
policies. In all four groups, women were more likely
than men to be protected by smoke-free policies. Over-
all, about one-third of employees worked in places that
either had no policy on smoking or allowed smoking
in private work areas. These minimal policies were
reported by 33.9 percent of African Americans, 29.7
percent of Asian Americans and Pacific Islanders, 37.3
percent of Hispanics, and 35.6 percent of whites. This
report did not present data on American Indians and
Alaska Natives.

  Members of the racial/ethnic minority groups
considered in this report tend to favor restrictions on
tobacco smoking (see Royce et al. 1993 for data on
African Americans). In the 1992-1993 CPS, Asian
Americans and Pacific Islanders and Hispanics were
generally more likely to support the total restriction
of cigarette smoking in restaurants, hospitals, indoor
workplaces, and indoor shopping malls (Table 7) (U.S.
Bureau of the Census, NC1 Tobacco Use Supplement,
public use data tapes, 1992-1993). Smokers were more

288 Chapter 5

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

likely to agree with partial restrictions of cigarette
smoking (limiting smoking to some areas within each
enclosed space) than to support the total restriction of
cigarette smoking in each of the public places included
in the CPS. Results of an ABC News/The Washington
Post poll conducted in February 1993 showed that
larger proportions of African Americans (54.3 percent)
and Hispanics (52.9 percent1 favored banning smok-
ing in public places, compared with whites (48.3 per-
cent) (Roper Center for Public Opinion Research 1993).
The same poll showed that fairly similar proportions
of Hispanics (87.9 percent), African Americans (84.3
percent), and whites (84.1 percent) felt that ETS was a
health risk. However, Hispanics (50.8 percent) and
African Americans (44.2 percent) reported worrying
more about ETS than whites (34.4 percent).

  Data from the 1992 California Tobacco Survey
showed that members of racial/ethnic groups had lim-
ited support for the complete ban of cigarette smok-
ing in restaurants and in workplaces (Pierce et al.
1994a). For example, smoking bans in restaurants drew
support from 53.5 percent of Hispanics, 41.9 percent
of African Americans, 35.0 percent of Asian Americans
and Pacific Islanders, and 34.7 percent of whites. The
data on smoking bans in the workplace were similar.
Hispanics (54.5 percent) were more likely to support
banning cigarette smoking in the workplace than were
Asian Americans and Pacific Islanders (43.5 percent),
African Americans (40.2 percent), and whites (34.4
percent).

  More recently, findings from a 1993 survey indi-
cate that residents of eight California cities (Fresno,
Hercules, Indio, Los Angeles, Paradise, Sacramento,
San Bernardino, and San Diego) significantly sup-
ported strong ETS controls (Sherwood et al. 1994). In
this 1993 survey, 78 percent of whites supported a com-
plete ban on smoking in restaurants, compared with
91.4 percent of Asian Americans, 89.5 percent of His-
panics, 82.6 percent of American Indians, and 82.5 per-
cent of African Americans. In addition, 84.5 percent
of whites strongly supported a complete ban on smok-
ing in the workplace, compared with 93.5 percent of
Asian Americans, 92.0 percent of Hispanics, 87.9 per-
cent of African Americans, and 85.6 percent of Ameri-
can Indians.

  The degree to which existing no-smoking poli-
cies are enforced in racial/ethnic communities is
unknown. In a recent survey of 39 American Indian
tribes, Glasgow and colleagues (1995) found signifi-
cant intertribal variations in the types of policies and
places covered by clean indoor air policies. For

example, 64 percent of the tribes reported having a no-
smoking policy that designated tribal schools, council
meeting areas, and private offices as nonsmoking ar-
eas, but none banned smoking in bingo halls. Those
tribes that received a specially developed policy work-
book and direct consultation on ways to implement
tobacco control policies were found to have adopted
stringent policies within two years of having received
the intervention materials (Lichtenstein et al. 1995). A
recent observational study of American Indian facili-
ties in California, Idaho, New Mexico, New York, Or-
egon, and Washington found that smoking policies
and practices varied considerably across settings (Hall
et al. 1995). Tribal schools and Indian health care fa-
cilities had the most restrictive policies. Tribal council
meeting areas and private offices were less likely to be
designated nonsmoking areas. No-smoking signs were
observed most frequently in clinics (46 percent) and
tribal offices (37 percent); no-smoking posters also were
prominent in clinics (49 percent). Evidence of smok-
ing (e.g., persons smoking, cigarette stubs, and ash-
trays) was observed most frequently in tribal offices
and cultural centers or community buildings (Hall et
al. 1995).

  A number of programs have tried to promote
clean indoor air policies and practices among mem-
bers of the racial/ethnic minority groups included in
this report, but little information is available on their
effectiveness. For example, Asian Americans for Com-
munity Involvement of Santa Clara County, based in
San Jose, California, has targeted 400 Asian American
restaurants and businesses to encourage them to have
smoke-free areas. However, the researchers had diffi-
culties assuring Asian American merchants that pro-
viding smoke-free areas would be good for business
(Jung 1993).

  Among American Indians, efforts have been
made to help various tribes develop comprehensive
smoke-free programs. For example, Glasgow and col-
leagues (1995) worked with 39 tribes in Washington,
Oregon, and Idaho to review, modify, and develop
tobacco-use policies that would protect tribal mem-
bers from ETS. Tobacco policy committees were es-
tablished to advise tribes during the policymaking
process. A tobacco policy workbook also was devel-
oped to guide the tribes. Although tribal leaders
expressed support for more stringent tobacco-use
policies, changes in tobacco policies were not produced
through the tobacco policy committees as the project
had originally planned.

Tobacco Control and Education Efforts  289


Surgeon General's Report

Table 7. Percentage of adults who think that smoking should be allowed in some areas or not allowed at
    all in selected public locations, * by race/ethnicity and smoking status, Current Population Survey,
     United States. 1992-1993

Characteristic

African
Americans

%    &C1+

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

  %     L?SI      %     KI      %   ZI     %   XI

Total          50.8   0.7     52.4
Nonsmokers     44.3   0.9     39.1
Smokers        69.5   1.3     73.4

Total          22.8   0.6
Nonsmokers     18.5   0.7
Smokers        35.0   1.4

Total          39.3   0.7     43.9
Nonsmokers     32.6   0.8     30.1
Smokers        58.5   1.4     65.8

Total           45.3   0.7     42.5
Nonsmokers     53.0   0.9     58.7
Smokers        23.5   1.2     16.9

Total          75.3   0.6     71.3
Nonsmokers      80.0   0.7     83.5
Smokers        62.0   1.4     51.8

Total          57.0   0.7     52.2    3.3      71.8     1.4      70.9   0.8    55.7   0.3
Nonsmokers     64.6   0.8     68.3    4.0      75.8     1.5      75.7   0.9    65.1   0.3
Smokers        35.6   1.4     26.5    4.7      50.5     4.1      50.3   2.1     27.6   0.5

Restaurants (allowed in some areas)

3.3      42.1     1.6      38.1   0.9    52.9   0.3
4.1      37.6     1.7     33.5   0.9    44.4   0.3
4.7      66.4     3.9      58.8   2.1     78.6   0.5

Hospitals (allowed in some areas)

26.6    2.9      12.8     1.1      12.9   0.6    25.8   0.2
15.6    3.1      11.2     1.1      10.5   0.6     19.0   0.3
44.3    5.3      21.7    3.4      23.4   1.8    46.3   0.6

  Indoor work areas (allowed in some areas)

3.3      24.7    1.4      25.8   0.8    40.7   0.3
3.9      21.0     1.4      21.6   0.8     32.4   0.3
5.0      44.3     4.1      44.1   2.1    65.5   0.5

  Restaurants (not allowed)

3.3      54.5     1.6      58.8   0.9    43.1   0.3
4.2      59.8     1.7     64.2   1.0    52.9   0.3
4.0      25.9    3.6      34.9   2.0    13.6   0.4

  Hospitals (not allowed)

3.0      85.1     1.1      85.7   0.6     72.5   0.3
3.2      86.9     1.2      88.3   0.6    79.9   0.3
5.3      75.8    3.5      74.2   I.8    50.6   0.6

Indoor work areas (not allowed)

*In response to the question about each place, "Do you think that smoking should be allowed in all areas, in some
areas, or not allowed at all?"
`95% confidence interval.
Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
1992-1993.

290 Chapter 5


Tobacco Use Among US. Racial/Ethnic Minority Groups

Table 7. Continued

Characteristic

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

%    XI      %    ?CI      %     &CI      %   KI     %   KI

Total
Nonsmokers
Smokers

Total
Nonsmokers
Smokers

Total
Nonsmokers
Smokers

Total
Nonsmokers
Smokers

Total
Nonsmokers
Smokers

Total
Nonsmokers
Smokers

Bars and cocktail lounges (allowed in some areas)

44.2   0.7     36.6    3.2     45.7     1.6     38.8   0.9    44.0   0.3
44.2   0.9     38.5    4.1      46.4     1.8      39.0   1.0    44.9   0.3
44.3   1.4     33.3    5.0      42.2     4.0      37.8   2.0    41.3   0.6

         Indoor sporting events (allowed in some areas)

30.3   0.7     25.8    2.9      23.0     1.4      22.4   0.7    28.7   0.3
27.1   0.8     17.9    3.3      21.1     1.4      20.2   0.8    23.9   0.3
39.2   1.4     38.2    5.2      32.8    3.8      31.9   1.9    43.3   0.6

         Indoor shopping malls (allowed in some areas)

39.9   0.7     40.8    3.3      32.3     1.5     28.2   0.8    41.6   0.3
35.7   0.8     31.7    4.0      29.1     1.6     25.2   0.9    35.2   0.3
51.7   1.4     54.8    5.3      49.5     4.1      41.3   2.1    61.2   0.6

           Bars and cocktail lounges (not allowed)

25.6   0.6     22.2    2.8      29.8    1.5     31.3   0.8    22.6   0.2
31.8   0.8     33.2    4.0      33.5     1.7     35.6   1.0    28.8   0.3
8.1   0.8      5.2    2.4       9.6     2.4      12.1   1.4     4.0   0.2

           Indoor sporting events (not allowed1

64.5   0.7     68.2    3.1      72.3     1.4      72.9   0.8    65.9   0.3
68.9   0.8     79.3    3.4      74.8     1.5      75.8   0.9    72.3   0.3
52.5   1.4     50.5    5.3      59.5    4.0      60.0   2.0    46.5   0.6

           Indoor shopping malls (not allowed)

54.4   0.7     52.3    3.3      62.7    1.6      67.2   0.8    52.6   0.3
59.7   0.8     65.2    4.0      66.5     1.7      70.8   0.9    60.6   0.3
39.7   1.4     32.3    5.0      42.7    4.0      51.3   2.1    28.6   0.5

Tobacco Control and Education Efforts  291


Surgeon General's Report

Economic Efforts to Reduce Tobacco Use

  Numerous efforts have been made to reduce the
use of cigarettes through excise and sales taxes. Be-
cause these taxes increase the price of cigarettes, higher
tax rates generally curb the demand for cigarettes, and
ultimately, tobacco consumption (Grossman 1989;
Peterson et al. 1992; Keeler et al. 1993; Townsend et al.
1994). Peterson and colleagues (1992) evaluated the
effects of state cigarette tax increases on cigarette sales
in the 50 states from 1985 through 1988. The research-
ers found that state cigarette tax increases were
associated with an average decline in cigarette con-
sumption of three cigarette packs per capita (a decline
of about 2.4 percent). Likewise, larger tax increases
were associated with larger declines in consumption.
In a recent study in Britain, Townsend and colleagues
(1994) found that individuals of low-socioeconomic
status were more responsive to changes in the price of
cigarettes than those who were more affluent.

  As of June 30,1996, all states, the District of Co-
lumbia, and 451 localities currently impose taxes on
cigarettes in addition to the federal tax (Tobacco Insti-
tute 1997). As of December 31,1997, state taxes ranged
from a low of 2.5 cents in Virginia to a high of $1 in
Alaska; the average state tax was 37.76 cents per pack
(CDC, Office on Smoking and Health, State Tobacco
Activities Tracking and Evaluation System, unpub-
lished data).

  Members of some racial/ethnic minority groups
have supported increases in taxes for tobacco prod-
ucts. In a 1990 survey of California smokers, 29.1 per-
cent of African American smokers and 34.5 percent of
Hispanic smokers reported that they would support a
cigarette tax increase (Burns and Pierce 1992). A much
smaller proportion of whites who smoke (20.0 percent)
supported such an increase. Recently, larger propor-
tions of California adults have supported an increase
in cigarette taxes. The 1992 California Tobacco Sur-
vey among both smokers and nonsmokers found that
cigarette tax increases were supported by 60.2 percent
of Asian Americans and Pacific Islanders, 50.4 percent
of Hispanics, 49.5 percent of African Americans, and
49.8 percent of whites (Pierce et al. 1994a). Further-
more, a 1993 nationwide survey conducted for the ACS
found that Hispanics (71 percent) and African Ameri-
cans (63 percent) supported an increase of $2 per pack
to pay for a national health insurance program (Marttila
& Kiley, Inc. 1993). These proportions were fairly
similar to those found among whites (66 percent).

  Although tobacco taxes are effective in discour-
aging smoking, some people consider increases in
excise taxes to be regressive because the poorer
members of society pay a higher proportion of their
income in taxes. Wasserman (19921, for example, states:

With respect to excise tax increases, however, we
must be mindful of the distributional conse-
quences of higher taxes. More precisely, because
low-income smokers do not appear to be any more
responsive to higher cigarette prices than high-
income smokers, higher excise taxes will result in
disproportionate economic harm, and, in some
cases, could lead poorer smokers to forgo food,
shelter, and needed health care to fulfill the per-
sistent and pernicious demands of their smoking
habits. As a result, higher cigarette taxes should
be accompanied by measures to compensate the
poor for the larger burden that they will necessar-
ily have to bear. For example, federal and state
income tax structures could be modified to facili-
tate such compensation (p. 20).

  A 1990 federal government report supported this
argument by presenting data from the 1984-1985
Consumer Expenditure Survey Interview showing that
families in the lowest income quintile spent 4 percent
of their posttax income on tobacco products, compared
with families in the highest quintile, who spent 0.5
percent of their posttax income on tobacco products
(U.S. Congressional Budget Office 1990). On the other
hand, some argue that the hardship of increased taxes
on the poor is outweighed by the fact that smoking-
related health costs and suffering decline among
persons who smoke fewer cigarettes or stop smoking
because of the higher taxes on tobacco. A group of
economists meeting in 1995 concluded that additional
research on costs is needed before an optimal cigarette
excise tax from an economic perspective can be deter-
mined (Warner et al. 1995). These economists agreed
that the strongest argument currently for increasing
cigarette taxes is the protection of children.

  The actual effects of excise tax initiatives on mem-
bers of racial/ethnic minority groups are difficult to
ascertain. Nevertheless, reductions in the consumption
of tobacco products resulting from increases in excise
taxes should ultimately benefit members of U.S.
racial/ethnic groups by lowering their prevalence of

292 Chapter 5


Tobacco Use Among U.S. RaciaZIEthnic Minority Groups

cigarette smoking and by limiting or lowering their
exposure to ETS. California's experience after increas-
ing the tax on cigarettes shows that a number of
community-based projects, school-based interventions,
and research activities, which directly benefit members
of the racial/ethnic groups and could not have been
funded from other sources of tax revenue, can be

funded through the revenue generated by the increased
taxes (Breslow and Johnson 1993). In addition, given
the need to help community-based programs and or-
ganizations rely less on tobacco industry support
(Satcher and Robinson 1994), earmarked tax revenues
may prove to be a viable alternative.

Efforts to Control Tobacco Advertising and Promotion

  Tobacco products are heavily advertised in
racial/ethnic publications and in racial/ethnic com-
munities. Efforts to restrict the effects of advertising
and promotion of tobacco products in racial/ethnic
communities have been limited by various factors,
including the communities' reliance on the tobacco
industry (see Chapter 4), difficulties in mobilizing com-
munities that are faced with problems perceived to be
in need of more immediate attention (e.g., affordable
housing, unemployment, unequal education, and
racial/ethnic minority discrimination), the lack of
trained community leaders interested in health issues,
and possibly the lack of infrastructure for tobacco pre-
vention and control initiatives in racial/ethnic com-
munities (Robinson et al. 1995). As a result, persons
residing in racial/ethnic communities are continually
exposed to the advertising and promotion of tobacco
products. A recent study in Los Angeles County, for
example, examined the risk of exposure to outdoor
advertising of cigarettes among residents of various
communities (Ewert and Alleyne 1992). The results
suggest that persons residing in the city of Los Angeles
were more likely to be exposed to cigarette and alcohol
billboard advertisements than residents of nearby sub-
urbs. Cigarettes were advertised on 59 of the 299 bill-
boards (19.7 percent) surveyed on 46.2 miles of streets.
The number of cigarette advertisements was 4.6 times
greater in the city of Los Angeles than in its suburbs.

  Members of some racial/ethnic minority groups
tend to be more likely than whites to support a ban on
tobacco product advertisements (Table 8). Data from
the 1992-1993 CPS showed that 37.5 percent of whites
supported a ban on advertising tobacco products, com-
pared with 44.7 percent of Hispanics, 39.5 percent of
Asian Americans and Pacific Islanders, and 38.3 per-
cent of African Americans (U.S. Bureau of the Census,
NC1 Tobacco Use Supplement, public use data tapes,
1992-1993). In each racial/ethnic group, women and

nonsmokers were more supportive of a total ban on
tobacco advertising than were men and smokers. The
1992 California Tobacco Survey found that adult Cali-
fornians supported the banning of such advertising
in newspapers and magazines as well as on billboards
(Table 9) (Pierce et al. 1994a). The same survey also
showed support for banning tobacco companies from
sponsoring cultural events, Hispanics tend to show
the greatest level of support for these measures,
whereas whites support them the least. Data from the
1992-1993 CPS also showed that fairly large percent-
ages of racial/ethnic group members would support
a ban on the free distribution of tobacco samples
(Table 10) (U.S. Bureau of the Census, NC1 Tobacco
Use Supplement, public use data tapes, 1992-1993).
Hispanics (59.4 percent) and Asian Americans and
Pacific Islanders (57.5 percent) were the most likely
respondents to state that they supported such a ban.
In all groups, women and nonsmokers were more
likely than men and smokers to favor the ban.

  The 1994 RWJF Youth Access Survey (Table 4)
found varying support for restricting or banning dif-
ferent types of tobacco advertising. Hispanics and
African Americans were more likely than whites to
support such proposals (Nancy Kaufman et al., un-
published data). Hispanics were more supportive of
bans on billboard, newspaper, and magazine adver-
tising than were African Americans and whites. Re-
quiring plain packaging of tobacco products (brand
name and warning label in black letters on white
background) was supported substantially more by
Hispanics than by African Americans or whites.

  In recent years, the tobacco industry has shifted
expenditures for advertising to promotional market-
ing, with 89 percent of 1995 expenditures devoted to
nonadvertising promotions (Federal Trade Commis-
sion 1997). The RWJFYouth Access Survey found that
broad-based support exists for eliminating coupon

Tobacco Control and Education Efforts  293


Surgeon General's Report

Table 8.  Percentage of adults who think that the advertising of tobacco products should be always allowed
    or not allowed at all," 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   Hispanics      Whites

%    &C1+     %    KI       %    KI      %    *I     %   XI

Total
Always
Not at all
Men
Always
Not at all
Women
Always
Not at all

Nonsmokers
Always
Not at all
Men
Always
Not at all
Women
Always
Not at all

Smokers
Always
Not at all
Men
Always
Not at all
Women
Always
Not at all

17.3    0.6     21.5    2.7      12.6    1.1      13.7
38.3   0.7    36.6   3.2      39.5    1.6     44.7

19.8    0.9     24.0    4.2      15.6    1.7      16.8    1.0    25.5 0.4
35.2    1.1     30.5   4.5      35.9    2.2     39.2   1.3    32.9 0.4

15.7    0.7     19.4    3.5       9.7    1.3      11.2   0.8    17.9 0.3
40.3    0.9     41.6    4.4      43.0    2.2     49.2   1.2    41.5 0.4

13.6    0.6     13.0    2.9      10.5    1.1      11.4   0.6    16.7 0.2
42.2    0.8     44.3   4.2      41.8    1.7     47.8    1.0    42.0 0.3

16.5    1.0     15.6   4.8      13.4    1.8      14.0    1.1    20.7 0.4
38.3    1.4     38.1    6.4      38.3    2.5      42.3    1.5    37.0 0.5

11.8    0.7     11.2    3.5       8.2    1.3      9.6   0.8    13.4 0.3
44.5    1.1     48.7   5.6      44.7    2.4     51.6    1.3    46.3 0.4

28.2    1.3     34.7    5.1      23.7    3.5      24.0    1.8    35.6 0.5
27.2    1.3     24.3    4.6      27.5    3.6      31.1    1.9   23.9 0.5

27.5    1.9     34.8    7.1      23.2    4.1      25.4   2.3
28.1    1.9     20.1    6.0      28.1    4.4     29.9    2.5

28.7    1.8     34.5    7.2      25.0    6.5      21.9   2.8
26.5    1.7     28.5    6.8     26.1    6.6      32.9    3.1

21.4 0.2
37.5 0.3

38.8 0.8
21.5  0.7

32.4 0.7
26.2 0.7

"In response to the question, "Do you think advertising of tobacco products should be always allowed, allowed
under some conditions, or not allowed at all?"
+95% confidence interval.

Source: U.S. Bureau of the Census, National Cancerlnstitute Tobacco Use Supplement, public use data tapes,
1992-1993.

promotions, such as promotional gear or free cigarettes
by mail (Nancy Kaufman et al., unpublished data).
Hispanics continue to be more supportive of promo-
tional bans than non-Hispanics, with 89.8 percent of
Hispanics supporting elimination of coupons for ob-
taining free cigarettes by mail, compared with 79.5
percent of African Americans and 80.4 percent of
whites. In addition, 82.4 percent of Hispanics favor
elimination of cigarette pack coupons that can be ex-
changed for promotional items such as clothing, com-
pared with 76.5 percent of African Americans and 67.8

percent of whites. The public is more ambivalent about
not allowing tobacco-company sponsorship of sport-
ing or entertainment events in which their cigarette
brand names are featured during television broadcasts.
Hispanics were more supportive of such a ban than
were African Americans and whites (Table 4).

  Racial/ethnic minority communities have begun
to respond to the tobacco industry's targeted adver-
tising andmarketing efforts by mobilizing against the
industry. The strong community response in Phila-
delphia against the planned introduction of Uptown

294 Chapter 5

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

Table 9. Percentage of Californians* who support curtailment of tobacco advertising and promotion
    efforts, by race/ethnicity, 1992

                      African       Asian Americans/
Curtailment               Americans      Pacific Islanders     Hispanics     Whites

Ban advertising in newspapers
and magazines                 60.2             51.2             74.7         47.7

Ban advertising on billboards       64.9            57.6            78.1        54.9

Ban sponsorship of sporting or
cultural events

63.7             59.4             70.1        50.7

*Data on American Indians and Alaska Natives are not reported because of small sample size.
Source: Pierce et al. 1994a.

cigarettes, a brand targeting African Americans, re-
sulted in the cancellation of the test marketing of the
cigarette by its producers and a renewed interest in
tobacco control efforts among African Americans in
Philadelphia (see Chapter 4). The Coalition Against
Uptown Cigarettes, which led the campaign, suc-
ceeded by building on previous efforts by Philadel-
phia organizations and individuals to control tobacco
use among the city's African Americans. These orga-
nizations include some African American clergy as well
as voluntary associations, particularly the ALA and
the ACS, the Fox Chase Cancer Center, the local
Committee to Prevent Cancer among Blacks, and the
Philadelphia chapter of the National Black Leadership
Initiative on Cancer (NBLIC). Indeed, the NBLIC in
Philadelphia served as a common meeting ground
for leaders from various agencies and provided op-
portunities for the development of mutual trust needed
during the campaign. The NBLIC had been formed
several years before under the leadership of Louis W.
Sullivan, M.D., then and now president of Morehouse
School of Medicine. Subsequently, Dr. Sullivan pro-
vided strong support to the coalition's efforts in his
role as Secretary of Health and Human Services. The
fact that the Uptown coalition was led by African
Americans in this historic benchmark in the tobacco
control movement was central to its ultimate success.
Moreover, the participation of Philadelphia's African
American clergy and the participation of an African
American minister as a key coalition spokesperson
were critical in obtaining community support for the
Coalition Against Uptown Cigarettes. This support
added to the campaign's credibility and guaranteed
its success as a grassroots communications vehicle.

  The experience of the Coalition Against Uptown
Cigarettes is significant not only for the result it

achieved but also because it provides a case study in
community mobilization. The coalition focused its ef-
forts primarily on African Americans-both smokers
and nonsmokers-with the goal of derailing the intro-
duction of Uptown cigarettes by convincing smokers
to refuse to sample the new brand. To accomplish this,
the coalition crafted messages that targeted R.J.
Reynolds rather than smokers. In addition, the coali-
tion aimed at forming a partnership among African
American smokers and nonsmokers around the issue
of limiting minors' access to this new tobacco product.
Also central to the success of the Coalition Against
Uptown Cigarettes was its strategic use of mass media
(Robinson and Sutton, in press). Coalition leaders ex-
panded the debate beyond health; identified the tobacco
industry's major positions related to economics, civil
rights, and self-determination; and developed specific
counterarguments. For example, when tobacco indus-
try supporters argued that tobacco control advocates
were taking away smokers' right of free choice, coali-
tion spokespersons countered by stating that the
community had not asked for Uptown cigarettes, that
excessive billboard advertising of cigarettes in African
American communities did indeed take away choices,
that smokers had the right to choose to reject Uptown
cigarettes, and that communities had the right to choose
what products entered their neighborhoods.

  Another example of community mobilization in
tobacco control occurred early in 1995, when a new
mentholated cigarette brand named "X" being mar-
keted in Boston was withdrawn by its manufacturer
and distributor after protests by the African American
community, led by the NAAAPI and Boston-based
Churches Organized to Stop Tobacco (COST) (Jackson
1995). X cigarettes were packaged in the Afrocentric
colors red, black, and green and featured a prominent

Tobacco Control and Education Efforts  295


Surgeon General's Report

Table 10.  Percentage of adults who think that giving away free tobacco samples should be always allowed or
    not allowed at all,* by raceiethnicity, smoking status, and gender, Current Population Survey, United
     States, 1992-1993

Characteristic

AfliCiUl   American Indians/  Asian America.4
Americans   Alaska Natives    Pacific Islanders   Hispanics      Whites

%    KI+ %    KI       %    &Cl      %    &Cl %   KI

Total
Always
Not at all
Men
Always
Not at all
Women
Always
Not at all

Nonsmokers
Always
Not at all
Men
Always
Not at all
Women
Always
Not at all

Smokers
Always
Not at all
Men
Always
Not at all
Women
Always
Not at all

11.4    0.5     12.8    2.2
49.9   0.7     49.9   3.3

13.4    0.8     14.6
46.8    1.2     46.4

10.0    0.6     11.2
52.0    0.9     52.9

7.7
55.9

9.4   0.8     8.1
52.6    1.4     57.8

6.8   0.5     5.8
57.9    1.1     63.7

21.8    1.2     22.1
33.3    1.4     32.1

22.5    1.8     22.8
33.9    2.0     31.3

21.1    1.6     21.3
32.7    1.9     32.9

0.5     6.8
0.9     61.2

0.8
1.6

3.5            1.3
4.9   5;::    2.3   5;::


2.8       4.8    1.0      5.8
4.5      62.7    2.2      63.9


2.1       5.3    0.8      5.9
4.1      61.0    1.7      63.5

3.6       7.1    1.3      7.8
6.5      55.9    2.6      58.6

2.6       3.9    0.9      4.6
5.3      65.1    2.3      66.9


4.4      15.7    3.0      15.5
5.0      38.9    4.1      41.1

6.3      16.5    3.6      16.4
7.0      39.2    4.8      39.1

6.2      13.8    5.2      14.1
7.1      38.4    7.3      44.1

0.5
0.9

12.2
54.3

0.8    15.3
1.3    48.9

0.6     9.4   0.2
1.2    59.1   0.4

0.5     8.4   0.2
1.0    62.2   0.3

0.8    11.2   0.3
1.5    56.3   0.5

0.5     6.0   0.2
1.2    67.3   0.4

1.5    23.6   0.5
2.1    30.6   0.5

2.0    26.9   0.7
2.6    28.4   0.7

2.3    20.5   0.6
3.3    32.9   0.7

*In response to the question, "Do you think that giving away free samples by tobacco companies should be always
allowed, allowed under some conditions, or not allowed at all?"
+95% confidence interval.
Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
1992-1993.

"X," a symbol associated with African American leader     NAAAPI demanded in writing that X cigarettes
Malcolm X. Although X cigarettes were manufactured   be withdrawn. Extensive media coverage was given
and distributed by two relatively small companies with   to NAAAPI leaders invited to speak, as part of Boston
modest marketing efforts, African American commu-   Black History Month events, to large audiences about
nity leaders feared that even a small success could fuel   the need for communities to mobilize against tobacco.
the creation of similar products by major tobacco com-   As a result of NAAAPI's organizing efforts, the cre-
panies with larger resources for advertising and   ator and distributor of X cigarettes (Stowecroft Brook
promotion. Unlike the case of Uptown cigarettes,   Distributors, Charlestown, Massachusetts) and the
however, both the manufacturer and the distributor   manufacturer (Star Tobacco Corporation, Petersburg,
of X cigarettes denied that their product was targeted   Virginia) received protests from around the country,
to an African American market.            including calls from organizations in the African

296 Chapter 5


Tobacco Use Among U.S. lXaciallE:l:~~ic Minority Groups

American Tobacco Control Network of California. This
successful strategy demonstrated again the effective-
ness of united action against tobacco within the Afri-
can American community and the ability of NAAAPI
and its African American tobacco control network to
extend the achievements of the Uptown experience.

  In other racial/ethnic communities, some groups
have rejected billboards advertising tobacco products.
In Detroit, for example, Wayne County Commissioner
Alberta Tinsley-Williams founded the Coalition
Against Billboard Advertising of Alcohol and Tobacco,
which enlisted the support of churches, schools, and
civic groups to seek the removal of such billboards.
Other communities have gone even further. For
example, inspired by the anonymous Chicagoan
"Mandrake," who painted over tobacco and alcohol
billboards in ethnic neighborhoods, Reverend Calvin
Butts led parishioners on walking tours in New York
City to document and whitewash billboards advertis-
ing tobacco and alcohol (Associated Press 1990). Such
acts were emulated by Dallas County, Texas, Commis-
sioner John Wiley Price and Chicago-based Reverend
Michael L. Phleger (Collins 1990). These grassroots
efforts culminated in a meeting of African American
community leaders in Greensboro, North Carolina, in
1991. This meeting led to the founding of a national
group to combat tobacco and alcohol advertising in
ethnic communities, NAAAPI (Food & Drirrk Daily
1991). Chaired by the Reverend Jesse W. Brown, the
NAAAPI aims to increase public awareness of the dev-
astating effects of cigarette and alcohol advertising
among African Americans. The NAAAPI has gained
affiliates in various communities throughout the
United States. In 1994, the association supported ef-
forts to drape covers over cigarette billboards in Afri-
can American communities and led memorial services
for persons who had died because of tobacco use.

  Another example of community mobilization
against the advertising and promotion of tobacco prod-
ucts is taking place in California. To coordinate
racial and ethnic-specific, state-funded activities sup-
ported by the increase in the cigarette sales tax, the
California Department of Health Services's Tobacco
Control Section developed and funded four racial/
ethnic minority networks, the first of which was the
Hispanic/Latin0 Tobacco Education Network. This
network was hosted by the University of San Fran-
cisco through 1996 and has attracted more than 500
members. The other networks include the Asian
Pacific Islander Tobacco Education Network (initially
hosted by the Asian American Health Forum), which
comprises approximately 200 organizations; the Afri-
can American Tobacco Education Network (initially

sponsored by the Bay Area Urban League), which has
approximately 300 members; and the American Indian
Tobacco Education Network. These networks have
been charged with coordinating and mobilizing to-
bacco control efforts among various communities and
helping community agencies to better design and
implement their programs. The various networks have
different goals, responsibilities, and levels of funding,
but one common thread is their commitment to ensur-
ing that racial/ethnic communities take an active role
in defining their own tobacco control needs. In gen-
eral, the networks organize a variety of strategy and
training sessions, media and advocacy campaigns, and
technical assistance programs. They also help develop
and evaluate resources on tobacco control and preven-
tion and promote networking among their members.
Although evaluations of these networks have not yet
been completed, the networks' role as catalysts is al-
ready evident. Thus far, the networks have garnered
the support of community agencies funded to carry
out tobacco control efforts in California. For example,
70 percent of the funded community agencies in Cali-
fornia reported attending meetings of these racial/
ethnic minority networks during the summer of 1993
(Elder et al. 1993a).

  One emergent network is the International
Multicultural Partnership, which grew out of the
ASSIST program and provides technical assistance to
racial/ethnic communities interested in tobacco pre-
vention and control. It is a consortium that includes
members from over 31 states and several countries.
Its mission is to develop and implement culturally
appropriate health education programs and services
that will effectively reach those population groups at
highest risk of tobacco-related illness and death.

  In addition to efforts to control tobacco advertis-
ing in specific racial/ethnic communities, the FDA
regulations approved by President Clinton in August
1996 broadly support such activities in racial/ethnic
and other communities in the form of the provisions
that ban billboards advertising tobacco products within
1,000 feet of schools and playgrounds, limit in-store
advertising (except in adult-only facilities) and bill-
boards to black-and-white text, limit advertising to
black-and-white text in publications with significant
readership under age 18, prohibit brand logos on vari-
ous promotional items, and prohibit sponsorship of
sporting or entertainment events using brand or prod-
uct identification. The FDA regulations are intended
to reduce teenage access and attraction to tobacco prod-
ucts among all racial and racial/ethnic minority groups
(Federal Register 1996).

Tobacco Corltrol and Education Efforts  297


Surgeon General's Report

Tobacco Product Regulations

  An important approach to controlling and pre-
venting tobacco use is the drafting and enacting of
product regulations. These large social interventions
range from the use of cigarette warning labels to the
licensing of tobacco product sales, and they can regu-
late the product's packaging, its distribution, and even
its components. Because most of these regulations af-
fect all people residing in the United States, rather than
just members of racial/ethnic communities, they are
not described in detail here. The 1994 Youth Access
Survey commissioned by RWJF found significant pub-
lic support among all those surveyed for requiring

tobacco companies to list the additives to their prod-
ucts on package labels (African Americans, 88.9 per-
cent; Hispanics, 90.4 percent; and whites, 93.6 percent).
Most respondents also supported government regu-
lation of cigarettes, although support was somewhat
stronger among Hispanics (81.1 percent) than among
African Americans (72.6 percent) and whites (69.5 per-
cent) (Table 11).

  Among the few tobacco product regulations to
specifically target a racial/ethnic group are Spanish-
language warning labels, which appear in cigarette ad-
vertisements and promotions in Spanish-language

Table 11.  Public beliefs about and support for policies related to nicotine and tobacco product regulation,
     Robert Wood Johnson Foundation Youth Access Survey, 1994

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

Characteristic                            %    kC1+       %   kC1        %    KI

Think nicotine in cigarettes is addictive

Believe that cigarette companies deliberately
adjust nicotine levels to keep smokers
addicted to cigarettes

Favor requiring tobacco companies to gradually
reduce the amount of nicotine in cigarettes

Favor requiring insurance companies to cover
the cost of programs to quit smoking
Favor requiring tobacco companies to list
additives on package labels the way food and
drug companies are required to list
ingredients

Agree that because the government regulates
all other products containing nicotine, such as
nicotine patches and nicotine gum, the
government should also regulate cigarettes

90.9





57.5



77.7



66.7







88.9







72.6

2.90       86.8 4.16       92.6 1.65

5.41       56.8 5.62       54.9 3.06



4.68       84.8 4.02       79.1   2.43



5.35       77.0 4.64       63.4 2.96

3.64       90.4 3.41       93.6 1.63

5.00       81.1 4.19       69.5 2.82

*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.

298 Chapter 5

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

publications or on billboards located in Hispanic
communities. The use of warning labels is one of the
earliest and best known mechanisms that the federal
government has employed to inform the public about
the health hazards of smoking. Warning labels have
been required on cigarette packages and in cigarette
advertising since 1966, and four rotating health warn-
ings have been required on cigarette packages and ad-
vertisements since October 12, 1984, through Public
Law 98-474. Warning labels are not required on ciga-
rettes made for export, cigarettes manufactured abroad
by U.S. tobacco companies, or other tobacco products,
such as cigars, pipe tobacco, and roll-your-own
cigarette tobacco. Warning labels on smokeless tobacco
containers have been required since passage in 1986
of Public Law 99-252, which took effect in 1987.

   Little is known about the level of awareness or
effectiveness of cigarette warning labels among
members of racial/ethnic groups or members of the U.S.
population at large. A 1991 study of Hispanics in San

Conclusions

Francisco has shown that Hispanics are more aware of
the presence of warning labels on cigarettes (69.3 per-
cent) than on other products, such as diet soda (27.2
percent), wine (27.6 percent), beer (31.5 percent), and
aspirin (36.7 percent) (Marfn 1994). The same study also
found that the level of awareness of cigarette warning
labels was higher among highly acculturated Hispan-
ics (76.5 percent) than among less acculturated Hispan-
ics (65.5 percent). This finding may be attributable to
the fact that highly acculturated Hispanics have greater
fluency in English-the language used for most prod-
uct warning labels and cigarette packages.

  Support for warning labels does not seem to dif-
fer significantly across racial/ethnic minority groups.
In a 1992 Louis Harris and Associates poll of 488 smok-
ers, 65 percent of Hispanics, 58 percent of African
Americans, and 56 percent of whites favored legisla-
tion that required stronger warning labels on cigarette
packages than those currently required by law (Louis
Harris and Associates, unpublished data).

1.  More research is needed on the effect of culturally
appropriate programs to reduce tobacco use
among racial/ethnic minority groups. Interven-
tions should be language appropriate; addressing
psychosocial characteristics such as depression,
stress, and acculturation may increase the accep-
tance of programs by members of racial/ethnic
  groups.

2.  To be culturally appropriate, tobacco control pro-
grams must reflect the targeted racial/ethnic
group's cultural values, consider the group's
psychosocial correlates of tobacco use, and use
strategies that are acceptable and credible to mem-
bers of the group. Culturally competent program
staff must be aware and accepting of cultural dif-
  ferences, be able to assess their own cultural val-
ues, be conscious of intercultural dynamics when
persons of different cultures interact, be aware of
a racial/ethnic group's relevant cultural charac-
teristics, and have the skills to adapt to cultural
diversity.

3.  Numerous strategies are needed to control tobacco
use among racial/ethnic youths: restricting mi-
nors' access to tobacco products, establishing cul-
turally appropriate school-based programs, and
designing mass media efforts geared to young
people's interests, attitudes, expectations, and
norms. Recent provisions of the Synar Amend-
ment, designed to prevent minors' access to to-
bacco products, and the FDA regulations aimed
at reducing the access to and appeal of tobacco
products to young people are intended to reduce
tobacco use among all youth, including members
of racial/ethnic minority groups.

4.  Members of racial/ethnic groups are less likely
than the general population to participate in smok-
ing cessation groups and to receive cessation ad-
vice from health care providers. Barriers to ethnic
group participation include limited cultural com-
petence of health care providers and a lack of trans-
portation, money, and access to health care.

Tobacco Control and Educafion Efforts  299


Surgeon General's Report

5.  Available data indicate that racial/ethnic groups
support smoking restrictions, such as increasing
cigarette excise taxes, banning cigarette advertise-
ments, restricting access to cigarette vending ma-
chines, raising the legal age of purchase,
prohibiting sponsorship of events by tobacco com-
panies, and establishing clean indoor air regula-
  tions. Additional research is needed to evaluate
how best to build on this base of public opinion
support to strengthen existing tobacco prevention
and control programs within racial/ethnic
  communities.

6.  Prevention and cessation efforts in racial/ethnic
communities are limited by underdeveloped to-
  bacco control infrastructures and low levels of re-
sources for research, program development, and
program dissemination. Greater resources are
needed in racial/ethnic minority communities to
  build tobacco control infrastructures and to
develop initiatives.

300 Chapter 5

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

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310 Chapter 5

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

List of Tables and Figures

Chapter 1

Introduction and Summary of Conclusions

Table 1.

U.S. population distribution, by race/
ethnicity and Hispanic origin, and
percentage change, 1980-1990 8

Table 2.

Selected demographic characteristics for
the U.S. population, by race/ethnicity,
1990 9

Table 3.

Estimated percentage distribution of
the U.S. population, by race/ethnicity
and Hispanic origin, 1990-2050  10

Chapter 2

Patterns of Tobacco Use Among Four Racial/Ethnic
Minority Groups

Table 1.

Percentage of adult African Americans
who reported being current cigarette
smokers, overall and by gender, age, and
education, National Health Interview
Surveys, United States, 1978-1995
aggregate data 22

Table 2.

Percentage of adult African American
smokers who reported smoking ~15,
15-24, or 2 25 cigarettes per day, overall
and by gender, age, and education,
National Health Interview Surveys,
United States, 1978-1995 aggregate
data 24

Table 3.

Percentage of adult African American
ever smokers who have quit, overall and
by gender, age, and education, National
Health Interview Surveys, United States,
1978-1995 aggregate data 26

Table 4.

Current cigarette smoking status among
persons who reported that they were
daily smokers 1 year before being
surveyed, Current Population Survey
National Cancer Institute Supplement,
1992-1993 27

Table 5.

Percentage of African American women
of reproductive age who reported being
current cigarette smokers, overall and by
education, National Health Interview
Surveys, United States, 1978-1995
aggregate data 28

Table 6.

Percentage of live-born infants' mothers
who reported smoking during preg-
nancy, by year and race/ethnicity, U.S.
final natality statistics, 1989-1995  29

Table 7.

Trends in the percentage of high school
seniors who were previous-month
smokers, by race/ethnicity and gender,
Monitoring the Future surveys, United
States, 1976-1979,1980-1984,1985-1989,
1990-1994 32

Table 8.

Percentage of African Americans and
whites 20-34 years of age who reported
being current cigarette smokers, by age
group and gender, National Health
Interview Surveys, United States,
1978-1995 aggregate data 33

Table 9.

Percentage of African Americans and
whites 20-24 years of age who reported
being current cigarette smokers, by
education and gender, National Health
Interview Surveys, United States,
1978-1995 aggregate data 34

Table 10.  Percentage of African American and
    white high school seniors who reported
    recently using or not using cigarettes
     and other selected substances, Monitor-
    ing the Future surveys, United States,
    1976-1994 aggregate data 37

Table 11.  Cumulative percentages of recalled age
    at which a respondent first tried a
    cigarette and began smoking daily,
    among African American, Hispanic, and
     white men and women aged 30-39,
     National Household Surveys on Drug
     Abuse, United States, 1994-1995  40

List of Tables and Figures  311


Surgeon General's Report

Table 12.

Table 13.

Table 14.

Table 15.

Table 16.

Table 17.

Table 18.

Percentage of African American and
white high school seniors who reported
previous-month and heavy smoking, by
selected variables, Monitoring the
Future surveys, United States,
1976-1994 42

Percentage of American Indian and
Alaska Native adults who reported
being current cigarette smokers, overall
and by gender, age, and education,
National Health Interview Surveys,
United States, 1978-1995 aggregate
data 46

Percentage of adult American Indian
and Alaska Native smokers who re-
ported smoking <15,15-24, or 2 25
cigarettes per day, overall and by
gender, age, and education, National
Health Interview Surveys, United States,
1978-1995 aggregate data 47

Percentage of adult American Indian
and Alaska Native ever smokers who
have quit, overall and by gender, age,
and education, National Health Inter-
view Surveys, United States, 1978-1995
aggregate data 48

Percentage of American Indian and
Alaska Native women of reproductive
age who reported being current cigarette
smokers, overall and by education,
National Health Interview Surveys,
United States, 1978-1995 aggregate
data 49

Percentage of American Indian and
Alaska Native adults who reported
being current cigarette smokers, overall
and by region/state, gender, age, and
education, Behavioral Risk Factor
Surveillance System, 1988-1992
aggregate data 50

Percentage of adult American Indian
and Alaska Native smokers who re-
ported smoking <15,15-24, or 2 25
cigarettes per day, overall and by
region/state, gender, age, and educa-
tion, Behavioral Risk Factor Surveillance
System, 1988-1992 aggregate data  52

Table 19.

Table 20.

Table 21.

Table 22.

Table 23.

Table 24.

Table 25.

Percentage of adult American Indian
and Alaska Native smokers who re-
ported they quit smoking, overall and
by region/state, gender, age, and
education, Behavioral Risk Factor
Surveillance System, 1988-1992
aggregate data 54

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  56

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 57

Percentage of adult Asian American and
Pacific Islander smokers who reported
smoking <15,15-24, or 2 25 cigarettes
per day, overall and by gender, age, and
education, National Health Interview
Surveys, United States, 1978-1995
aggregate data 58

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 59

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 60

Percentage of Chinese and Vietnamese
men who reported they smoke and the
number of cigarettes they smoke per
day, by age, education, annual house-
hold income, and level of acculturation,
Behavioral Risk Factor Surveillance
System, California, 1990 and 1991
aggregate data 62

312  List of Tables and Figures

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

Table 26.

Table 27.

Table 28.

Table 29.

Table 30.

Table 31.

Table 32.

Table 33.

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 63

Summary of selected findings on the
percentage of Asian American and
Pacific Islander adults who smoke,
overall and by gender, i975-1995  64

Percentage of adult Hispanics who
reported being current cigarette smok-
ers, overall and by gender, age, and
education, National Health Interview
Surveys, United.States, 1978-1995
aggregate data 67

Percentage of adult Hispanic smokers
who.reported smoking <15,15-24, or
2 25 cigarettes per day, overall and by
gender, age, and education, National
Health Interview Surveys, United States,
1978-1995 aggregate data 68

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 70
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 72

Percentage of self-reported cigarette
brand use among adult current cigarette
smokers, overall and by race/ethnicity
and gender, National Health Interview
Surveys (NHIS) 1978-1980 combined,
Adult Use of Tobacco Survey (AUTS)
1986, and NHIS 1987  80

Percentage of self-reported cigarette
brand use among adolescent current
cigarette smokers, by race/ethnicity,
Teenage Attitudes and Practices Survey
(TARS), 1989 and 1993  82

Table 34.

Table 35.

Table 36.

Table 37.

Table 38.

Table 39.

Table 40.

Table 41.

Relationship between smoking status
and race/ethnicity among adults, before
and after controlling for education,
National Health Interview Surveys,
United States, 1987,1988,1990, and 1991
aggregate data 84

Percentage of all adults and nonsmokers
who reported levels of exposure to
environmental tobacco smoke in the
home, by race/ethnicity and gender,
National Health Interview Surveys,
United States, 1991-1993 aggregate
data 87

Age-adjusted prevalence of current
cigarette smoking among adults, overall
and by race/ethnicity and gender,
National Health Interview Surveys,
United States, 1994 and 1995 aggregate
data 88

Cigarette smoking status and number of
cigarettes smoked per day among
adults, overall and by race/ethnicity and
gender, National Health Interview
Surveys, United States, 1987,1988,1990,
and 1991 aggregate data 90

Percentage of adults who reported using
cigars, pipes, chewing tobacco, snuff, or
any form of tobacco, overall and by
race/ethnicity and gender, National
Health Interview Surveys, United-States,
1987 and 1991 aggregate data  92

Percentage of white adults who reported
being current cigarette smokers, overall
and by gender, age, and education,
National Health Interview Surveys,
United States, 1965-1995 98

Percentage of adult white smokers who
reported smoking <15,15-24, and 2 25
cigarettes per day, overall and by
gender, age, and education, National
Health Interview Surveys, United States,
1965-1995 100

Percentage of adult white ever smokers
who have quit, overall and by gender,
age, and education, National Health
Interview Surveys, United States,
1965-1995 104

List of Tables and Figures  313


Surgeon General's Report

Table 42.

Table 43.

Table 44.

Table 45.

Table 46.

Table 47.

Table 48.

Table 49.

Table 50.

Percentage of white women of reproduc-
tive age who reported being current
cigarette smokers, overall and by
education, National Health Interview
Surveys, United States, 1965-1995  206

Percentage of white adults who reported
being current cigarette smokers, overall
and by gender, age, and education,
National Health Interview Surveys,
United States, 1978-1995 aggregate
data 107

Percentage of adult white smokers who
reported smoking <15,15-24,225
cigarettes per day, overall and by
gender, age, and education, National
Health Interview Surveys, United States,
1978-1995 aggregate data 108

Percentage of adult white ever smokers
who have quit, overall and by gender,
age, and education, National Health
Interview Surveys, United States,
1978-1995 aggregate data 710

Percentage of white women of reproduc-
tive age who reported being current
cigarette smokers, overall and by
education, National Health Interview
Surveys, United States, 1978-1995
aggregate data 112

Percentage of adult African Americans
who reported being current cigarette
smokers, overall and by gender, age, and
education, National Health Interview
Surveys, United States, 1965-1995  122

Percentage of adult African American
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, 1965-1995 114

Percentage of adult African American
ever smokers who have quit, overall and
by gender, age, and education, National
Health Interview Surveys, United States,
1965-1995 118

Percentage of African American women
of reproductive age who reported being
current cigarette smokers, overall and by
education, National Health Interview
Surveys, United States, 1965-1995  120

Table 51.

Table 52.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

Figure 7.

Figure 8.

Sample sizes for birth cohorts, by
gender, race/ethnicity, and education,
National Health Interview Surveys,
1978-1980,1987 and 1988 combined,
and Hispanic Health and Nutrition
Examination Survey, 1982-l 984  122

Comparison of current smoking preva-
lence between reconstructed estimates
from National Health Interview Surveys
(NHISs), 1987 and 1988 combined, NHIS
cross-sectional survey estimates, and
Gallup poll estimates 124

Trends in the prevalence of cigarette
smoking among African American
and white men and women, National
Health Interview Surveys, United States,
1965-1995 23

Trends in daily smoking among African
American and white high school seniors,
by gender, United States, 1977-1996  30

Trends in daily smoking among
African American, Hispanic, and
white high school seniors, United States,
1977-1996 31

Trends in smoking among African
Americans and whites aged 20-34 years,
United States, 1978-1995 35

Use of cigarettes and alcohol among
African American and white high school
seniors, United States, 1976-1979 and
1990-1994 38

Use of cigarettes and illicit drugs among
African American and white high school
seniors, United States, 1976-1979 and
1990-1994 39

Cigarette smoking prevalence among
successive birth cohorts of African
American men, by education, National
Health Interview Surveys, United States,
1978-1980,1987, and 1988 75

Cigarette smoking prevalence among
successive birth cohorts of African
American women, by education, Na-
tional Health Interview Surveys, United
States, 1978-1980,1987, and 1988  76

314  List of Tables and Figures


Figure 9.

Figure 10.

Figure 11.

Figure 12.

Figure 13.

Figure 14.

Figure 15.

Figure 16.

Cigarette smoking prevalence among
successive birth cohorts of Hispanic
men, by education, Hispanic Health and
Nutrition Examination Survey, 1982-
1984 77

Cigarette smoking prevalence among
successive birth cohorts of Hispanic
women, by education, Hispanic Health
and Nutrition Examination Survey,
1982-1984 77

Reconstructed prevalence of smoking
among African American adults aged
20-29 years, by gender and education,
National Health Interview Surveys,
United States, 1910-1988 78

Reconstructed prevalence of smoking
among Hispanic adults aged 20-29
years, by gender and education, His-
panic Health and Nutrition Examination
Surveys, 1920-1984 79

Trends in the age-adjusted prevalence
of current cigarette smoking among
African American, American Indian
and Alaska Native, Asian American and
Pacific Islander, Hispanic, and white
adults, National Health Interview
Surveys, United States, 1978-1995
aggregate data 88

Trends in the age-adjusted prevalence
of current cigarette smoking among
African American, American Indian and
Alaska Native, Asian American and
Pacific Islander, Hispanic, and white
men, National Health Interview
Surveys, United States, 1978-1995
aggregate data 89

Trends in the age-adjusted prevalence
of current cigarette smoking among
African American, American Indian and
Alaska Native, Asian American and
Pacific Islander, Hispanic, and white
women, National Health Interview
Surveys, United States, 1978-1995
aggregate data 89

Comparison of smoking prevalence
estimates from selected U.S. surveys,
1910-1991 123

Tobacco Use Among US. Racial/Ethnic Minority Groups

Chapter 3

Health Consequences of Tobacco Use
Among Four Racial/Ethnic Minority Groups

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Table 9.

Table 10.

Death rates per 100,000 U.S. residents for
malignant diseases of the respiratory
system, by race/ethnicity and gender,
United States, 1950-1995, selected
years 139

Age-adjusted death rates for selected
smoking-related causes of death, by
race/ethnicity and gender, United States,
1992-1994 141

Death rates for lung cancer among
American Indians and Alaska Natives,
by Indian Health Service (IHS) area,
1984-1988 146

Age-adjusted death rates for selected
smoking-related causes of death among
Mexican Americans, Puerto Rican
Americans, and Cuban Americins,
United States, 1992-1994 148

Odds ratios for the risk of lung cancer,
by gender, race/ethnicity, and smoking
status, case-control study, New Mexico,
1980-1982 149

Age-adjusted incidence and death rates
for selected smoking-related cancers, by
race/ethnicity and gender, National
Cancer Institute's Surveillance, Epidemi-
ology, and End Results (SEER) Program,
1988-1992 150

Age-adjusted cancer death rates among
American Indians and Alaska Natives at
all 12 Indian Health Service areas,
United States, 1984-1988 255

Odds ratios and 95% confidence inter-
vals for the risk of oral cancer associated
with cigarette smoking, by race/
ethnicity and smoking status, 1984-
1985 156

Odds ratios for the risk of urinary
bladder cancer associated with smoking,
by gender, race/ethnicity, and smoking
status 157

Rates of selected infant outcomes, by
mother's race/ethnicity, United
States 168

List of Tables and Figures  315


Surgeon General's Report

Table 11.

Table 12.

Table 13.

Table 14.

Table 15.

Table 16.

Table 17.

Table 18.

Figure 1.

Figure 2.

Figure 3.

Risk of sudden infant death syndrome
associated with smoking, by race/
ethnicity, selected studies, United
States 170

Exposure to household smoke among
children 5 years of age and younger
and percentage distribution, by level
of exposure since birth and selected
characteristics, United States, 1988  173

Criteria for drug dependence  I76

American Psychiatric Association
diagnostic criteria for substance
dependence 177

Human pharmacology of nicotine  178

Incidence of nicotine withdrawal
symptoms, United States 179

Percentage of adult smokers who
reported that they smoked their first
cigarette within 10 minutes and within
30 minutes of awakening, by race/
ethnicity and number of cigarettes
smoked per day, National Health
Interview Survey, United States,
1987 182

Percentage of men and women who
considered smoking a habit or addiction,
overall and by smoking status, Current
Population Survey, United States, 1992-
1993 184

Incidence of cancer of the lung and
bronchus, by race/ethnicity and gender,
National Cancer Institute's Surveillance,
Epidemiology, and End Results (SEER)
Program, 1973-1994 138

Age-adjusted lung cancer death rates
among American Indian and Alaska
Native men in selected states compared
with rates among all U.S. men,
1968-1987 144

Age-adjusted lung cancer death rates
among American Indian and Alaska
Native women in selected states com-
pared with rates among all U.S. women,
1968-1987 145

Figure 4.

Figure 5.

Chapter 4

SEER cancer incidence and U.S. death
rates, 1988-1992, ratio of African
American rate to white rate for all
ages, by cancer site  154

Serum cotinine levels by number of
cigarettes smoked daily for African
Americans, Mexican Americans, and
whites, National Health and Nutrition
Examination Survey, United States,
1988-1991 180

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

Table 1.

High school seniors' perceptions
about the risks associated with cigarette
smoking, Monitoring the Future sur-
veys, United States, 1980-1989  230

Chapter 5

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

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Percentage of adult smokers who would
like to stop smoking, by race/ethnicity
and gender, National Health Interview
Survey, United States, 1993  261

Adults' beliefs about the health effects of
smoking, by race/ethnicity, gender, and
smoking status, National Health Inter-
view Survey, United States, 1992  264

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  267

Public support for and beliefs about
policies regarding tobacco access and
marketing, by selected characteristics,
Robert Wood Johnson Foundation Youth
Access Survey, 1994 270

Percentage of adult smokers who have
received advice to quit smoking from
either a medical doctor or a dentist, by
race/ethnicity and gender, Current
Population Survey, United States, 1992-
1993 285

316  List of Tables and Figures


Tobacco Use Among U.S. RacialJEfhnic Minority Groups

Table 6.

Table 7.

Table 8.

Percentage of adults who reported that
no one is allowed to smoke anywhere
inside the home, by race/ethnicity,
smoking status, and gender, Current
Population Survey, United States, 1992-
1993 288

Percentage of adults who think that
smoking should be allowed in some
areas or not allowed at all in selected
public locations, by race/ethnicity and
smoking status, Current Population
Survey, United States, 1992-1993  290

Percentage of adults who think that the
advertising of tobacco products should
be always allowed or not allowed at all,
by race/ethnicity, smoking status, and
gender, Current Population Survey,
United States, 1992-1993 294

Table 9.

Table 10.

Table 11.

Figure 1

Percentage of Californians who support
curtailment of tobacco advertising and
promotion efforts, by race/ethnicity,
1992 295

Percentage of adults who think that
giving away free tobacco samples
should be always allowed or not al-
lowed at all, by race/ethnicity, smoking
status, and gender, Current Population
Survey, United States, 1992-1993  296

Public beliefs about and support for
policies related to nicotine and tobacco
product regulation, Robert Wood
Johnson Foundation Youth Access
Survey, 1994 298

Billboard used by the California Depart-
ment of Health Services in targeting
Hispanics to quit smoking  261

List of Tables and Figures  317

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

Glossary

ACS

AIDS

ALA

APA

ASSIST

AUTS

BRFSS

CARDIA

CDC

CES-D

CHD

CI

CIS

COMMIT

COPD

COSSMHO

COST

CPS

CPS-I

DNA

DOC

DSM-Ilf

American Cancer Society
acquired immunodeficiency
syndrome
American Lung Association
American Psychiatric Association
American Stop Smoking
Intervention Study
Adult Use of Tobacco Survey

Behavioral Risk Factor Surveillance
System
Coronary Artery Risk Development
in (Young) Adults
Centers for Disease Control and
Prevention

Center for Epidemiological
Studies Depression Scale
coronary heart disease

confidence interval

Cancer Information Service

Community Intervention Trial
for Smoking Cessation
chronic obstructive pulmonary
disease

National Coalition of Hispanic
Health and Human Services
Organizations
Churches Organized to Stop Tobacco
Current Population Survey
Cancer Prevention Study 1
deoxyribonucleic acid
Doctors Ought to Care
Diagnostic and Statistical Manual
of Mental Disorders, Third Edition

DSM-IV

ETS

FAO

FDA

FEV,

FTC

GGPD

GAO

GAS

HHANES

HMO

HRSA

ICD

ICD-9

IHD

IHS

LBW

LST

MTF

MTV

NAAAPI

NAACP

NBLIC

Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition
environmental tobacco smoke

Food and Agriculture Organization
of the United Nations

Food and Drug Administration
forced expiratory volume after one
second

Federal Trade Commission
glucose-6-phosphate dehydrogenase
U.S. General Accounting Office

Great American Smokeout

Hispanic Health and Nutrition
Examination Survey
health maintenance organization

Health Resources and Services
Administration

Manual of the International Statistical
Classification of Diseases, injuries and
Causes of Death
International Classification of Diseases,
Ninth Revision

ischemic heart disease

Indian Health Service

low birth weight

Life Skills Training
Monitoring the Future surveys

Music Television

National Association of African
Americans for Positive Imagery

National Association for the
Advancement of Colored People
National Black Leadership Initiative
on Cancer

Glossary 319


Surgeon General's Report

NCHS

NC1

NHANES I

NHANES II

NHANES III

NHEFS

NHIS

NHSDA

NIDA

NMA

NMFS

NMIHS

OR

PUSH

RFLP

RWJF

National Center for Health Statistics

National Cancer Institute

National Health and Nutrition
Examination Survey I

National Health and Nutrition
Examination Survey II

National Health and Nutrition
Examination Survey III
NHANES I Epidemiologic
Follow-up Study
National Health Interview Survey
National Household Survey on
Drug Abuse
National Institute on Drug Abuse

National Medical Association

National Mortality Followback
Survey

National Maternal and Infant
Health Survey

odds ratio

People United to Save Humanity
restriction fragment length
polymorphism
The Robert Wood Johnson
Foundation

SAIAN

SEER

SESUDAAN

SHOUT

SIDS

SMART

STAT

SUDAAN

TAPS

TAPS-II

UNCF

USDHEW

USDHHS

YRBS

Survey of American Indians and
Alaska Natives

Surveillance, Epidemiology, and
End Results Program
Standard Errors Program for
Computing of Standardized Rates
from Sample Survey Data
Students Helping Others
Understand Tobacco

sudden infant death syndrome
Self-Management and Resistance
Training
Stop Teenage Addiction to Tobacco
Professional Software for Survey
Data Analysis
Teenage Attitudes and Practices
Survey
Teenage Attitudes and Practices
Survey II
United Negro College Fund
U.S. Department of Health,
Education, and Welfare

U.S. Department of Health and
Human Services

Youth Risk Behavior Survey

320 Glossa y

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

Index

A

A Su Salud 282

Absorption of nicotine. See Nicotine pharmacology
Abstinent smokers, effects of nicotine
administration 177
Academic performance and smoking initiation  36,
228

Access of minors to tobacco products
   ease of access 266-269
  enforcement of legislation  266,268
  over-the-counter sales of cigarettes  266,269
  perception of ease by adult members of
   ethnic groups 267
  vending machines 268-269
Acculturation
  effectiveness of warning labels  299
  factor in coronary heart disease incidence  163
  Hispanics 228,237
   initiation of tobacco use  234-235
  smoking cessation 235,237
  smoking prevalence 61,65,235
  tobacco advertising and promotion  227,229
Actors, appearance in tobacco ads  243
Addiction, nicotine. See Nicotine dependence
and addiction
Adolescent African American mothers and use
of tobacco 27-28
Adolescent Health Survey 49
Adolescents
  cigarette brand preference 80-83
  risk factors to predict cigarette smoking
    228-229,230-231
  smoking initiation 40,225-229
  smoking prevalence 2844
   use of smokeless tobacco  44,49+X, 174-l 75
   See also Youth
Adult literacy programs tobacco industry
support 217
Adult Use of Tobacco Survey (AUTS)  21,79,80,
96 (description)
Adults, psychosocial factors of use  225-238
Advertising, tobacco products
  bans, ethnic group support  293-297
  billboards 215,221,222,244,293
   convenience stores 222
   endorsements 242
  ethnic targeting 13,220-224,240-244
  ethnicity of models 240-242
  immigrants 223,242

impact on youth 220
in-store advertising displays 222
print advertisements 214-215,221
revenues 214-215
role models 242

stimulation of cigarette consumption
207,220-223

  targeting youth 207
   television ban 224
African American Tobacco Control Network of
California 297
AiF

airflow obstruction and smoking,
Japanese men 159

and stroke incidence, Asian Americans  165
at smoking onset 36
differences in smoking prevalence, by ethnicity
   African Americans 22-23
   American Indians and Alaska
    Natives 46

Asian Americans and Pacific
Islanders 62-63
Hispanics 66-67

Aggregation problems in data collection.
See Data collection and analysis
Alameda County Low Birth Weight Study
Group 168

Alcohol use and smoking
  among youth 37-38
Alpha Kappa Alpha Sorority  216
American Cancer Society (ACS) 280,292,295
American Health Foundation study  156
American Indian Cancer Control Project of
California 276,286

American Lung Association (ALA)  274,275,295
American Psychiatric Association (APA) diagnostic
criteria for drug dependence  177
American Stop Smoking Intervention Study
(ASSIST) 269

Anemia and smoking, effects on birth weight  271
Angina. See also Coronary heart disease (CHD)
incidence and mortality
Antismoking campaigns. See Mass media; School-
based health education approaches
Antismoking policies. See Smoking bans in
public places

Arts, tobacco industry support of. See Tobacco
industry, support for arts
Asian Americans for Community Involvement  289
Asian American Health Forum  297
Asian Pacific Islander Tobacco Education
Network 297
Asthma 7 60

lndex 321


Surgeon General's Report

Athletes, appearance in tobacco ads  214,243
Athletic events. See Sponsorship by tobacco
industry; Cigarette promotion campaigns
Attempts to quit smoking. See Smoking cessation
programs

Attention. See Nicotine, physiological effects
Attitudes toward tobacco use
  among adults 264-265
  among youth 36,38,41
  belief that smoking is addictive  283-284
  immigrants to the United States  262
  parental attitudes 40
  smoking in public places  287-291
   See also Cultural values
Attrition rates in group approaches to cessation.
See Smoking cessation, attrition rate

B

Barbers/beauty parlor operators, involvement in
cessation efforts 287
Behavioral Risk Factor Surveillance System (BRFSS)
  American Indians and Alaska Natives  45,46,
    50,51-56,144

Asian Americans and Pacific Islanders  56,58,
59,61,62-64

description of 21,95

  ethnic differences in quitting smoking  283
  Hispanics 164
   measures of tobacco use  97,98
Behavioral alternatives to cigarette smoking  260
Bill of Rights touring exhibition  218,222
Billboard advertising. See Advertising, tobacco
control, tobacco products
Biochemical markers of tobacco use
   ethnic differences  179-l 81
  measurements among pregnant women  167
   smokeless tobacco users 183
  youth 32-34

Birth weight. See Infant outcomes, effects of

smoking during pregnancy
Black Clergy for Substance Abuse Prevention  286
Black History Month 222,296
Bladder cancer. See Urinary bladder cancer
Blood pressure. See Hypertension
Boston, marketing of X brand cigarettes  295-296
Boy and Woman Bear culturally appropriate software
package 273

Brain function. See Nicotine, physiological effects
Brand preference  79-83. See also Cigarette brands
Brand recognition. See also Cigarette promotion
campaigns; Cigarette brands

Bronchitis 141,158,160
Bureau of the Census  187
Bureau of Vital Statistics  187

California

  "Proposition 99" 217,275
  smoking cessation hot lines  277
  smoking cessation efforts 297
  use of revenue from cigarette taxes  277
California Department of Health Services  284
California Tobacco Survey 68,182,268,283-284,
289,292

Cancer. See specific types of cancer
Cancer Information Service (CIS) hot line, National
   Cancer Institute 277
Cancer Prevention Study I (CPS-I)  161
cancer registries 138,147
Carbon monoxide as an indicator of smoking  33,34
Cardiovascular disease. See also Coronary heart
disease (CHD) incidence and mortality
Cardiovascular effects of nicotine. See Nicotine,
physiological effects
Center for Epidemiological Studies Depression
Scale 234,237

Centers for Disease Control and Prevention
(CDC) 282,284

Cerebrovascular disease
   African Americans 165
   American Indians and Alaska Natives  165
   Asian Americans and Pacific Islanders
     165-166
  Hispanics 166

Ceremonial and religious rites involving
tobacco 44,209

Cervical cancer 152
Cessation of smoking. See Smoking cessation
programs

Charleston Heart Study 162
Chewing tobacco. See Smokeless tobacco use
Chicago Community Based Interventions for
Low-Income African Americans 281
Chicago Lung Association's multifaceted smoking
cessation intervention 281
Child Health and Development Studies  167
Children

as motivators to quit smoking among
Hispanics 260

exposure to environmental tobacco smoke
in home 173

involvement in smoking cessation
campaigns 269,271

322 index

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

  lung function and environmental tobacco
    smoke 172
Chinese Community Smoke-Free Project  277
Cholesterol and cardiovascular disease risk  162
Chronic obstructive pulmonary disease (COPD)
   African Americans 158
   American Indians and Native
     Americans 158-l 59
   Asian Americans and Pacific Islanders  159
  Hispanics 159-l 60
Churches Organized to Stop Tobacco (COST)  296
Cigar smoking 91-94
Cigarette brands
  555 State Express 218
  Alpine 242
  American Spirit 223
   Belair 242
  Benson & Hedges 79,80,82
  Camel 79,80,82,220,224,243
   Chesterfield 242
   Dorado 220
   Eve 243
  Kent 79,80,243
  Kool 79,80,82,243
   L&M 243
  Lucky Strike 243
  Marlboro 79,80,82,83,218,220,224,242,
    243
  Merit 79,81,82
   Mild Seven 223
   More 219
  Newport 79,81,82,220-221,224,242
  Oasis 242
   Old Gold 241
  Pall Mall 79,81
   Parliament 219
   Richmond 242
   Rio 220
   Riviera 242
  Salem 79,81,224,242
  Salem Extra 244
  Spring 242
  Spud 242
  Super M 244
  Uptown 222,224,294
  Vantage 79,81
  Viceroy 243
  Virginia Slims 79,81,223-224
  Winston 79,81,82,243
  X 224,295296
  See also Brand preference; Brand recognition;
   Cigarette promotion campaigns

Cigarette consumption
  among ethnic groups
     African Americans 22-28,4143, 74-78,
        112-121

American Indians and Alaska
Natives 44-55

Asian Americans and Pacific
   Islanders 56-66
Hispanics 66-74,75-77
targeted ads as external cues to
smoke 223-224

Cigarette manufacturers. See Tobacco companies
Cigarette prices. See Revenues
Cigarette promotion campaigns
  Chesterfield film campaign 242
  coupons 223,294
   cultural events  213,218-219,297. See also
   Tobacco industry, support for ethnic
   communities, pride, and culture
   Marlboro Man 243
   Marlboro Tour `93  2 12
  samples 296
  sports events 294
  Viceroy race car driver  243
  See also Advertising, tobacco products; Brand
   recognition; Cigarette brands
Cigarettes, hand-rolled, lung cancer death rate  149
Civil rights movement 243
Clean air policies. See Smoking bans in public places
Coalition Against Billboard Advertising of Alcohol
and Tobacco 297

Coalition Against Uptown Cigarettes  295
Cocaine use in conjunction with cigarette
smoking 37

Cognition. See Nicotine, physiological effects
Committee to Prevent Cancer Among Blacks  295
Communication skills training for youth  278
Community

  approach to smoking cessation  278-283
  dependence on tobacco industry  213-219
  loyalty to tobacco industry  213
  meeting of community leaders in
     Greensboro 297
  mobilization/involvement in antitobacco
   campaigns
        California 297
     Uptown cigarettes 294-295
     X cigarettes 295-296
  projects, limitations of 263,265,293
  volunteer health representatives  282
Community Intervention Trial (COMMIT) for
Smoking Cessation 181,183,236,260
Congressional candidates, campaign support from
tobacco industry 217

Index 323


Surgeon General`s Report

Congressional Hispanic Caucus 215
Consumer Expenditure Survey Interview
Survey 292

Coping mechanism, cigarette smoking  275
Coronary Artery Risk Development in (Young)
Adults (CARDIA) 172,181,186
Coronary heart disease (CHD) incidence and
mortality
   African Americans  160-l 61
   American Indians and Alaska Natives
    161-162

Asian Americans and Pacific Islanders
162-163

  Hispanics 163-l 64
Cotinine. See Biochemical markers of tobacco use
Cultural events, tobacco industry support of.
See Tobacco industry, support for cultural events
Cultural values

as depicted in tobacco ads  222-224
cigarettes as indicator of affluence  222-224
Hispanic attitudes toward smoking  223
tobacco as a gift  210
See also Attitudes toward tobacco use; Social
influences

Current Population Survey (0%
  attitudes concerning minors' ease of access to
   tobacco products  267
  ban on tobacco samples  293
  classification of ethnicity  186,187
   US-1 161
  efforts to restrict youth access to tobacco  266
  employer-provided smoking cessation
   programs 286
  ethnic differences in prevalence  87
  ethnic differences in quitting smoking  183,
     184
  Hispanics and coronary heart disease  163
  quitting behavior 25,48,57,70
  workplace/public place smoking
    restrictions 288,289,290-291
Current smokers, definition of  97

D

Dance troupes, tobacco industry support of  219
Data collection and analysis
  accuracy of findings on youth smoking
   prevalence 31-36
  aggregation problems 239
  bias against Asian Americans with low
   English skills 61

bias in selection for studies  61
bias of findings 31

differential misclassification bias 30-32,34
differential school dropout rates, African
American youth 31,32,228
multivariable logistic regression technique
83,85

noncomparability of tobacco use studies  238
nongeneralizability of tobacco use studies  238
nonreporting problems in tobacco use
studies 238

  reporting bias 31,239
  retrospective analysis methodology 74
  sources of data 95-96
  tobacco smoke exposure, infant
     outcomes 168-l 71
  unavailability of data on specific ethnic
   groups 44,56,259,277
Death rates
  by cancer

cervix/uteri 148,150,152,153,155
esophagus 148,150,153
kidney/renal pelvis 148,150,155
larynx 148,155
lung/bronchus  144,146,148,150
ora!/pharynx 148,153-155
pancreas 152
stomach 155

    urinary/bladder, 152,156
  by ethnicity 139,144,146
Decision-making skills training for youth  271
Decline in smoking. See Smoking prevalence,
decline in smoking
Definitions

  cigarette smoking and cessation  97
  number of cigarettes smoked daily  97
  use of cigars, pipes, and smokeless tobacco  97
Dentists, advice to patients  285
Depressive symptoms and smoking  234
See also Center for Epidemiological Studies
Depression Scale

Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition (DSM-IVT")  179,181
Doctors, in cigarette ads  243
Doctors Ought to Care (DOC)  215
Don't Let Your Dreams Go Up in Smoke  286
Dropouts, high school 228
Drug use and smoking. See type of drug

E

Economics

dependency on tobacco sales, American Indian
reservations 213

efforts to reduce tobacco use  292-293

324 Index

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

  expenditures on tobacco promotion in ethnic
     communities 213-219
Education
  by ethnic group
    African Americans 83,84
    American Indians and Alaska Natives
     83,84
    Asian Americans and Pacific Islanders
     83,84
   Hispanics 83,84
  levels of, and smoking  25,26,28
Educational materials, smoking intervention.
See Smoking cessation programs
Elimination of nicotine. See Nicotine pharmacology
Emphysema 158,160
Employment
  employer antismoking policies 287-288
  employer-provided smoking cessation
   programs 286
  labor force composition of tobacco
    factories 208-209
English proficiency. See Language/linguistics
Environmental Protection Agency
  assessment of environmental tobacco smoke
    risks 287-289
Environmental tobacco smoke (ETS)
  exposure and ethnicity  86-87,172-l 73,287,
     289
  exposure in public places  287-291
  exposure to household smoke  288
  fetal exposure 167
   infant outcomes  167-l 71
  nonsmokers' exposure 172-l 73
  perceived dangers of 261-263
  pregnant women 285
  Sudden Infant Death Syndrome  169-l 71
  workplace exposure 287-288
  See also Smoking bans in public places
Esophageal cancer 151-153
Ethnic groups
   definition of  7-8,186-l 87
  demographic characteristics 8-11
   exclusion from tobacco studies  61
   health outcomes 187
Ethnic labels, see Ethnic groups, definition of
Ever smokers, definition 97

F

Fagerstrom dependence questionnaire 179
Familialism 212
Federal Trade Commission 140,181

Federal workplace antismoking policies  287-288
Fetal morbidity and mortality. See Infant outcomes,
effects of smoking during pregnancy

Filters, packaging of Uptown cigarettes  224
Focus groups 40,286
Food and Agriculture Organization of the

United Nations 211

Food and Drug Administration  207,266,297
Food, Tobacco, Agriculture, and Allied Workers

Union 209

For You and Your Family  284
Forced expiratory volume as a measure of

pulmonary function 159
Former smokers, definition 97
Freedom from Smoking@ for You and Your Family  281
Freedom from Smoking in 20 Days  281
Funding initiatives for public health  6

G

Gateway Program 217
Gender differences
  smoking prevalence
     African Americans 22-24,41
     American Indians and Alaska
      Natives 4448, SO-56
     Asian Americans and Pacific
       Islanders 56-59
    Hispanics 66-69
  smoking trends national data  23-28,78-81
General Social Survey 233
Genetic risk, lung cancer and CYPlAl gene  142
Gingival bleeding and recession  174
See also Periodontal disease
Government regulation of cigarettes,
support for 298-299
Great American Smokeout 280,283
Great Alaska Spit-Out 273
Group approaches to smoking cessation  277-278
Guide to Black Organizations  217

H

Harlem Dowling-West Side Center for Children
and Family Services 216
Harlem Hospital 221
Health care facility access  277,283-284
Health care providers 283-284,285
Health consequences/risks of tobacco use
  knowledge of
    among adults 235,264-265
    among blue collar workers  263

Index 325


Surgeon General's Report

    among ethnic groups 12,265
    among pregnant women 171
Health insurance 216,263
Health Status of Minorities and Low-income Groups  6
Healthy People 2000 5
Heart, Body, and Soul  286
Heart attack. See Myocardial infarction
Hey, Girlfriend, Let's Talk About Smoking and You  285
Hispanic Health and Nutrition Examination Survey
(HHANES)
  chronic obstructive pulmonary disease
     159
  cigarette smoking prevalence
    among adults 66-67,79
    among successive birth cohorts  74,76,
        122
    among women of reproductive age  71
    among young people 72
  description of 21,95
   environmental tobacco smoke and clean indoor
   air policies 287
  long-term trends in cigarette smoking  78
  methodological issues  186
  quitting behavior 183
Hispanic/Latin0 Tobacco Control Network  297
History of tobacco use
  by ethnic group
      African Americans 208-209
      American Indians and Alaska
        Natives 209-210
      Asian Americans and Pacific
        Islanders 227-212
    Hispanics 212
Honolulu Heart Program 159
Housing projects 236,263
Hypertension 160,162,163

I

Immigration, impact on smoking prevalence
61,234
In-store advertising displays. See Advertising,
tobacco products
Income and increases in cigarette taxes  292
Indian Health Service (IHS)
   cancer death rates
    age-adjusted 255
    lung cancer 243-146
   cervical cancer 152
  classification of smoking status  186
  regional differences in cancer death  144
   smokeless tobacco use  49-50

smoking cessation programs for pregnant
women 285

Infant outcomes, effects of smoking during
pregnancy
  birth weight  166-l 69
  morbidity and mortality  169-l 71
  Sudden Infant Death Syndrome  169-l 71
International Multicultural Partnership 297
Interviewing methods. See Data collection and
analysis

It`s No Joke, Don't Smoke!  274
It's the Law voluntary compliance program  268
It's Your Life-It's Our Future  276

J

Jackie Robinson Foundation Awards Dinner  219
Jargon, use in cigarette ads  242-243

K

Kaiser Permanente 61,161
Kool Achiever Awards  218

L

Labor unions 208-209
La'm The^ Nho D?Bd Hlit ThuG "c?  276
Language/linguistics
  proficiency, as barrier to knowledge of health
   consequences 234
  proficiency, as barrier to tobacco control
   messages 262

proficiency as measure of acculturation
smoking prevalence 234
translation of smoking cessation
materials 274,281
use of non-English words in tobacco product
materials 222

Law abidance 228,232
Leadership Conference on Civil Rights  216
League of United Latin American Citizens  216
Legends Campaign 282-283
Legislation

sale of tobacco to minors (Synar
Amendment) 266

  FDA tobacco product regulations  297
Liberalism, factor in smoking status  232
Life Skills Training (LST) Program  271
Lifestyle factors and decline in smoking
by ethnic group

African American youth 36-38

326 Index

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

Low birth weight. See Infant outcomes, effects of
smoking during pregnancy, birth weight
Lung cancer 137-135
   African Americans  138-l 43
  American Indians and Alaska Natives
     143-145

Asian Americans and Pacific Islanders
145-147
Hispanics  7 47-l 49

M

Magazines, ethnic

African Americans 218,241-243
portrayal in tobacco ads  241
American Indians' portrayal in tobacco
ads 223,241
Hispanics 214
perception as trustworthy information
source 241,274

  See also Advertising tobacco products; Mass
   media; Newspapers
Manual of the international Classification of Diseases,
Injuries and Causes of Death (ICD)  287
Marijuana use in conjunction with smoking  37,44
Mass media
   radio 274

  television 241,274
  See also Advertising, tobacco products;
   Magazines, ethnic; Newspapers
Maternal smoking. See Pregnancy and smoking
Media literacy 241
Medicinal usage of tobacco. See Religious use of
tobacco

Memory. See Nicotine, physiological effects
Menthol cigarettes  79,142,224,242,243,244
Metabolism of nicotine. See Nicotine pharmacology
Milwaukee County Youth Initiative  217
Minors' access to tobacco.  See Access of minors to
tobacco products

Misconceptions about causes of cancer  263
Monitoring the Future (MTF) surveys
  description of 21,96
  perceptions of risks of cigarette
   smoking 230-231
  predictors of cigarette smoking in African
   American youth 226
  smoking cessation 97
  smoking prevalence
    American Indian and Alaska Native high
       school seniors 49
      decline 36
    young people 28,30,32,37,42,44,
        72-74

MTV 274

Muscle relaxation. See Nicotine pharmacology
Musical events, ethnic targeting by tobacco
industry 218-219
Myocardial infarction  160,Z 64

N

National Association for the Advancement of
Colored People (NAACP) 213,216
National Association of African Americans for
Positive Imagery (NAAAPI) 224,287,296,297
National Association of Black Social Workers  216
National Association of Negro Business and
Professional Women's Clubs 216
National Black Caucus of State Legislators  215
National Black Leadership Initiative on Cancer
(NBLIC) 295

National Black Police Association  216
National Cancer Institute (NC11  25,74,265,
277,279

National Cancer Institute Advisory Panel on
Tobacco-Use Reduction Among High-Risk
   Youth 269

National Center for Health Statistics (NCHS)
147,154,163

National Coalition of Hispanic Health and Human
Services Organizations (COSSMHO) 215,218
National Direct0 y of Asian Pacific American
Organizations 217

National Direct0 y of Hispanic Organizations  217
National Coalition of 100 Black Women  216
National Conference of Black Lawyers  216
National Death Index 263
National Health and Nutrition Examination Surveys
(NHANES I, II, III)  71,86,161,164,181
National Health Interview Survey (NHIS)
   adults

beliefs about health effects of
smoking 264-265
cigarette brand preferences  79
cigarette smoking frequency  182
current cigarette smoking  87-90
effects of education and race/ethnicity
on smoking behavior  83
ethnic differences in quitting
smoking 183
exposure to environmental tobacco
smoke 86-87,172
involvement of health care
providers 283-286
information needs 262-263
lung cancer death rates  146

Index 327


Surgeon General's Report

     measures of tobacco use  97
    pipe and cigar use  91-92
    prevalence of smoking 35,92-93,
      98-121,122-124
    quitting behavior 261
    smoking prevalence estimates  124
    smoking status and ethnicity  84
     use of smokeless tobacco  94
   African Americans
    and chronic obstructive pulmonary
       disease 158
    prevalence among successive birth
      cohorts 74-75,76,140
    prevalence of cigarette smoking  22,
       23-24
    quitting behavior 25-26
    women of reproductive age  26-28
    young people 3044
  American Indians and Alaska Natives
    prevalence of cigarette smoking  4445
    quitting behavior 46,48
    women of reproductive age  4849
    young people 49-50
  Asian Americans and Pacific Islanders
    prevalence of cigarette smoking  56
    quitting behavior 57
    women of reproductive age  57,59
    young people 59-60
  Hispanics
    prevalence among successive birth
       cohorts 77
    prevalence of cigarette smoking  66-69
    quitting behavior 70,237
    women of reproductive age  71-72
    young people 72-74
National Heart, Lung, and Blood Institute  272
National High Blood Pressure Education
Program 286
National High School Senior Surveys.
See Monitoring the Future survey
National Hispanic Scholarship Fund  217
National Household Survey on Drug Abuse
(NHSDA) 28,36,72,182
National Institute on Drug Abuse (NIDA)  28,72
National Longitudinal Mortality Study  286
National Maternal and Infant Health Survey
(NMIHS) 27,28,49,170
National Medical Association (NMA)  276,282,283
National Medical Expenditure Survey  44
National Minority AIDS Council  2 16
National Mortality Followback Survey (NMFS)  161
National Natality Survey 27
National Pregnancy and Health Survey  28,72
National Research Council 172

National Survey of Family Growth  27,71
National Survey of Oral Health in U.S. School
Children 174

National Urban League 215,216
National Vital Statistics System  138
Native American Indians, by region and tribe
(smoking survey) 50-56
Neighborhood tobacco product advertising
221-222,293-297

Neural actions of nicotine. See Nicotine,
physiological effects

Neurotransmitter release, changes caused by
nicotine See Nicotine, physiological effects
New York City, proposed ban on public
smoking 218

Newsletters, smoking prevention campaigns  274
Newspapers  214,218. See also Magazines, ethnic
Nicotine dependence and addiction  181-l 84
Nicotine pharmacology  175-l 84
Nicotine, physiological effects  175-l 79. See ako
Withdrawal symptoms, nicotine
Nicotine replacement therapy 286
Nicotine yield 179
Nonsmokers
  exposure to environmental tobacco
    smoke 137
  support for bans on tobacco ads  293-298

0

100 Black Men of America, Inc.  216
One Day at a Time  286
Operation PUSH (People United to Save
Humanity) 213,216
Opportunities Industrialization Centers of
America 216

Oral cancer l53-155,174
Oral lesions  174-l 75
Oral leukoplakia 174
Outdoor advertisements. See Advertising, tobacco
products

Over-the-counter sales of cigarettes. See-Access of
minors to tobacco products
Oxygen-carrying capacity, maternal, and effects
of smoking 171

P

Packaging 224
Parental attitudes toward smoking  40
Parental cigarette smoking, as risk factor for
initiation 229

328 Index

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

Passive smoke exposure. See Environmental
tobacco smoke

Pathways to Freedom Community Demonstration
Project 280

Pathways to Freedom: Winning the Fight Against
Tobacco 276

Patterns of tobacco use. See Cigarette consumption
Peace pipe  22 0
Peer tobacco use 231-233
Perinatal mortality 166
Periodontal disease 174
Personal consultation for smoking cessation
   face-to-face 278
  telephone 278

Pew Charitable Trusts 217
Pharyngeal cancer 174
Philadelphia Mayor's Commission on Literacy  217
Physicians

  advice to patients regarding smoking  283-285
  appearance in tobacco advertisements  243
Physiological measurement of cigarette smoking.
See Biochemical markers of tobacco use
Pipe smoking

definition for surveys 92
history of 91-92

  prevalence of 92-92
Point-of-sale displays. See Advertising, tobacco
products

Political campaign contributions by tobacco
companies 217

Portland Life Center 216
Power distance 283
Predictors of tobacco use and initiation  231-233
Pregnancy and smoking
  abruptio placentae 171
   African American vs. white  167-l 69
  and other drug use  168
  birth weight 166,167-169,171,185
  ectopic pregnancy 171
  intention to breast-feed as predictor of smoking
    cessation 260

intrauterine growth retardation 166
preterm delivery 169
reduction of cigarette consumption  27,71,
167,269

Sudden Infant Death Syndrome (SIDS)
167,169-171

See also Infant outcomes, effects of smoking
during pregnancy; Smoking prevalence,
during pregnancy

Prevalence of cessation 8
Prevalence of smoking. See Smoking prevalence
Preventing Tobacco Use Among Young People: A Report
of the Surgeon General  44,220

Prevention programs. See Mass media; School-based
health education approaches
Product endorsements. See Advertising, tobacco
products
Product targeting

American Spirit cigarettes, American
Indians 223

Dorado cigarettes, Hispanics 220,222
Mild Seven cigarettes, Asian Americans  223
Rio cigarettes, Hispanics 220,222
Uptown cigarettes, African Americans  222,
223-224,294

Project SHOUT 271-272
Project SMART 271
Programa Latin0 Para Dejar de Fumar  279-280
"Proposition 99" tobacco tax initiative  217,277
Psychosocial risk factors 225-233
Public health objectives 5. See also Healthy People

2000

Public places, antismoking policies. See Smoking
bans in public places

Public service announcements 279

Q

Quit attempts. See Smoking cessation programs,
quit attempts

Quit for Life, employer-provided program  282
Quit Today! 280

R

Race. See Ethnic groups
Racial discrimination 224,260
Radio. See Mass media
Rappers/Pick It antismoking message  221
Rates of smoking. See Cigarette consumption
Recidivism. See Relapse
Regular smoking, definition of  97
Reinforcing effects of smoking tobacco  2 76
Relapse 25,122,261-262
Religion as protective factor  42,226,232
Religious use of tobacco  210
Reporting bias. See Data collection and analysis
Reproductive health. See Pregnancy and smoking;

Smoking prevalence, during pregnancy
Resource guides for ethnic groups, tobacco industry
support of  2 16-2 17
Retrospective analysis methodology. See Data
collection and analysis
Revenues. See Advertising, tobacco products,
  revenues

Index 329


Surgeon General`s Report

Risk-taking behavior, factor in tobacco use  44,73,
95

Robert Wood Johnson Foundation (RWJF). See Youth
Access Survey

Role models. See Advertising, tobacco products
Rompa Con El Vicio. Una Guia Para Dejar de
Fumar 275

S

Salem FreshsideTM Salute 218
Salem Open tennis tournament  221
Sales to minors. See Access of minors to tobacco
products

San Antonio Heart Study  164
School-based health education approaches  269-273
School performance. See Academic performance
and smoking initiation
Schools, antismoking policies 289
Second-hand smoke. See Environmental tobacco
smoke

Self-help approach to smoking cessation  275-277
willpower 275

Self-reports of nicotine addiction, by ethnicity
181-183

Self-service tobacco displays,
elimination of 266,269
Sex differences. See Gender differences
Sharing cigarettes 211,212
Si Puedo 280

Sickle cell trait and smoking, effects on birth
weight 171

Sidestream smoke. See Environmental tobacco
Smoke
Smokefree policies. See Smoking bans in pubIic
places
Smokeless tobacco addiction 283
Smokeless tobacco use
  by ethnic group
     African Americans 44,94,174
      American Indians and Alaska
       Natives 49-50,55,94,174
      Asian Americans and Pacific
      Islanders 60,94,174
     Hispanics 74,94
  cessation programs 234
   effects of  174-l 75
   factors associated with initiation  232-233
  prevalence 233-235
  Skoal Bandit promotion 218,219
  use by adolescents 174,232-233
Smokers, acceptance of. See Attitudes toward
tobacco use; Cultural values; Social influences

Smokers, definitions 97
Smoking abstinence, overnight, and loss of nicotine
tolerance 178
Smoking: Facts and Quitting Tips for Black
Americans 277
Smoking: Facts and Quitting Tips for Hispanics  277
Smoking bans in public places  287-292
   enforcement in ethnic communities  289
Smoking cessation programs
  age at cessation 46
  among members of ethnic groups  14,
    274-283,286-287
  approaches 259
   attrition rate 277
  culturally appropriate 259-262,273,274-283,
    286,287
  desire to quit 260-262
  education and ethnicity as factors  85
  employer-provided programs 286
  family-centered interventions 260
  Freedom from Smoking in 20 Days  281
   health benefits of 263-265
   home visits 278
   information needs 262-263
  motivation to quit 260
  nontraditional providers and 286-287
  perceived ability to quit  286
  pregnant women 285
  prevalence of former smokers
      African Americans 25
      American Indians and Alaska
        Natives 46
      Asian Americans and Pacific
        Islanders 57
     Hispanics 70
  quit attempts, African Americans  25-26,236
  See also Community; Group approaches to
   smoking cessation; Self-help approach to
   smoking cessation
Smoking initiation
   adolescents 225
  by ethnic group
     African Americans 40, 78,226
     American Indians and Alaska
       Natives 227
      Asian Americans and Pacific
        Islanders 227
    Hispanics 40,78-79,228-229
  long-term trends, birth cohort analysis  78-79
  multiple group studies 229
  targeted advertising 223,240-244
Smoking prevalence
  among adults 21-23,26-28
  among ethnic groups 12

330 Index

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

  among young people
     African Americans 28-31,44
     American Indians and Alaska
        Natives 49
     Asian Americans and Pacific
       Islanders 59-60
    Hispanics 72-73
  See also Monitoring the Future surveys
  by ethnic group
     African Americans 22-25,35,74-75,233
     American Indians and Alaska
      Natives 4446,50-56,233
     Asian Americans and Pacific
      Islanders 56-59,234
    Hispanics 66-70,75-77,234-235
  comparisons among ethnic groups  87-91
  decline in smoking
     African Americans 27,30,31,36,38,41,
      74-75,78
     American Indians and Alaska
       Natives 49
     Asian Americans and Pacific
      Islanders 56-57,59,61
    Hispanics 69,71,75-76,78-79
  decreased by cigarette taxes  292-293
  during pregnancy
     African Americans 26-28,29,285
     American Indians and Alaska
      Natives 29,49,285
     Asian Americans and Pacific
      Islanders 29,59,285
    Hispanics 29,71-72,285
  education and ethnicity as factors in
   smoking status 83-86
  in Asian countries 65-66
  in Latin American countries  69
  in women of reproductive age
      African Americans 26-28
     American Indians and Alaska
       Natives 4849
     Asian Americans and Pacific
      Islanders 57,59
    Hispanics 71-72
  regional and tribal tobacco use  50-56
  retrospective analysis and assessment of
       African Americans 74-75
     Hispanics  75-76 See also Gender
         differences
Smoking prevention programs. See Mass media;
School-based health education approaches
Smoking recidivism. See Relapse
Smoking reduction during pregnancy.
See Pregnancy and smoking
Snuff use. See Smokeless tobacco use

Social influences

smoking prevalence in Latin America  212
status-seeking behavior 224,240-241
tobacco use at American Indian social
gatherings 210

  See also Cultural values
Social Learning Theory 282
Social skills/peer pressure
  resistance training for youth  271
Sociodemographic factors and decline in smoking
by African American youth  36
Socioeconomic status
  coronary heart disease deaths  161
  exposure to school-based smoking prevention
   programs 269

factor in the response to changes in cigarette
price 292

  smoking prevalence 83
  targeting of ads 240-244
Software, interactive learning programs  273
Sponsorship by tobacco industry. See Tobacco
industry

Stages of change 225
Stanford Five-City Multifactor Risk Reduction
Project 279,284

Stomach cancer 155
Stop Teenage Addiction to Tobacco (STAT)  268
Stress. See Coping mechanism, cigarette smoking
Strong Heart Study 45
Stroke as the major form of cerebrovascular
disease 164
Sue Khoe La Vang!  283
sudden infant death syndrome (SDS)  169-l 71
Surveillance, Epidemiology, and End Results (SEER)
Program 138,146,149,151,152,156,186
Surveys. See specific survey:
  Adult Use of Tobacco Survey (ALTS)
  Behavioral Risk Factor Surveillance System
    (BRFSS)

Current Population Survey (Cl%)
Hispanic Health and Nutrition Examination
Survey (HHANESI

Monitoring the Future (MTF) surveys
National Health and Nutrition Examination
Surveys (NHANES)

National Health Interview Survey (NHIS)
Surveillance, Epidemiology, and End Results
(SEER) Program

Teenage Attitudes and Practices Survey (TAPS)
Youth Access Survey, Robert Wood Johnson
Foundation (RWJF)

  Youth Risk Behavior Survey (YRBS)
Synar Amendment. See Legislation

Index 331


Surgeon General's Report

T

U

Task performance. See Nicotine, physiological
effects
Taxes on tobacco products
   excise taxes 292-293
   sales taxes 292-293
Teach For America 217
Teenage Attitudes and Practices Survey (TAPS)  21,
32,36,73,81,83,96,228,266,267
Terms related to tobacco use  8
Television. See Mass media
Tobacco, alternative uses. See Religious use of
tobacco
Tobacco companies
   American Tobacco Co. 242,244
   British American Tobacco Co.  212
  China National Tobacco Corporation  211
  Brown & Williamson Tobacco Corp.  217,224,
     242
  Japan Tobacco Inc. 223
  Liggett & Myers 242,243
   Lorillard 223,241,242,243
   Parliament 219
  Philip Morris 216,217,218,222,241,242
  RJR Nabisco (R. J. Reynolds)  215,216,217,
    219,223,224,244
   Sante Fe Tobacco Co.  223
   Tobacco Institute 216
   United States Tobacco Co.  219
Tobacco control. See Smoking cessation programs
Tobacco industry
   African American involvement 208-209,
     213-214
  Asian production 211
  community loyalty 213
  funding of community agencies and
   organizations 215-217
  Latin American production 212
  shift of expenditures to promotional
   marketing 293
  support for arts 218-219
  support for cultural activities  218-219
  support for education 217
  support for ethnic communities, pride, and
    culture 213,216
Tobacco Use. See Smokeless tobacco use; Smoking
prevalence
Tobacco-Use Reduction Among High-Risk Youth,
NC1 Advisory Panel 269
Tobacco Workers International Union  208
Tumor suppressor gene p53  143

Union of Pan Asian Communities  287
United Cambodian Community, Inc.  287
United Negro College Fund (UNCF)  215,216,217,
219

United Tobacco Workers 209
Urinary bladder cancer 156-157

V

Values, used as a means of smoking cessation and
health promotion effort 260
Vending machines 268-269
Victory Over Smoking-A Guide to Smoking
Cessation for You and Your Family  277
Vietnamese Community Health Promotion
Project 283

Virginia Slims fashion show  211

W

Warning labels 298
Warning signs mandated by state, prohibition of
sales to minors 268
Weight control and cigarette smoking  38-39,277
Withdrawal symptoms, nicotine  178-l 79
Women. See Gender differences; Smoking
prevalence

Workplace environmental tobacco smoke
exposure 287-288

See nlso Environmental tobacco smoke

Y

Young Men's Christian Association  216
Youth

advertising, effectiveness of 41
alcohol use 37,38
attitudes toward tobacco use  3841
knowledge of health consequences
of smoking 227

skills training 271

  See also Adolescents; Mass media; School-based
   health education approaches; Smoking
   initiation; Smoking prevalence
Youth Access Survey, Robert Wood Johnson
Foundation (RWJF) 269,293,298
Youth access to tobacco. See Access of minors to
tobacco products

Youth Risk Behavior Survey (YRBS)  29,36,44,73,
74,96

332 Index