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Thousand Oaks (CA): Sage Publications, 1994. 204 Chapter 3 Chapter 4 Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups Introduction 207 Historical Context of Tobacco 208 African Americans 208 American Indians and Alaska Natives 209 Asian Americans and Pacific Islanders 211 Hispanics 222 Economic Influences 213 Tobacco Industry Support for Racial/Ethnic Minority Communities 213 Employment Opportunities 213 Advertising Revenues 214 Funding of Community Agencies and Organizations 215 Support for Education 217 Support for Political, Civic, and Community Campaigns 217 Support for Cultural Activities 218 Support for Sports Events 219 Advertising and Promotion 220 Magazine Advertisements 221 Outdoor Advertisements 221 In-Store Promotions 222 Racial/Ethnic Symbols, Names, and Events 222 Targeted Products 223 Psychosocial Determinants 225 Initiation and Early Use of Tobacco 225 African Americans 226 American Indians and Alaska Natives 227 Asian Americans and Pacific Islanders 227 Hispanics 228 Multiple Group Studies 229 Prevalence of Risk Factors for Cigarette Use 229 Factors Associated with Initiation of Cigarette Use 231 Factors Associated with Initiation of Smokeless Tobacco Use 232 Summary, Initiation and Early Use of Tobacco 233 Tobacco Use Among Adults 233 African Americans 233 American Indians and Alaska Natives 233 Asian Americans and Pacific Islanders 234 Hispanics 234 Summary, Tobacco Use Among Adults 235 Smoking Cessation 235 African Americans 235 American Indians and Alaska Natives 237 Asian Americans and Pacific Islanders 237 Hispanics 23 7 Summary, Smoking Cessation 237 Methodological Limitations of the Literature 238 Chapter Summary 239 Conclusions 240 Appendix. A Brief History of Tobacco Advertising Targeting African Americans 240 Early Assumptions 240 Early Targeted Advertising Efforts (194Os-1960s) 242 Recent Targeted Advertising Efforts (Late 196Os-1980s) 243 References 245 Tobacco Use Among U.S. Racial/Ethnic Mitzorify Groups Introduction Tobacco use is determined and influenced by several kinds of factors: (1) individual factors (per- ceptions, self-image, peers); (2) social factors (societal norms); (3) environmental factors, such as advertising and economics; and (4) cultural factors, such as traditional uses of tobacco, acculturation, and the historical context of the tobacco industry in various communities. Behavior and patterns of tobacco use result from each of these factors and from their com- plex interplay, which is difficult to study and measure. Although available evidence has demonstrated that these factors contribute to behavior, research has been unable to quantify the distinct effect of each one and the effects of their interaction. The lack of definitive literature points to the need for further research to bet- ter quantify the ways in which a person's exposure to various social, environmental, and cultural influences affects tobacco use behavior. Most likely, it is not a single factor but rather the convergence or interaction of some or all of these factors that significantly influ- ences both a person's decision to use tobacco and pat- terns of tobacco use (U.S. Department of Health and Human Services [USDHHS] 1989; Lynch and Bonnie 1994; USDHHS 1994). This chapter examines the com- plex factors that influence tobacco use among the four major racial/ethnic minority groups. Tobacco has a role in all communities through social, economic, and cultural connections. These con- nections include (1) social customs, such as the shar- ing and giving of tobacco in Asian communities; (2) employment opportunities and economic growth provided to racial/ethnic groups through tobacco agriculture and manufacturing; (3) tobacco industry support of community leaders and organizations; (4) tobacco industry sponsorship of cultural events; and (5) ceremonial and medicinal uses of tobacco. Indeed, tobacco's history has led to some positive social perceptions of tobacco, perceptions that may also influence use. Cigarette advertising and promotion may stimu- late cigarette consumption by (1) encouraging children and adolescents to experiment with and initiate regu- lar tobacco use, (2) deterring current tobacco users from quitting, (3) prompting former users to begin using again, and (4) increasing daily consumption by serv- ing as an external cue to smoke (Centers for Disease Control [CDC] 1990a). Whether or not they are intended to do so, advertising and promotional activi- ties appear to influence risk factors for adolescent tobacco use (USDHHS 1994). Cigarette advertising appears to affect young people's perceptions of the per- vasiveness, image, and function of smoking. Because misperceptions in these areas constitute psychosocial risk factors for the initiation of smoking, cigarette ad- vertising appears to increase young people's risk of smoking. The Food and Drug Administration (FDA) recently concluded that although advertising may not be the most important factor in a child's decision to smoke, studies establish that it is a substantial con- tributing factor (Federal Register 1996). A different kind of influence is found in psycho- social variables, which help explain why people start using tobacco, why some continue using it, and why some stop using it. Published research findings are scant about individual and interpersonal factors that influence tobacco use among African Americans, American Indians, Alaska Natives, Asian Americans, Pacific Islanders, and Hispanics. This paucity of data, in fact, both inspired and hampered the development of this report. Although research findings based on samples of the majority white population may be applicable to racial/ethnic populations, such generalizability has not been sufficiently studied. Furthermore, cultural differences exist among commu- nities and members of various racial/ethnic groups in values, norms, expectancies, attitudes, and the histori- cal context of tobacco and the tobacco industry. Such differences, in turn, may influence both the prevalence of cigarette smoking in a particular racial/ethnic mi- nority group and the effect of certain associated risk factors (Marin et al. 1990a; Vander Martin et al. 1990; Robinson et al. 1992a). Another important factor that may influence to- bacco use behavior is the actual infrastructure within a community for conducting tobacco control activities that support a non-tobacco-use norm. This capacity of the community for tobacco control activities is also discussed in Chapter 5 of this report because it directly affects such programs, in addition to the influence it may have on the environmental context of tobacco use. The first part of this chapter summarizes the his- tory of tobacco use among members of the four major racial/ethnic groups in the United States-African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispan- ics. The association between the tobacco industry and these communities, including economic influences and the role of targeted advertising and promotion, is also Factors That Inflllelrce Tobacco Use 207 Surgeon General's Repot9 described. The second part of the chapter discusses tory of tobacco advertising targeting African Ameri- psychosocial influences associated with initiation of cans. Because so little information is available on the tobacco use, maintenance, and cessation among the history of cigarette advertising aimed at American In- four groups. Unfortunately, the limited information dians, Alaska Natives, Asian Americans, Pacific Island- available affects the length and comprehensiveness of ers, and Hispanics, these groups are not discussed in the presentation. The appendix presents a short his- the appendix. Historical Context of Tobacco African Americans The first recorded landing of Africans in the United States was in 1619, when a group of indentured servants was brought to Jamestown, Virginia (Foner 1981), and Jamestown quickly became the center for profitable tobacco trade with England and other Eu- ropean nations (USDHHS 1992). Indeed, a significant portion of the early colonies' wealth derived from the exportation of tobacco (Northrup and Ash 1970). Cot- ton did not become preeminent until the invention of the cotton gin in 1793 (Foner 1981). Tobacco farming was widespread throughout the south, and although tobacco was later supplanted by other crops (includ- ing cotton) in many areas, it remains a major crop in six states-Georgia, Kentucky, North Carolina, South Carolina, Tennessee, and Virginia (Gale 1993). Whites initially were employed in tobacco culti- vation, but as tobacco prices fell in Europe, tobacco companies began using less expensive labor (Kulikoff 1986). Among other factors, the need for a larger and less expensive labor force to grow tobacco led the colo- nies to gradually transform the status of Africans from indentured servants, who earned their freedom after a period of involuntary servitude, to slaves, who were the property of their masters for life. In addition to slaves, many free African Americans worked in to- bacco farming during the 18th and 19th centuries. In- deed, more free African Americans were employed in tobacco production than in any other occupational category in the south during that time (Northrup and Ash 1970). Slaves also hired themselves out as tobacco laborers, and some earned enough funds to purchase their freedom. After emancipation, freed African Americans who had obtained some acreage began farming to- bacco because it was a cash crop that did not require much land to be profitable. In particular, freed African Americans farmed tobacco in Georgia, North Carolina, South Carolina, and Virginia. Nevertheless, the number of tobacco farms owned by African Ameri- cans has declined dramatically in the 20th century, pos- sibly because so many African Americans, including tobacco farm owners and laborers, were migrating to the north (U.S. Commission on Civil Rights 1982; Gale 1993). In the colonial period and early years of the United States, African Americans and whites worked side by side in cigarette-manufacturing factories, which tended to be primarily small cottage industries. However, the introduction of the cigarette-making machine in the mid-1880s changed this pattern. Be- cause white women were viewed as the only group that had the manual dexterity needed to operate the machines, and it was socially unacceptable for Afri- can American men and women to work alongside white women, African Americans were replaced as factory workers and relegated to less skilled, menial, field jobs (Northrup and Ash 1970; Meyer 1992). Dur- ing the early 19OOs, the dirtiest, unhealthiest, and low- est paying jobs in tobacco factories were carried out by African American women (Jones 1984). Because the jobs held by African Americans in stemming and processing the tobacco leaf were low paying, the to- bacco industry made little effort to mechanize such jobs before the early 1930s. Thus, many African Americans remained employed in the tobacco industry, even as tobacco factories began replacing people with labor- saving machines (Northrup and Ash 19701. The high concentration of African Americans in certain occupations helped them gain a foothold in one of the few areas in which organized labor had achieved success in the south. Initial unionizing efforts by the Tobacco Workers International Union began in the early 20th century (Kaufman 1986). The efforts of the United Tobacco Workers Local 22 to encourage Afri- can American members to register for and vote in municipal elections are credited with the election of an African American to the city council of Winston- Salem, North Carolina, in 1947. At the same time, a 208 Cl1f7ptcr 4 Tobacco Use Among U.S. Racial/Ethnic Minority Groups rival-the Food, Tobacco, Agriculture, and Allied Workers Union-sought to involve African Americans in its unionizing efforts as equals. United Tobacco Workers Local 22, which represented workers at the R.J. Reynolds Tobacco Company in Winston-Salem, remained one of the strongest unions in the south. The union represented equal numbers of African Ameri- can and white workers. In addition, African Ameri- can women held significant leadership roles in the union (Lerner 1973; Foner 1981). This early unioniza- tion among African Americans in tobacco-producing states was of such historic importance that it is con- sidered one of the first civil rights movements (Korstad and Lichtenstein 1988). Probably as a result of the ra- cial divisions within the union movement and the re- sidual power held by African American workers, R.J. Reynolds was the first company to have African Ameri- cans operate cigarette-making machines after World War II and, in 1961, to open a factory with integrated production lines and desegregated facilities (Northrup and Ash 1970). Nevertheless, tobacco cultivation has not contrib- uted significantly to the economic well-being of Afri- can Americans in the southern states. In each of the decennial censuses conducted between 1960 and 1990, about one-third of all counties in the south where tobacco is a major agricultural product have been iden- tified as areas of persistent poverty. These poverty- stricken counties-concentrated in Georgia, North Carolina, and South Carolina-tend to have more farms owned and operated by African Americans than the south in general (Gale 1993). In addition, econo- mies of scale and the increasing mechanization of to- bacco growing have accelerated the decrease in tobacco farming, particularly by African Americans (U.S. Com- mission on Civil Rights 1982; Gale 1993). For example, by 1987, more than 50 percent of the farms operated by African Americans specialized in livestock produc- tion, and only 11 percent specialized in tobacco grow- ing (Gale 1993). In summary, tobacco has been a part of the expe- rience of African Americans since the early 16OOs, when Africans were first brought to the Americas. The rela- tionship between African Americans and tobacco growers and manufacturers has changed in the postslavery era but remains strong and complex, par- ticularly since the mid-1940s. The strength derives from the important economic role of tobacco among African Americans, and the complexity comes from the contradictory social and economic forces that affected the African American worker. In addition, changing market forces helped make African Ameri- cans significant users of tobacco. As a result, the rela- tionship of African Americans to the tobacco industry was no longer primarily dependent on their role as workers in the tobacco labor force but was now influ- enced as well by their status as consumers. For ex- ample, until the mid-1940s, many African Americans held low-paying jobs in tobacco-related agriculture and industry; around the time of World War II, how- ever, some tobacco companies began to advertise to African Americans. Advertising efforts increased in the 195Os, a decade that saw African American men surpass white men in smoking prevalence. During this same time, the tobacco industry was hiring and pro- moting African American workers. Other influences affecting African Americans' ties to tobacco were the tobacco industry's increased attention to and positive steps toward civil rights in the 1950s and 196Os, the broadcast ban on tobacco advertising that led the to- bacco industry to seek more targeted market segments in the 197Os, and the expansion of African American political power in the 1980s and 199Os, which served to give the tobacco industry additional access to the African American community (Robinson et al. 1992bl. The historical patterns underpinning the African American community's relationship to tobacco may affect African Americans' attitudes and behaviors to- wards tobacco. American Indians and Alaska Natives Tobacco has long played an important role in the cultural and spiritual life of North and South American Indians and Alaska Natives. When the Eu- ropeans colonized the Americas, tobacco already was being cultivated and used in many parts of the conti- nent. Early European explorers documented the cultivation and farming of tobacco and its extensive use among tribes throughout most of North and South America (Hedge 1910; Linton 1924) and in Alaska's interior (Sherman 1972)---findings that have been sup- ported by archaeological discoveries at a variety of sites (Haberman 1984). When Europeans first arrived in the Americas, tobacco served various purposes among American Indians and Alaska Natives, including ceremonial, re- ligious, and medicinal functions (McCullen 1967; Seig 1971; Ethridge 1978). In ceremonial and religious rites, tobacco was a significant part of sacramental offerings. For example, tobacco was used to ensure good luck in hunting and to seal peace and friendship agreements. When used for medicinal purposes, tobacco often was mixed with other substances in topical ointments and ingested for internal healing. For example, in the Factors That I~zflueme Tobacco Use 209 Surgeon General's Report northwest region of North America, tobacco was com- bined with shell lime powder and then formed into small marble-sized balls that were dissolved in the mouth (Linton 1924). Tobacco smoke often was used during prayers to aid in healing and was prescribed to cleanse people, places, and objects of unwanted spir- its. Tobacco smoke also was used at the beginning of meetings as a ritual to cleanse the room and secure the truth from the spoken word. Early inhabitants of the American continent also inhaled tobacco smoke (Linton 1924). They often placed burning or smoldering tobacco on the bare ground or on a mound and then waved the smoke to- ward their faces using the palms of their hands. Early inhabitants also smoked rolled sheets of dried tobacco leaves (cigars) and wrappings of cut tobacco, and they smoked tobacco through a flaxen reed. The most com- mon way to smoke tobacco was to place cut tobacco within the bowl of a calumet-either a stone or a hollowed-out bone pipe (Linton 1924). Tobacco smoking was part of many solemn oc- casions among American Indians, such as when lead- ers met (Paper 19881. In some tribes, the pipe became such a powerful object that it was considered sacred. Only certain individuals could use the pipe, and only sacredly gathered tobacco could be burned in a pipe's bowl (Linton 1924). The Hopi Tribe used tobacco reli- giously, blowing smoke in the four sacred directions to invoke good planting and to encourage rainfall. Other tribes, such as the Delaware, Iroquois, and Sioux, smoked tobacco during prayers, at the opening of the sacred bundle-a collection of religious artifacts (Paper 1988). Tobacco also was used between enemies in battle to signify a truce. If one party offered the pipe and the other party accepted it, this signified the end of the battle, and both parties would then put down their weapons. As a result, the smoking of tobacco leaves, often with the peace pipe, became associated with the American Indian as a common symbol that had significant positive social and cultural connotations. During the 17OOs, tobacco became one of the most important commodities traded among American In- dians and Alaska Natives. For example, Alaska Na- tives in the Arctic and sub-Arctic regions depended on trade with tribes from the east and south of the North American continent to obtain tobacco products (Fortuine 1989). Among the items traded were special smoking vessels, such as pipes made of stone quar- ried in what is now Wisconsin and Minnesota (Linton 1924; Paper 1988). With the European colonization of the American continent, tobacco became known in Europe, where it was at times expressly forbidden, primarily because of health concerns about the dangers of tobacco spit- ting. Following tobacco practices in the Americas, early European explorers smoked tobacco the way it was smoked by American Indians (Linton 1924). In- deed, many of the pipes these explorers used were fashioned after tribal pipes. Europeans also adopted many of the tribes' medicinal uses of tobacco. How- ever, the use of tobacco for recreational purposes was widely accepted and soon became primary. Euro- peans also began to chew tobacco raw rather than in a mixture of powdered shells or roots, as was the cus- tom of North American tribes. Most early American Indian tobacco harvesting was done with farming technologies that originated in the Southern part of North America (Paper 1988). For example, nonfarming nomadic tribes and light farming tribes scattered tobacco seeds on holy grounds near waterways or marshes and let the plants grow without much cultivation. In fact, the Iroquois pro- hibited their people from cultivating tobacco plants or coming in contact with them while the plants were growing to maturity. Other tribes, such as the Blackfeet, Crow, and some Northern Plains Indian people, grew tobacco plants instead of food crops in small sacred patches for medicinal and ceremonial uses (Linton 1924). Over the centuries as American Indians and Alaska Natives experienced vast cultural and political upheaval, their attitudes about tobacco changed sig- nificantly. Today, among some contemporary Ameri- can Indian and Alaska Native groups, tobacco use has lost some of its traditional attributes and no longer is endowed with the same special meaning. However, some American Indians have maintained the traditional practices associated with tobacco. For example, tobacco is given as a gift to traditional healers and dancers at powwows and many other social gatherings, and it is presented to honor persons celebrating important events, such as marriages. Many American Indians consider tobacco to be a medicine that can improve their health and assist in spiritual growth when used in a sacred and respectful manner. It is important to rec- ognize the positive social context in which tobacco is viewed in American Indian communities and to recog- nize the difficulties these connotations may cause in preventing tobacco use among youth and helping adults to quit. It is possible that tobacco control efforts could be enhanced by emphasizing the distinction be- tween sacred uses of tobacco on ceremonial occasions and addictive tobacco use by individuals. An additional complicating factor for tobacco control efforts among this population is that American Indians have become 210 Clznpter 4 Tobacco Use Among U.S. Racial/Ethnic Minority Groups increasingly reliant on tobacco sales and on the revenues these sales bring to the reservations (see Tobacco Industry Support for Racial/Ethnic Minority Communities later in this chapter). Asian Americans and Pacific Islanders Because about 63 percent of the Asian Americans and Pacific Islanders in the United States are immi- grants (U.S. Bureau of the Census 19931, their lives have been influenced by the history of tobacco use in Asia and the Asian Pacific. Asia's many countries and cul- tures have different traditions regarding the use of to- bacco. These differences are also reflected in Asian Americans and Pacific Islanders themselves. Tobacco was introduced in Asia in the early 17th century by Europeans (Goodman 1992). Like the introduction of opium in China, the exportation of tobacco to Asia has led to an addiction that has dramatically changed the health behaviors of Asians (Chen and Winder 1990). The Dutch brought tobacco to China, where it was mixed with opium. The Chinese subsequently intro- duced tobacco in Mongolia, Tibet, and Eastern Siberia (Goodman 1992). Early Portuguese explorers then carried tobacco to India, Japan, and Java in 1605, and the Japanese in turn introduced tobacco in Korea (Laufer 1924). Asians later used tobacco in ways more similar to its medicinal uses in other parts of the world. In China, for example, tobacco was used as a remedy against colds, malaria, and cholera. The beliefs about the usefulness of tobacco as a medicine were so in- grained in China during the 17th century that two imperial edicts (1638 and 1641) prohibiting its use failed to curtail tobacco use. Currently, tobacco is a crop of great significance in Asia. In 1990, Asian countries produced approxi- mately 60 percent of the world's tobacco crop (Goodman 1992). By 1995, United Nations statistics showed that Asian countries were producing 63.2 per- cent of tobacco leaves in the world (Food and Agricul- ture Organization of the United Nations [FAOI 1996). Both China (34.1 percent) and India (9.0 percent) ranked above the United States (6.3 percent) in the percentage of total tobacco leaf production (FAO 1996). In China, the manufacture and sale of tobacco prod- ucts are part of the economic role that tobacco plays. After foreign investment was legalized in China in 1979, the China National Tobacco Corporation entered into joint ventures with Philip Morris, R.J. Reynolds, and other foreign tobacco companies. The China Na- tional Tobacco Corporation has dramatically increased production after implementing western technology, and its 183 cigarette factories, 150 tobacco drying plants, 30 research institutes, and 520,000 workers make up a strong part of the local economy (Frankel and Mufson 1996). Whereas cigars, pipes, snuff, chewing tobacco, cheroots (cigars), bidis (cigarettes of India), and kreteks (clove cigarettes) initially were more commonly used than regular tobacco cigarettes in Asia, cigarettes now are an integral part of contemporary Asian and Asian Pacific life. As expected, Asians and Pacific Islanders who migrate to the United States bring with them the attitudes and expectancies that have characterized the use of tobacco in their countries of origin. Sharing ciga- rettes, particularly among adult male guests, is a ges- ture of hospitality in a number of Asian cultures (Tamir and Cachola 1994). For example, distributing ciga- rettes, particularly U.S. cigarettes, at Cambodian wed- dings is a customary way of honoring the bride and groom. In China, foreign visitors are expected to give cartons of cigarettes to their hosts. In this regard, the importance of using tobacco as a form of social ex- change is very similar to the reinforcement given to tobacco use among Hispanics. Cigarette smoking also has acquired utilitarian uses in some Asian countries. In Southeast Asia, for example, cigarette smoking is perceived as a way to keep warm at night and to keep mosquitoes away (Mackay and Bounxouie 1994). In some provinces in China, anecdotal information indicates that babies and toddlers are given puffs of lighted cigarettes to stop them from crying (Mackay et al. 1993). Cigarette smoking in Asian society has been popularly associated with affluence and sophistication (Frankel and Mufson 1996). Accordingly, the promo- tion of cigarette smoking in Asian countries follows patterns fairly similar to those found in the United States, where cigarette smoking is glamorized and of- ten associated with affluence. In a recent article, Sesser (1993) recounted how in one week of traveling in Asia he "attended a Virginia Slims fashion show at a Tai- wanese disco, watched the finals of the Salem Open tennis tournament in Hong Kong, and followed the progress of the Marlboro Tour `93, a bicycle race in the Philippines" (p.78). Cigarettes made in the United States are not only promoted in those Asian countries where the importation of foreign cigarettes is allowed, but also in China, where U.S. cigarettes are not freely sold (Stebbins 1990). In these cases, brand recognition is an important outcome of promotional campaigns once the market is opened to imported cigarettes. Before market access trade actions by the United States in the 198Os, advertising was unnecessary in most Asian countries because tobacco production was operated through state-owned tobacco monopolies. Factors That Influence Tobacco Use 211 Surgeon General's Report As a result, few brands were available for purchase. The expansion of large transnational corporations (e.g., British American Tobacco Company, Ltd., and Philip Morris Companies Inc.) into Asian markets brought about more brand competition and, thus, more advertising. Advertising techniques have included sponsorship of rock concerts and teen dances and ex- tensive radio and outdoor advertising (Frankel and Mufson 1996). According to a study reported by the National Bureau of Economic Research using data from Japan, Taiwan, South Korea, and Thailand, ". . . in 1991, average per capita cigarette consumption was nearly ten percent higher than it would have been had the markets remained closed to U.S. cigarettes" (Chaloupka and Laixuthai 1996, p. 13). The paucity of information about tobacco use among Asian Americans and Pacific Islanders ham- pers the formation of substantive conclusions about the relationship between community attitudes and behaviors and the historical relationship with tobacco and the tobacco industry. Existing information, how- ever, is sufficient to show that factors associated both with the respective native cultures and with accultura- tion are important. Tobacco prevention and control programs must take these cultural factors into account to positively influence the norms, attitudes, and be- haviors of these racial/ethnic communities. Hispanics The cultivation and processing of tobacco have played a significant role in the economies of most Latin American countries, including Brazil (Nardi 19851, Colombia (De Montana 1978), Cuba (River0 Muniz 1964), and Mexico (Ros Torres 1984). In 1995, the level of production of tobacco leaf in South America alone reached 9.1 percent of the world total (FAO 1996). In the United States, Hispanics, primarily those of Cuban ancestry, have played a key role in the manu- facture of cigars in Florida factories. As is true of all immigrants, Hispanics who migrate from Latin America are influenced by historical conditions in their native countries regarding tobacco and the tobacco industry and bring with them the attitudes and ex- pectancies that characterize tobacco use in their coun- tries of origin. These attitudes and expectancies are often modified as the process of acculturation takes place (Marin et al. 1989a). The history of tobacco use in Central and South America as well as in the Caribbean predates the ar- rival of the European explorers and therefore has ac- quired a rich lore. Tobacco played a prominent role in religious and healing practices of native inhabitants of those regions. It was used by shamans or spiritual leaders to induce trancelike states, ensure fertility, and facilitate spiritual consultations. Many cultural and social norms surrounded tobacco, all of which have contributed to defining the role of tobacco in these societies. Tobacco became a staple crop of the Ameri- cas when the predominant means of obtaining food shifted from hunting to agriculture. Tobacco manu- facture and trade played a significant role in the econo- mies of the Caribbean, Latin America, and North America. A detailed account of the history of tobacco in the Americas can be found in the Surgeon General's report Smoking and Health in the Americas (USDHHS 1992). Recent surveys also indicate that Hispanic ciga- rette smokers have group-specific expectancies and attitudes that differentiate them from smokers of other racial/ethnic groups. These expectancies and attitudes are the product of social conditions and norms that have dictated the use of tobacco in Latin American countries for the last few centuries and are also the effects of certain relevant cultural values, such as simpath (a social mandate for positive social relations), personalismo (the value placed on personal relation- ships), and fmnilialism (the normative and behavioral influence of relatives) (Marin and Marin 1991). Among many Hispanics in the United States, cigarette smok- ing is a social activity (Marin et al. 1989a; 1990a,b). Although tobacco use remains a social activity among all communities, given the cultural values of simpatiu and personalismo, sharing cigarettes often serves as a particularly strong form of social affiliation and friend- ship. This norm must often be considered when to- bacco prevention and control programs are initiated within Hispanic communities. 212 Chapter 4 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Economic Influences Tobacco Industry Support for Racial/Ethnic Minority Communities The tobacco industry's longtime economic support for U.S. racial/ethnic communities may have contributed to the survival of many of these commu- nities' institutions (Robinson et al; 1992b). For example, the tobacco industry supports African Ameri- can communities in five main ways: (1) direct employ- ment of African Americans, (2) support for social services and civil rights organizations, (3) contributions to politicians and political organizations, (4) support for educational and ctiltural programs, and (5) con- tracts with small businesses (Blum 1989; Robinson et al. 1992a,b). More recently, the tobacco industry also has provided economic support to American Indian, Alaska Native, Asian American, Pacific Islander, and Hispanic communities. As detailed below, the tobacco industry has em- ployed members of racial/ethnic communities prima- rily in farming and manufacturing, although some have been employed in sales and marketing positions. The industry's support for social services and civil rights organizations and its involvement in educational and cultural activities have been wide-ranging: This support has included contributions to endowments, scholarship funds, and literacy campaigns as well as support for artistic groups, exhibits, and performances. Contributions from tobacco companies and tobacco- related political action committees have underwritten the growth of racial/ethnic political power at the local, state, and national levels. In addition, many to- bacco companies use the services of minority-owned businesses either through their own internal programs or through formal alliances with such groups as Op- eration PUSH (People United to Save Humanity) and the National Association for the Advancement of Col- ored People (NAACP). In addition, tobacco product sales and promotions have contributed to the econo- mies of racial/ethnic communities. For example, the sale of cigarettes and smokeless tobacco contributes to the economies of small corner convenience stores catering to racial/ethnic minority communities in ur- ban areas. Tobacco is an important income-generating resource also on some Indian reservations. Because reservations are exempt from paying excise and sales taxes on tobacco products, tobacco shops are operated to produce additional income for the community. Al- though these shops are legally restricted to selling tax-free cigarettes to American Indians, this restriction is rarely monitored. A number of reservations are located a short distance from major cities whose resi- dents often drive to the reservations to purchase tax- free or low-tax cigarettes and other tobacco products. The interrelationships between the tobacco in- dustry and racial/ethnic group leaders, industries, and community agencies may have served to strengthen bonds between the industry and the four racial/eth- nit groups that are the subject of this report. These relationships are based on several factors, one being that the tobacco industry has often been the only source of funds for community initiatives. In addition, the tobacco industry has built personal alliances with members of racial/ethnic groups through employment and personal relationships (Robinson et al. 1992b). Indeed, Philip Morris's record in making financial com- mitments to community programs a$ a result of racial/ethnic-related networking has been noted (Stanley 1996). Efforts in African American commu- nities to put tobacco control strategies in place have had to overcome some leaders and organizations who were reticent about such action because the commu- nity had a positive relationship with the tobacco in- dustry, partly based on the industry's strong support for local economic, social, and cultural activities (Robinson et al. 1992b). Many leaders and members of these communities have a positive predisposition toward both the industry and cigarette smoking. Employment Opportunities Although the tobacco industry initially discrimi- nated against African Americans, excluding them from many types of factory jobs, it eventually began hiring many African Americans in manufacturing positions (Northrup and Ash 1970). By the 193Os, African Ameri- cans made up about half of all persons employed in the process of taking tobacco from its leafy state to a finished product (Northrup and Ash 1970; Foner 1981). African Americans have been concentrated in the tobacco industry for three main reasons: (1) factories were located in the Southern states, where the African American population was largest; (2) more laborers were needed as the demand for cigarettes grew after World War I; and (3) other opportunities opened for whites in an expanding economy, leaving African Americans with few job alternatives because of racial Factors That Influence Tobacco Use 213 Surgeon General's Report discrimination and other factors (Northrup and Ash 1970). In the last few decades, the involvement of Afri- can Americans in the production and marketing of tobacco has changed significantly. By 1960, African Americans represented less than 25 percent of tobacco workers-a decline from more than 50 percent 30 years earlier. Possible reasons for this dramatic decrease include (1) the migration of African Americans from southern to northern states; (2) the imposition of the minimum wage, which eliminated many of the low- paying jobs in which African Americans were concen- trated; (3) the mechanization of tobacco factories, which required fewer people to produce the same number of cigarettes; and (4) the inability of unions to change the poor working conditions of African Ameri- can workers, leading to their exodus from those com- panies (Northrup and Ash 1970). Today, the tobacco industry employs African Americans as well as members of other racial/ethnic minority groups in a variety of factory, marketing, and promotional positions. In the latter two types of posi- tions, members of racial/ethnic groups conduct pro- motional and marketing activities with owners of local shops and convenience stores serving racial/ethnic neighborhoods in urban areas and racial/ethnic en- claves in metropolitan areas. The tobacco industry was one of the early lead- ers among corporations in providing opportunities in management to qualified African Americans. Two African American executives of tobacco companies were honored in 1997 by the Business Policy Review Council at its annual Corporate Pioneers Gala Tribute for their long-term contributions as corporate pioneers in breaking down color barriers in the business world (US Newswire, Inc. 1997). Members of various racial/ethnic communities also have been employed as models or spokespersons in the advertising and promotion of tobacco products. Advertising and public relations agencies select racial/ ethnic minority models and celebrities to promote and advertise tobacco products to targeted racial/ethnic groups in print and outdoor advertisements. These easily recognizable racial/ethnic models and celebri- ties are essential to targeted advertising, and advertis- ing agencies have relied heavily on members of racial/ ethnic communities to fill these modeling jobs. For example, the tobacco industry used African American athletes extensively to advertise tobacco products dur- ing the 1950s and 196Os, when racial integration was taking place in sports (see the appendix). In a study of advertising in Ebony magazine during the 1950s and 196Os, investigators found that African American ath- letes were used in cigarette advertisements far more frequently than other African American celebrities and entertainers (Pollay et al. 1992). The use of well-known athletes, entertainers, and public figures in tobacco in- dustry marketing and public relations campaigns has continued into the 1990s. Advertising Revenues By placing advertisements in racial/ethnic pub- lications, primarily those with limited circulations, tobacco companies have become important contribu- tors of advertising revenues for these publications (Blum 1986). As a result, many racial/ethnic minority publications-including community-oriented newspa- pers and national magazines-rely on revenues from tobacco advertising (Cooper and Simmons 1985; Milligan 1987; Blum 1989; Tuckson 1989; Robinson et al. 1992b). Some racial/ethnic publications indepen- dently sought closer economic ties with the tobacco industry For example, after the ban on the broadcast advertising of tobacco products took effect in 1971, a group of African American newspaper publishers ap- proached the tobacco companies and asked them to in- crease their business with African American media (Williams 1986). Corporate media leaders are aware of the reli- ance of African American publications on tobacco advertising (Robinson 1992). The publisher of Target Market News, an African American consumer- marketing publication, has suggested that "reducing cigarette ads could deprive the inner city of much- needed revenues" (Johnson 1992b, p. 27). Similarly, the president of an African American advertising agency has predicted that "if they kill off cigarette and alcohol advertising, black papers may as well stop printing" (Johnson 1992b, p. 27). In 1988, the National Black Monitor, a monthly insert in about 80 African American newspapers, published a three-part tribute to the tobacco industry. The National BlackMonitor has defended its relationship with the tobacco industry and has stated that "black newspapers . . . could not have survived without the past and continuing support from the tobacco industry" (1990, p. 4). National and local publications directed at other racial/ethnic groups also frequently carry tobacco product advertisements and promotions. These include full-page, four-color advertisements in magazines and full-page advertising spreads in community newspa- pers. In 1989, for example, Hispanic magazine ran a short story contest, sponsored by Philip Morris, which offered a $1,000 honorarium and publication of the winning story. The contest was promoted in a special issue cel- ebrating Hispanic Heritage Month, and announcements 214 Chapter 4 Tobacco Use Among U.S. Racial/Ethnic Minority Groups appeared in a message from the editor on the magazine's first page and in a one-page display. The relatively high level of tobacco product ad- vertisements in racial/ethnic and general publications is problematic because the editors and publishers may limit stories dealing with the damaging effects of to- bacco or limit the level of antitobacco information in their publications for fear of retribution from tobacco companies (Evans 1990; Robinson et al. 1992a; Warner et al. 1992). Their concerns may be valid. For example, when New: week published an article on the nonsmok- ers' rights movement, tobacco advertisers removed all tobacco advertisements from that issue and ran them later (Warner 1985). In addition, a study of cancer cov- erage and tobacco advertising over a six-year period in three African American popular magazines (Ebony, Essence, and jet) found that these magazines published only nine articles that focused on cancers caused by cigarette smoking (six on lung or bronchus cancer, one on bladder cancer, and two on throat cancer). In the articles on lung cancer, smoking was rarely discussed as a major contributing cause; smoking was not men- tioned as a cause of throat cancer (Hoffman-Goetz et al. 1997). Although magazines and newspapers with large circulations can sustain the sporadic loss of advertis- ing revenues, the livelihood of racial/ethnic publica- tions can be effectively threatened by such losses, Tobacco companies typically place less than 10 per- cent of their advertising budgets with small African American weeklies (Russ 1993); however, these adver- tisements may often mean the difference between sur- vival and failure for small publications (Tuckson 1989; Robinson et al. 1992b). Magazine advertisements of tobacco products have decreased recently in all types of publications (Federal Trade Commission [FTC] 1997), indicating that magazines distributed nation- ally, including those serving racial/ethnic minority communities, may rely somewhat less on tobacco companies for advertising revenues. For example, 6.5 percent of Ebony's full-page advertisements were for tobacco products in 1993, compared with 9.4 percent in 1988,13.5 percent in 1983, and 11.6 percent in 1978 (Gerard0 Marin and Raymond Gamba, unpublished data). Additionally, a comparison of revenues gener- ated from advertising for the first 11 months of 1989 showed that major African American publications such as Iet, Ebony, and Essence received proportionately higher revenues from tobacco companies than did major mainstream publications (Ramirez 1990). Industries associated with the tobacco industry may also provide public relations support to racial/ ethnic publications. In 1992, for instance, an adver- tisement in Ebony paid for by the Nabisco Foods Group (RJR Nabisco, Inc., of which R.J. Reynolds Tobacco Company is a subsidiary) saluted the magazine's publisher and seven other African American entre- preneurs as "role models to our nation's youth and as inspiration to all of us" (Nabisco Foods Group 1992, p. 2). Eight-sheet billboards are also frequently used to advertise tobacco products in racial/ethnic commu- nities. These billboards are small (5 x 11 feet) and are often placed close to eye level on the sides of build- ings and stores. In 1985 alone, tobacco companies spent $5.8 million on eight-sheet billboards in African American communities; this amount accounted for 37 percent of total expenditures for this medium. Tobacco companies spent $1.4 million on such billboards in Hispanic neighborhoods (Davis 1987). Funding of Community Agencies and Organizations The tobacco product and alcoholic beverage in- dustries have made significant financial and in-kind contributions to various racial/ethnic community or- ganizations at the local, regional, and national levels. These contributions have at times been described as marriages of convenience in which community orga- nizations and agencies receive much-needed income and tobacco companies gain, at a minimum, name rec- ognition and goodwill (Maxwell and Jacobson 1989). Trade publications suggest that such community rela- tions efforts are "effective . . . devices to augment mi- nority advertising efforts and throw some water on any hot spots" (DiGiacomo 1990, p. 32). Recipients of tobacco industry support include most of the larger national organizations as well as a plethora of smaller local community agencies. In fiscal year 1989, for ex- ample, organizations receiving support from tobacco companies included the Congressional Hispanic Cau- cus, the National Black Caucus of State Legislators, the National Urban League, and the United Negro Col- lege Fund (UNCF) (Johnson 1992a,b). Internal tobacco industry documents released by Doctors Ought to Care (DO0 show that Philip Morris gave more than $17 million to racial/ethnic, educational, and arts groups in 1991 (Solberg and Blum 1992). One large racial/ethnic minority organization that has refused the support of the tobacco industry is the National Coalition of Hispanic Health and Human Services Organizations (COSSMHO), which has adopted a formal policy not to accept money from to- bacco companies or their subsidiaries. The diversity Factors That I@uence Tobacco Use 215 Surgeon General's Report of contributions to racial/ethnic community agencies can be illustrated through a review of contributions made to African American organizations. For example, Philip Morris has contributed to such organizations as the Leadership Conference on Civil Rights, the Na- tional Association of Black Social Workers, the National Association of Negro Business and Professional Women's Clubs, the National Black Police Association, 100 Black Men of America, Inc., the National Coali- tion of 100 Black Women, the National Conference of Black Lawyers, the National Minority AIDS Council, and Operation PUSH (Jackson 1992; Rosenblatt 1994). R.J. Reynolds has contributed to the NAACP; UNCF; and Opportunities Industrialization Centers of America, a national network of job training centers (Russ 1993). Other tobacco companies and the Tobacco Institute itself have made similar contributions to African American and Hispanic organizations (Robinson et al. 1992a). In communities where tobacco companies have offices and factories, additional programs and activi- ties have been funded to the benefit of whites as well as members of racial/ethnic communities. This sup- port has ranged from funding for local sites of the Young Men's Christian Association to sponsorship of Christmas tree-lighting ceremonies (Jackson 1992). The tobacco industry also has participated in special cel- ebrations and has sponsored awards and recognition events for various civic organizations. For example, at each year's conference of the National Urban League, Philip Morris presents the Herbert H. Wright Awards to African American executives of major cor- porations who have excelled in working on behalf of humanitarian causes. The awards are named in memory of one of the first African American execu- tives at Philip Morris. Promotional materials further document the to- bacco industry's involvement with racial/ethnic com- munities. Current information is difficult to obtain, but in 1986, RJR Nabisco published the booklet called A Growing Presence in the Mainstream, which summa- rized the company's involvement with racial/ethnic communities amid quotations from Martin Luther King, Jr., John F. Kennedy, Booker T. Washington, Maya Angelou, and the New Testament, along with photo- graphs of an African American member of the company's board of directors (RJR Nabisco, Inc. 1986). The booklet reported a number of the company's ac- complishments, including RJR Nabisco's record for employing members of racial/ethnic minority groups, the provision of more than 25 percent of RJR Nabisco's total company-paid employee group life insurance by African American-owned insurance firms, the advertising of RJR Nabisco's products in more than 200 racial/ethnic magazines and newspapers each year, and recognition by the UNCF as the largest con- tributor to the fund's schools since 1983. The booklet also listed 122 different organizations to which the company provided funding, including the National Urban League; the NAACP; the League of United Latin American Citizens; Howard University; Alpha Kappa Alpha Sorority; the Portland Life Center; the Harlem Dowling-West Side Center for Children and Family Services; New Jersey's Special Supplemental Food Pro- gram for Women, Infants and Children; the National Council of Negro Women; the National Puerto Rican Coalition; and ASPIRA, Inc., of New Jersey (RJR Nabisco, Inc. 1986). At the community level, tobacco companies rely on athletic, cultural, and social events to promote their products' images, often in association with small com- munity agencies. In African American and Hispanic communities, tobacco companies frequently sponsor street fairs, jazz festivals, Little League baseball teams, soccer teams, symphony orchestras, auto races, and art exhibits, just as they do in white communities (Blum 1986; Robinson et al. 1992b; Sanchez 1993). These con- tributions place community agencies in a particular dilemma, because many of the agencies' programs depend directly or indirectly on contributions received from the tobacco industry. At the same time, accep- tance of money and services from the tobacco indus- try may be perceived as an indirect endorsement of tobacco use. Community leaders generally are split in their opinions about the propriety of accepting sup- port from tobacco companies and alcoholic beverage companies (Robinson et al. 1992al. Opponents argue that the costs of compromised integrity, implicit en- dorsement of tobacco and alcoholic beverages, and current and future increases in disease and death in these communities are far greater than the benefits these funds provide. Proponents argue that these funds-when made available for such purposes as scholarships, conferences, business development, health fairs, and the organizations' survival-benefit the various racial/ethnic communities, particularly when other sources of financial support have been in short supply or unavailable. Strategies and policies that promote funding sources other than tobacco com- panies are needed to alleviate communities' reliance on tobacco-related support (Satcher and Robinson 1994). The tobacco industry also supports the opera- tions and activities of racial/ethnic organizations by providing special services, such as the publication of resource guides and other materials (Blum 1986). For 216 Chapter 4 Tobacco Use Among U.S. Racial/Ethnic Minority Groups example, Philip Morris has biennially published the Guide to Black Organizations since 1981 (Philip Morris Companies Inc. 1992). The guide lists national, regional, and local African American nonprofit orga- nizations throughout the United States, as well as Af- rican American state and regional caucuses of elected and appointed officials. Philip Morris also publishes and widely distributes two similar publications, the hJdiona1 Directory of Hispanic Organizations (Congres- sional Hispanic Caucus Institute, Inc. 1993) and the Na- tional Directoq of Asian Pacific American Organizafions 1997-1998 (Organization of Chinese Americans 1997). Support for Education colleges and universities were located (Blum 1985). In addition to supporting the UNCF, tobacco companies have supported African American higher education in a variety of other ways, such as through other scholarships and internship programs (Robinson et al. 1992b). In recent years, the tobacco industry has begun supporting adult literacy efforts. In 1990, Philip Mor- ris joined with the Pew Charitable Trusts and the Phila- delphia Mayor's Commission on Literacy to launch the Gateway Program, an adult literacy campaign de- signed to serve as a national model. Philip Morris con- tributed $1.5 million to the program and an additional $1.5 million for media support (Robinson et al. 1992b). In yet another outreach effort, Philip Morris subsidized the Milwaukee County Youth Initiative, a program designed to help low-income and minority families become more involved in the education of their chil- dren (Haile 1991). For years, the tobacco industry has contributed to programs that aim to enhance the primary and sec- ondary education of children, has funded universities and colleges, and has supported scholarship programs targeting-African Americans (the UNCF) and Hispan- ics