Tobacco Use Among U.S. Racial/Ethnic Minority Groups Riley WT, Barenie JT, Mabe PA, Myers DR. The role of race and ethnic status on the psychosocial correlates of smokeless tobacco use in adolescent males. Joltrnal ojfdo~escent Health 1991;12(1):1!5-21. River0 Mufiiz J. Tabaco, su Historia elz Cuba. La Habana (Cuba): Instituto de Historia, Comision National de la Academia de Ciencias de la Republica de Cuba, 1964. RJR Nabisco, Inc. A Grozoing Presence in the Mainstream. Winston-Salem (NC): RJR Nabisco, Programs for Mi- norities and Women, 1986. Robinson RG. The tobacco industry and the African American community: from compromise to empow- erment. Paper presented at the 8th World Conference on Tobacco or Health, Buenos Aires, March 30-April 3, 1992. Robinson RG, Barry M, Bloch M, Glantz S, Jordan J, Murray KB, et al. Report of the tobacco policy research group on marketing and promotions targeted at African Americans, Latinos, and women. Tobncco COIJ- trot 1992a;l(Suppl):S24-S30. Robinson RG, Pertschuk M, Sutton C. Smoking and African Americans: spotlighting the effects of smok- ing and tobacco promotion in the African American community. In: Samuels SE, Smith MD, editors. Im- proving the Health of the Poor: Strategies for Prez~entiol~. Menlo Park (CA): The Henry J. Kaiser Family Foun- dation, 1992b:123-81. Robinson RG, Shelton DM, Hodge F, Lew R, Lopes E, Toy I', et al. Tobacco control capacity index for com- munities of color in the United States. In: Slama K, editor. Tobacco and Health. New York: Plenum Press, 1995:359-65. Robinson RG, Sutton CD. The Coalition Against Up- town Cigarettes. In: Jernigan D, Wright I', editors. Making News, Chnnging Policy. Washington (DC): US Office of Personnel Management, Center for Substance Abuse Prevention, and The Marin Institute for the Pre- vention of Alcohol and Other Drug Problems, in press. Roman0 I'S, Bloom J, Syme SL. Smoking, social sup- port, and hassles in an urban African-American community. American Journal of Public Health 1991; 81(11):1415-22. Roper Center for Public Opinion Research. Attitudes on Smoking by Race. Telephone Survey Conducted from February 25 to 28, 1993. Storrs (CT): Roper Center for Public Opinion Research, University of Connecticut, conducted by ABC News/The Washington Post, 1993. Ros Torres MA. La Produccio'n Cigarrera a Finales de la Colonia: Ln Fobrica en Mexico. Mexico (DF): Instituto National de Antropologia e Historia, 1984. Rosenberg ND. Costly talk: activist refuses $5,000 award. The Milzuaukee Journal 1993 Sept 30;Sect A:l. Rosenblatt R. How do tobacco executives live with themselves? The Nezu York Times Magazine 1994 Mar 20:34. Rosser Reeves Inc. Arctic Lights: Strategic Brand Con- ference, Brand Issues/Strategies/Tactics: May 17,1979, minutes. Madison (WI): M86-426, Box 2, Papers of Rosser Reeves, State Historical Society of Wisconsin, 1979. Rothstein M. Uneasy partners: arts and Philip Morris. The New York Times 1990 Dee 18;Sect C:15 (co1 2). Rotzoll BW. New cigarettes target black kids, foes say. Chicago Sun-Times 1997 Feb 2;Sunday News Sect:23. Royce JM, Hymowitz N, Corbett K, Hartwell TD, Orlandi MA. Smoking cessation factors among Afri- can Americans and whites. American Journal of Public Health 1993;83(2):220-6. Russ VM. Is it philanthropy or a smoke screen? ciga- rette makers give to black causes. Philadelphia Daily News 1993 Aug 2;Lifestyle Sect:38,40. Sabogal F, Otero-Sabogal R, Perez-Stable EJ, Marin BV, Marin G. Perceived self-efficacy to avoid cigarette smoking and addiction: differences between Hispan- ics and non-Hispanic whites. Hispanic Journal of Behav- ioral Sciences 1989;11(2):13647. Samet JM, Howard CA, Coultas DB, Skipper BJ. Ac- culturation, education, and income as determinants of cigarette smoking in New Mexico Hispanics. Cancer Epidemiology, Biomarkers &Prevention 1992;1(3):23540. San Diego Union-Tribune. Fair board sends Marlboro packing: Marlboro cigarettes promotional contract with Del Mar Fair Board to end. San Diego Union- Tribune 1996 Apr 2:Sect A:l. Factors That Influence Tobacco Use 253 Surgeon General's Report Sanchez L. Anti-smoking efforts take aim at Latinos. The San Diego Union-Tribune 1993 June 25;Sect B:3 (co1 1). Satcher D, Robinson RG. The CDC and the NMA- partnerships to control tobacco in the African- American community. Journal of the National Medical Association 1994;86(7):493-6. Scheier LM, Newcomb MD. Differentiation of early adolescent predictors of drug use versus abuse: a developmental risk-factor model. Journal of Substance Abuse 1991;3(3):277-99. Schinke SP, Moncher MS, Holden GW, Botvin GJ, Orlandi MA. American Indian youth and substance abuse: tobacco use problems, risk factors and preven- tive interventions. Health Education Research 1989; 4(1):13744. Schinke SP, Orlandi MA, Schilling RF, Botvin GJ, Gilchrist LD, Landers C. Tobacco use by American In- dian and Alaska Native people: risks, psychosocial factors, and preventive intervention. Journal of Alcohol and Drug Education 1990;35(2):1-12. Schinke S, Orlandi M, Vaccaro D, Espinoza R, McAlister A, Botvin G. Substance use among Hispanic and non-Hispanic adolescents. Addictive Behaviors 1992;17(2):117-24. Schmeltzer J. "Mainstream" spending up by minori- ties; study shows buying of cars and computers surg- ing among African-Americans as upbeat view of economy spreads. Chicago Tribune 1996 Aug 28;Busi- ness Sect:l. Seig L. Tobacco, Peace Pipes, and Indians. Palmer Lake (CO): The Filter Press, 1971. Sesser S. Opium war redux. The New Yorker 1993; 69(29):78-89. Shelton DM, Merritt RK, Robinson RG. Tobacco con- trol strategies. In: Slama K, editor. Tobacco and Health. New York: Plenum Press, 1995:367-74. Sherman G. Tobacco pipes of the Western Eskimos. Beaver 1972;303(1):49-51. Siegel RK. Intoxication: Life in Pursuit of Artificial Para- dise. New York: E. I? Dutton, 1989. Simmons S. New cig is aimed at black smokers: Up- town to be tested here. Philadelphia Daily News 1989 Dee 14;Business Sect:51. Smith KW, McGraw SA, Carrillo JE. Factors affecting cigarette smoking and intention to smoke among Puerto Rican-American high school students. Hispanic Journal of Behavioral Sciences 1991;13(4):401-11. Smith L. Big apple breathes easy. Tobacco Control 1995;4(1):15-7. Solberg EJ, Blum A. Tobacco money buys minorities' political support. Tobacco Control 1992;1(4):245-6. Soley LC, Reid LN. Satisfaction with the informational value of magazine and television advertising. Journal of Advertising 1983;12(3):27-31. Spangler JG, Dignan MB, Michielutte R. Correlates of tobacco use among Native American women in west- ern North Carolina. American Journal of Public Health 1997;87(1):108-11. Stanley BN. New deal: an increasing number of minority-owned businesses land contracts with Philip Morris. Richmond Times-Dispatch 1996 Feb 12;Sect D:14. Stebbins KR. Transnational tobacco companies and health in underdeveloped countries: recommendations for avoiding a smoking epidemic. Social Science and Medicine 1990;30(2):227-35. Stern RA, Prochaska JO, Velicer WF, Elder JI? Stages of adolescent cigarette smoking acquisition: measure- ment and sample profiles. Addictive Behaviors 1987; 12(4):319-29. Stoddard JL, Johnson CA, Boley-Cruz T, Sussman S. Targeted tobacco markets: outdoor advertising in Los Angeles minority neighborhoods [letter]. American Journal of Public Health 1997;87(7):1232-3. Sussman S, Dent CW, Flay BR, Hansen WB, Johnson CA. Psychosocial predictors of cigarette smoking on- set by white, black, Hispanic, and Asian adolescents in Southern California. Morbidity and Mortality Weekly Report 1987;36(4 Suppl):llS-16s. Tamir A, Cachola S. Hypertension and other cardio- vascular risk factors. In: Zane NWS, Takeuchi DT, Young KNJ, editors. Confronting Critical Health Issues of Asian and Pacific Islander Americans. Thousand Oaks (CA): Sage Publications, 1994:20946. 254 Clzapter4 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Tide. Philip Morris. Tide 1948;22(33):18. Tobacco Merchants Association of the United States. The TMA Directory of Cigarette Brand Names 1913-1977. New York: Tobacco Merchants Association of the United States, 1978. Tomas Rivera Center. Resolving a Crisis in Education: Latin0 Teachers for Tomorrow's Classrooms. Claremont (CA): Tomas Rivera Center, 1993. Triandis HC, Marin G. Etic plus emit versus pseudo- etic: a test of a basic assumption of contemporary cross-cultural psychology. Journal of Cross-Culturd Psychology 1983;14(4):489-500. Tuckson RV. Race, sex, economics, and tobacco adver- tising [editorial]. Journal of tlze National Medical Asso- ciation 1989;81(11):1119-24. Ullman Gravure, Inc. TransPlastix dynamic plastic dis- plays [advertisement]. Printers' l~zk 1957;258(13):82. US Bureau of the Census. 2990 CeJzslls of Pop~/lation: Asians and Pacific Islanders in the United States. Washington (DC): US Department of Commerce, Eco- nomics and Statistics Administration, Bureau of the Census. Publication No. (X-3-5,1993. US Commission on Civil Rights. The Decline of Black Farming in America: A Report of the United States Com- mission on Civil Rights. Washington (DC): US Commis- sion on Civil Rights, 1982. US Congress. Advertising of Tobacco Products. Hear- ings before the Subcommittee on Health and the Envi- ronment of the Committee on Energy and Commerce, House of Representatives, 99th Congress, 2nd Sess. Washington (DC): US Government Printing Office. Serial No. 99-167, 1987. US Congress. Tobacco Issues (Part 2). Hearings before the Subcommittee on Transportation and Hazardous Materials of the Committee on Energy and Commerce, House of Representatives, 1Ols.t Congress. Washing- ton (DC): US Government Printing Office. Serial No. lOl-126,199O. US Department of Health and Human Services. Re- ducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411,1989. US Department of Health and Human Services. Tobacco Use in 1986: Methods and Basic Tabulations from Adult Use of Tobacco Survey. Rockville (MD): US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Dis- ease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (OM) 90- 2004,199O. US Department of Health and Human Services. Smok- ing and Health in the Americas. A 1992 Report of the Sur- gee!? General. Atlanta: US Department of Health and Human Services, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Pro- motion, Office on Smoking and Health. DHHS Publi- cation No. (CDC) 92-8419,1992. US Department of Health and Human Services. Pre- venting Tobacco Use Among Young People. A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. US Newswire, Inc. Business Policy Review Council to honor black corporate pioneers. Washington (DC): US Newswire, Inc., February 1,1997. Vander Martin R, Cummings SR, Coates TJ. Ethnicity and smoking: differences in white, black, Hispanic, and Asian medical patients who smoke. American Journal of Preventive Medicine 1990;6(4):194-9. Vanderschmidt HF, Lang JM, Knight-Williams V, Vanderschmidt GE Risks among inner-city young teens: the prevalence of sexual activity, violence, drugs, and smoking. Journal of Adolescent Health 1993;14(4): 282-8. Vega WA, Zimmerman RS, Warheit GJ, Apospori E, Gil AG. Risk factors for early adolescent drug use in four ethnic and racial groups. American Journal of Pub- lic Health 1993;83(2):185-9. Factors That Influence Tobacco Use 2.55 Surgeon General's Report Villarosa L. Body and soul. Women's Reviezo of Books 1994;11(10-11):13-4. Wall KA. Positioning your brand in the black market. Advertising Age 1973;44(25):71-6. Wallace JM Jr, Bachman JG. Explaining racial/ethnic differences in adolescent drug use: the impact of back- ground and lifestyle. Social Problems 1991;38(3):333-57. Wallace JM Jr, Bachman JG. Validity of self-reports in student-based studies on minority populations: issues and concerns. In: De La Rosa MR, Adrados J-LR, edi- tors. Drug Abuse Among Minority Youth: Advances in Research and Methodology. National Institute on Drug Abuse Research Monograph No. 130. Rockville (MD): US Department of Health and Human Services, Pub- lic Health Service, National Institutes of Health, Na- tional Institute on Drug Abuse, 1993:167-200, NIH Publication No. 93-3479. Walters DKH. Cigarettes; makers aim at special niches to boost sales. Los Angeles Times 1985 Sept 15;Business Sect:l(col3). Warnecke RB, Graham S, Rosenthal S, Manfredi C. Social and psychological correlates of smoking behav- ior among black women. JournaZ of Health and Social Behavior 1978;19(4):397-410. Warner KE. Cigarette advertising and media coverage of smoking and health. Nezo EngZand Journal of Medi- cine 1985;312(6):384-8. Warner KE. Selling Smoke: Cigmette Advertising and Public Health. Washington (DC): American Public Health Association, 1986. Warner KE, Goldenhar LM, McLaughlin CG. Cigarette advertising and magazine coverage of the hazards of smoking-a statistical analysis. Nezu England ]ournal of Medicine 1992;326(5):305-9. Watts WD, Wright LS. The relationship of alcohol, to- bacco, marijuana, and other illegal drug use to delin- quency among Mexican-American, black, and white adolescent males. Adolescence 1990;25(97):171-81. Webster C. Attitudes toward marketing practices: the effects of ethnic identification. Journal of Applied Business Research 1990-1991;7(2):107-16. Webster C. The effects of Hispanic subcultural identi- fication on information search behavior. Journal of Ad- vertising Research 1992;32(5):54-62. Weibel-Orlando J. Indians, ethnicity, and alcohol: con- trasting perceptions of the ethnic self and alcohol use. In: Bennett LA, Ames GM, editors. The American Expe- rience With Alcohol: Contrasting Cultural Perspectives. New York: Plenum Press, 1985:201-26. Weinrich S, Hardin S, Valois RF, Gleaton J, Weinrich M, Garrison CZ. Psychological correlates of adolescent smoking in response to stress. American Journal of Health Behavior 1996;20(1):52-60. Weiss W. Mass media and social change. In: King BT, McGinnies E, editors. Attitudes, Conflict, and Social Change. New York: Academic Press, 1972:137-54. Weng L-J, Newcomb MD, Bentler PM. Factors influ- encing noncompletion of high school: a comparison of methodologies. Educational Research Quarterly 1988; 12(2):8-22. Whittler TE. Viewers' processing of actor's race and message claims in advertising stimuli. Psychology and Marketing 1989;6(4):287-309. Wiecha JM. Differences in patterns of tobacco use in Vietnamese, African-American, Hispanic, and Cauca- sian adolescents in Worcester, Massachusetts. Ameri- can Journal of Preventive Medicine 1996;12(1):29-37. Wildey MB, Young RL, Elder JP, de Moor C, Wolf KR, Fiske KE, et al. Cigarette point-of-sale advertising in ethnic neighborhoods in San Diego, California. Health Values 1992;16(1):23-8. Williams L. Tobacco companies target blacks with ads, donations and festivals. Wall Street Journal 1986 Ott 6;33(col4). Wootten HM. Filters push cigarette sales up 4.9%. Printers' Ink 1957;261(13):22-7. Yamaguchi K, Kandel DB. On the resolution of role incompatibility: a life event history analysis of family roles and marijuana use. American Journal of Sociology 1985;90(6):1284-1325. Zane N, Sasao T. Research on drug abuse among Asian Pacific Americans. Drugs & Society 1992;6(3-4):181-209. Zbar JD. Marketing to Hispanics; the Spanish-language magazine is getting crowded with new entries as publishers and advertisers look to reach a growing market of 27 million people who spend $228 billion annually. Advertising Age 1996;67(12):27-8. 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