Tobacco Use Among U.S. Racial/Ethnic Minority Groups African Americans American Indians and Alaska Natives Asian Americans and Pacific Islanders Hispanics A Report of the Surgeon General DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health Suggested Citation U.S. Department of Health and Human Services. Tobmx~ Usr Among U.S. Racinl/Ethic Milmrity Group-Africarl A~~wrimm, Aurerknr~ Iudinrls nud Alnsh7 Nntiws, Asinrz Avwicam all[f Pn&c IsI~rzil~w; ~7nd His~~o~~ics: A Rcyrt (?f flw SLI~L'OII Gtwrml. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smok- ing and Health, 1998. For sale by the Superintendent of Documents, U.S. Government Printing Office, Washing- ton, D.C., 20402, S/N 017-001-00527-4. Use of trade names is for identification only and does not constitute endorsement by the U.S. Department of Health and Human Services. THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON. D c 20201 The Honorable Newt Gingrich Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: I am pleased to transmit to the Congress the Surgeon General's report on the health consequences of smoking, entitled Tobacco Use Among U.S. Racial/Ethnic Minority Groups. This report is mandated by Section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law 91-222) and includes the health effects of smokeless tobacco products, as mandated by Section 8(a) of the Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99-252). The report was prepared by the Centers for Disease Control and Prevention. This is the first Surgeon General's report to focus on tobacco use among four U.S. racial/ethnic minority groups: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. It provides a single, comprehensive source of data on each racial/ethnic group's patterns of tobacco use, physical effects related to tobacco smoking and chewing, societal and psychosocial factors associated with tobacco use, and a selection of specific tobacco control programs. Armed with accurate data, health professionals can plan appropriate programs to address more effectively the health needs of these groups. Smoking is the leading cause of preventable death in the United States. Certain racial/ethnic minority populations remain at high risk for using tobacco and often bear a disproportionate share of the human and economic cost of tobacco use. For instance, African Americans suffer the highest death rates from several diseases caused by smoking. Although some recent declines in lung cancer trends are encouraging, we have reason for great concern about recently reported increases in rates of smoking among African-American and Hispanic high school students. According to estimates from the U.S. Bureau of the Census, over the next 50 years, the size of these four racial/ethnic minority groups is expected 'to increase dramatically, becoming almost half of the U.S. population by the year 2050. This projection clearly indicates the need to develop effective strategies to prevent tobacco-related disease and death in these four minority population groups. Enclosure THE SECRETARY OF HEALTH AND HUMAN SERVICES WtTSHINGTON. D c 20201 The Honorable Albert Gore, Jr. President of the Senate Washington, D.C. 20510 Dear Mr. President: I am pleased to transmit to the Congress the Surgeon General's report on the health consequences of smoking, entitled Tobacco Use Among U.S. Racial/Ethnic Minority Groups. This report is mandated by Section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law 91-222) and includes the health effects of smokeless tobacco products, as mandated by Section 8(a) of the Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99-252). The report was prepared by the Centers for Disease Control and Prevention. This is the first Surgeon General's report to focus on tobacco use among four U.S. racial/ethnic minority groups: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. It provides a single, comprehensive source of data on each racial/ethnic group's patterns of tobacco use, physical effects related to tobacco smoking and chewing, societal and psychosocial factors associated with tobacco use, and a selection of specific tobacco control programs. Armed with accurate data, health professionals can plan appropriate programs to address more effectively the health needs of these groups. Smoking is the leading cause of preventable death in the United States. Certain racial/ethnic minority populations remain at high risk for using tobacco and often bear a disproportionate share of the human and economic cost of tobacco use. For instance, African Americans suffer the highest death rates from several diseases caused by smoking. Although some recent declines in lung cancer trends are encouraging, we have reason for great concern about recently reported increases in rates of smoking among African-American and Hispanic high school students. According to estimates from the U.S. Bureau of the Census, over the next 50 years, the size of these four racial/ethnic minority groups is expected to increase dramatically, becoming almost half of the U.S. population by the year 2050. This projection clearly indicates the need to develop effective strategies to prevent tobacco-related disease and death in these four minority population groups. Enclosure Foreword The United States of America is a rich blend of cultures. This diversity demands close attention from the agencies and individuals responsible for pro- tecting the public's health. For too long in tobacco control, attention to diversity has been less consistent than is necessary for planning and developing effective health programs. As a result, we sometimes lack sufficient information on which to base tobacco control interventions. With this report, we begin to address such problems and point the way to filling these gaps in knowledge. Tobacco use causes devastating disease and premature death in every population in the United States. For four major U.S. racial/ethnic minority groups- African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics-patterns of tobacco use, adverse health effects, and the effectiveness of interventions need to be understood in terms of tobacco's cultural and socioeconomic effects on the members of these groups. This report describes the complex factors that play a part in the growing epidemic of diseases caused by tobacco use in these four groups. Since 1964 when the first Surgeon General's report on smoking and health was released, this report is the first to focus exclusively on tobacco use among members of these four racial/ethnic groups. Together these groups constitute about 25 percent of the U.S. population, and that proportion is growing rapidly. Public health programs must effectively address the health needs of this significant pro- portion of people. Such action is of paramount importance to reducing tobacco use in the United States and meeting national health objectives for the year 2000. We hope that this report will provide the basis for renewing our commitment to develop more effective tobacco control programs and policies for people of every racial and ethnic background. In addition, the report can be used by parents and communities as a tool to develop their own solutions. With continued diligence, we shall strive to reach and exceed whenever possible our stated health goals by the year 2000 and reduce the enormous health burden caused by tobacco products. Claire V. Broome, M.D. Acting Director Centers for Disease Control and Prevention and Acting Administrator Agency for Toxic Substances and Disease Registry Preface from the Surgeor Gewral, U.S. Department of Health and Humau Services Effective strategies are needed to reduce tobacco use among members of U.S. racial/ethnic groups and thus diminish their burden of tobacco-related diseases and deaths. Cigarette smoking is the leading cause of preventable disease and death in the United States. There is enormous potential to reduce heart disease, cancer, stroke, and respiratory disease among members of racial and ethnic groups, who make up the most rapidly growing segment of the U.S. population. This Surgeon General's report is the first to address the diverse tobacco control needs of the four major U.S. racial/ethnic minority groups-African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. This report is also the only single, comprehensive source of data on each group's patterns of tobacco use, physical effects related to tobacco smoking and chewing, and societal and psychosocial factors associated with tobacco use. The findings detailed in this report indicate that if tobacco use is not reduced among members of these four racial/ethnic groups, they will experience increas- ing morbidity and mortality from tobacco use. The toll is currently highest for African American adults. Findings also suggest that some close, long-term rela- tionships between tobacco companies and various racial/ethnic communities could hamper U.S. efforts to lower rates of tobacco use by the year 2000. Also notable is the support that members of racial/ethnic groups have shown for legislative efforts to control tobacco use, sales, advertising, and promotion. As this report goes to press, discouraging news comes from a report published by the Centers for Disease Control and Prevention on the Youth Risk Behavior Survey about tobacco use among African American and Hispanic high school students. Past-month smoking increased among African American students by 80 percent and among Hispanic students by 34 percent from 1991 through 1997. The consistent decline once seen among young African Americans has sharply reversed in recent years. Past-month smoking prevalence increased from 13 per- cent to 23 percent among African Americans and from 25 percent to 34 percent among Hispanics. Although cancer remains common in Americans of all racial and ethnic groups, the pattern of increasing lung cancer deaths in the 1970s and 1980s among African American, Hispanic, and some American Indian and Alaska Native subgroups has been halted or reversed for some groups from 1990 through 1995. Some en- couraging news from Carrcer kideuce arzd Mortality, 1973-l 995: A Report Card for the U.S. was just published by the American Cancer Society, the National Cancer Institute, and the Centers for Disease Control and Prevention. The report described lung cancer trend data from 1990 through 1995 for African Americans, Asian Ameri- cans and Pacific Islanders, and Hispanics. Lung cancer death rates declined significantly for African American men and for Hispanic men and women from 1990 through 1995; death rates did not change significantly for African American women or for Asian American and Pacific Islander men or women. Although lung cancer trends may continue to decline among some racial/ethnic groups for sev- eral more years, recent increases in smoking prevalence among adolescent African Americans and Hispanics and among Asian American and Pacific Islander adoles- cent males, coupled with the lack of decline among American Indian and Alaska Native adults, do not bode well for long-term trends in lung cancer. One purpose of this report is to guide researchers in their future efforts to garner more information needed to develop effective prevention and control pro- grams. Several significant research questions need to be addressed. For example, why are African American youths smoking cigarettes in lower proportions than youths in other racial/ethnic groups ? How does acculturation affect patterns of tobacco use among immigrants to the United States? What are the differential effects of gender on tobacco use among members of certain racial/ethnic groups? What racial- and ethnic-specific protective factors and risk factors will promote the development of culturally appropriate interventions to prevent and control tobacco use? And to what extent are culturally specific tobacco control programs necessary to curb tobacco use among racial/ethnic populations? While research- ers are redirecting their focus, federal, state, and private tobacco control partners need to address program issues, such as how to develop and evaluate culturally appropriate prevention and cessation interventions. This report includes examples of numerous racial- and ethnic-specific tobacco control programs used in communities across the country. These and other racial/ethnic group-specific programs must be disseminated to all areas of the country, where program planners can develop their own strategies, taking into consideration the cultural attitudes, norms, expectations, and values of the targeted cultural groups. In each of these endealrors, we ivill succeed only if we are sensitive to our cultural differences and similarities. I challenge federal and state agencies as well as researchers and practitioners in the social, behavioral, public health, clinical, and biomedical sciences to join me in the pursuit of effective strategies to prevent and control tobacco use among racial/ethnic groups. By meeting this challenge, we will progress totvard achieving the nation's year 2000 tobacco-related health objectives and will help to prevent the unnecessary disability, disease, and deaths that result from tobacco use. David Satcher, M.D., Ph.D. Surgeon General and Assistant Secretary for Health Tobacco Use Amoq U.S. RaciallEtkic Mirlority Groups Acknowledgments This report was prepared by the U.S. Department of Health and Human Services under the general direc- tion of the Centers for Disease Control and Preven- tion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Claire V. Broome, M.D., Acting Director, Centers for Disease Control and Prevention, Atlanta, Georgia. James S. Marks, M.D., M.P.H., Director, National Center for Chronic Disease Prevention and Health Pro- motion, Centers for Disease Control and Prevention, Atlanta, Georgia. Virginia `3. Bales, M.P.H., Deputy Director, National Center for Chronic Disease Prevention and Health Pro- motion, Centers for Disease Control and Prevention, Atlanta, Georgia. Michael I? Eriksen, Sc.D., Director, Office on Smoking and Health, National Center for Chronic Disease Pre- vention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. The editors of the report were Gerard0 Marin, Ph.D., Senior Scientific Editor, Profes- sor, Department of Psychology, University of San Fran- cisco, San Francisco, California. Gayle Lloyd, M.A., Managing Editor, Office on Smok- ing and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Valerie R. Johnson, Senior Editor, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Anne M. Pritchett, Technical Editor, Cygnus Corpora- tion, Rockville, Maryland. Contributing authors were Neal L. Benowitz, M.D., Professor and Chief, Division of Clinical Pharmacology, Departments of Medicine, Pharmacy, and Psychiatry, School of Medicine, Uni- versity of California, San Francisco, California. Alan Blum, M.D., Associate Professor, Baylor College of Medicine, Houston, Texas. Ronald L. Braithwaite, Ph.D., Associate Professor, Di- vision of Behavioral Sciences and Health Education, Emory University School of Public Health, Atlanta, Georgia. Felipe G. Castro, M.S.W., Ph.D., Director, Hispanic Research Center, and Associate Professor, Department of Psychology, Arizona State University, Tempe, Arizona. Moon S. Chen, Jr., Ph.D., M.P.H., Professor, Depart- ment of Preventive Medicine, Ohio State University, Columbus, Ohio. David B. Coultas, M.D., Associate Professor of Medi- cine, School of Medicine, University of New Mexico, Albuquerque, New Mexico. Luis G. Escobedo, M.D., M.P.H., Medical Epidemiolo- gist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Dorothy L. Faulkner, Ph.D., M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Larri L. Fredericks, Ph.D., M.P.H., Associate Scientist, American Indian Cancer Control Project, Medical Re- search Institute, Berkeley, California. Gary A. Giovino, Ph.D., Chief, Epidemiology Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Sandra W. Headen, Ph.D., Assistant Professor, Depart- ment of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, North Carolina. Felicia Schanche Hodge, Dr.I?H., Principal Investiga- tor and Director, Center for American Indian Research and Education, Berkeley, California. Nancy J. Kaufman, R.N., M.S., Vice President, Robert Wood Johnson Foundation, Princeton, New Jersey. Juliette S. Kendrick, M.D., Medical Epidemiologist, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Gary King, Ph.D., Assistant Professor and Coordina- tor, Urban Health Research Program, School of Medi- cine, University of Connecticut Health Center, Farmington, Connecticut. Beverly S. Kingsley, Ph.D., M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Rod Lew, M.P.H., Health Education Director, Asian Health Services, Oakland, California. Ann M. Malarcher, Ph.D., Epidemiologist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Robert K. Merritt, M.A., Health Scientist, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Michael D. Newcomb, Ph.D., Professor, Department of Psychology, University of California, Los Angeles, California. John I? Peddicord, M.S., Computer Scientist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Richard Pollay, Ph.D., Professor of Marketing, and Curator, History of Advertising Archives, University of British Columbia, Vancouver, British Columbia, Canada. Amelie G. Ramirez, Dr.P.H., Associate Professor, De- partment of Family Practice, University of Texas, and Director, South Texas Health Research Center, San Antonio, Texas. Patricia A. Richter, Ph.D., M.P.H., Toxicologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Robert C. Robinson, Dr.P.H., Associate Director for Program Development, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Richard B. Rothenberg, M.D., M.P.H., Professor, De- partment of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia. Jonathan M. Samet, M.D., Chairman, Department of Epidemiology, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland. Michael W. Schooley, M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Dana Shelton, M.P.H., Epidemiologist, Office on Smok- ing and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Michael B. Siegel, M.D., M.P.H., Assistant Professor, Boston University School of Public Health, Boston, Massachusetts. Charyn D. Sutton, President, The Onyx Group, Bala Cynwyd, Pennsylvania. Scott L. Tomar, D.M.D., Dr.P.H., Assistant Professor, Department of Dental Public Health and Hygiene, School of Dentistry, University of California, San Fran- cisco, California. Bao-Ping Zhu, M.S., M.B.B.S., Ph.D., Visiting Scientist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Reviewers were Jasjit S. Ahluwalia, M.D., M.P.H., MS., Assistant Pro- fessor of Medicine, Emory University School of Medi- cine, Atlanta, Georgia. David G. Altman, Ph.D., Associate Professor, Depart- ment of Public Health Sciences, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina. Tobnccn Use Amon~q U.S. Racirzl/Ethic Minority Groups Glen Bennett, M.P.H., Coordinator, Office of Preven- tion, Education, and Control, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Gilbert J. Botvin, Ph.D., Director, Institute for Preven- tion Research, Department of Public Health, Cornell University Medical College, New York, New York. L. Jackson Brown, Director, Epidemiology and Oral Disease Prevention Program, National Institute of Dental Research, National Institutes of Health, Bethesda, Maryland. Linda Burhansstipanov, Dr.P.H., Director, Native American Cancer Research Program, American Medi- cal Center Cancer Research Center, Denver, Colorado. David Burns, M.D., Professor of Medicine, University of California at San Diego Medical Center, San Diego, California. W. Michael Byrd, M.D., M.P.H., Visiting Research Fel- low, Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts. Portia S. Choi, M.D., M.P.H., District Health Officer, Dr. Ruth Temple Health Center, Los Angeles, California. Nathaniel Cobb, M.D., Director, Cancer Prevention and Control Program, Indian Health Service Headquarters West, Albuquerque, New Mexico. Janet L. Collins, Ph.D., Director, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Robert J. Collins, D.M.D., Chief Dental Officer, U.S. Public Health Service, Rockville, Maryland. Linda S. Crossett, R.D.H., Research Scientist, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. K. Michael Cummings, Ph.D., Director, Smoking Con- trol Program, Roswell Park Cancer Institute, New York State Department of Health, Buffalo, New York. Dorynne J. Czechowicz, M.D., Associate Director for Medical and Professional Affairs, Division of Clinical Research, National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland. Ronald M. Davis, M.D., Director, Center for Health Promotion and Disease Prevention, Henry Ford Health System, Detroit, Michigan. Richard A. Daynard, Ph.D., J.D., Chairman, Tobacco Products Liability Project, Northeastern University School of Law, Boston, Massachusetts. Jane L. Delgado, Ph.D., President and Chief Executive Officer, National Coalition of Hispanic Health and Human Services Organization, Washington, D.C. John Elder, Ph.D., M.P.H., Professor, Graduate School of Public Health, San Diego State University, San Di- ego, California. Harmon Eyre, M.D., Deputy Executive Vice President for Medical Affairs and Research, American Cancer Society, Atlanta, Georgia. Michael C. Fiore, M.D., M.P.H., Director, Center for Tobacco Research and Intervention, University of Wis- consin Medical School, Madison, Wisconsin. Adele M. Franks, M.D., Assistant Director for Science, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Harold P. Freeman, M.D., Director of Surgery, Harlem Hospital Center, New York, New York. Thomas J. Glynn, Ph.D., Chief, Prevention Control Extramural Research Branch, National Cancer Insti- tute, National Institutes of Health, Rockville, Mary- land. Michael G. Goldstein, M.D., Associate Professor of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, Rhode Island. Robert A. Hahn, Ph.D., M.P.H., Epidemiologist, Epi- demiology Program Office, Centers for Disease Con- trol and Prevention, Atlanta, Georgia. Betty Lee Hawks, M.A., Special Assistant to the Direc- tor, Office of Minority Health, U.S. Department of Health and Human Services, Rockville, Maryland. Clark W. Heath, Jr., M.D., Vice President for Epidemi- ology and Surveillance Research, American Cancer Society, Atlanta, Georgia. Jack E. Henningfield, Ph.D., Vice President, Pinney Associates, Bethesda, Maryland. John H. Holbrook, M.D., Director of Internal Medicine, University of Utah Hospital, Salt Lake City, Utah. Thomas Houston, M.D., Director, Department of Pre- ventive Medicine and Public Health, American Medi- cal Association, Chicago, Illinois. Rudolph S. Jackson, Dr.P.H., Professor, Department of Health Education, North Carolina Central University, Durham, North Carolina. Elaine M. Johnson, Ph.D., Director, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Nora L. Keenan, Ph.D., Epidemiologist, Office of Sur- veillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Monina Klevens, D.D.S., M.P.H., Medical Officer, Di- vision of HIV/AIDS, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia. Norman A. Krasnegor, Ph.D., Chief, Human Learning and Behavior Branch, Center for Research for Moth- ers and Children, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland. Leonard E. Lawrence, M.D., President, National Medi- cal Association, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas. Edward Lichtenstein, Ph.D., Research Scientist, Oregon Research Institute, Eugene, Oregon. Douglas S. Lloyd, M.D., M.P.H., Associate Adminis- trator for Public Health Practice, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland. Judith Mackay, M.B.E., J.P., F.R.C.P., Director, Asian Consultancy on Tobacco Control, Kowloon, Hong Kong. Audrey F. Manley, M.D., M.P.H., President, Spelman College, Atlanta, Georgia. Alfred McAlister, Ph.D., Associate Professor and As- sociate Director, Center for Health Promotion Research and Development, The University of Texas at Austin, Austin, Texas. J. Michael McGinnis, M.D., Scholar-in-Residence, National Academy of Sciences, Washington, D.C. Bertha MO, Ph.D., M.P.H., Senior Program Officer, In- ternational Development Research Centre, Ottawa, Ontario, Canada. C. Tracy Orleans, Ph.D., Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, New Jersey. Terry F. Pechacek, Ph.D., Visiting Scientist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Cheryl L. Perry, Ph.D., Professor, Division of Epi- demiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. John P. Pierce, Ph.D., Sam M. Walton Professor for Cancer Research, Department of Family and Preven- tive Medicine, University of California, San Diego, California. Donald H. Reece, Tobacco Control Coordinator, Indian Health Service, Albuquerque, New Mexico. Patrick Remington, M.D., M.P.H., Chief Medical Officer, Wisconsin Division of Health, Madison, Wisconsin. Irene Reveles-Chase, M.P.H., Health Education Con- sultant, Tobacco Control Section, California Depart- ment of Public Health, Sacramento, California. Nancy A. Rigotti, M.D., Director, Quit Smoking Ser- vice, General Internal Medicine Unit, Massachusetts General Hospital, Boston, Massachusetts. Donald J. Sharp, M.D., Medical Epidemiologist, Of- fice on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Donald R. Shopland, Coordinator, Smoking and To- bacco Control Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland. Beverly R. Singer, M.A., Research Staff Associate, School of Social Work, Columbia University, New York, New York. Jesse L. Steinfeld, M.D., Surgeon General, U.S. Public Health Service, 1969-1973, San Diego, California. Jonathan R. Sugarman, M.D., M.P.H., Medical Epide- miologist, Portland Area Indian Health Service, Seattle, Washington. Michael J. Thun, M.D., Director, Analytic Epidemiol- ogy, American Cancer Society, Atlanta, Georgia. Michael H. Trujillo, M.D., M.P.H., Director, Indian Health Service, Rockville, Maryland. Kenneth E. Warner, Ph.D., Richard D. Remington Col- legiate Professor of Public Health, Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan. Raymond Weston, Ph.D., Postdoctoral Fellolz; Memo- rial Sloan-Kettering Cancer Center, Division of I'sychia- try, New York, New York. Judith Wilkenfeld, J.D., Assistant Director, Division of Advertising Practices, Federal Trade Commission, Washington, D.C. Jerome Williams, Ph.D., Professor of Marketing, Penn- sylvania State University, University Park, Pennsylvania. Ernst L. Wynder, M.D., President, American Health Foundation, New York, New York. Other contributors were Marco Andujar, Telecommunications Specialist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Ruth Atchison, Proofreader, Cygnus Corporation, Rockville, Maryland. Cheryl Baldwin, Graphic Artist/Desktop Publishing Specialist, High 5 Design, Gaithersburg, Maryland. Mary Bedford, Proofreader, Cygnus Corporation, Rockville, Maryland. Christine V. Bellantoni, Graduate Student, University of Connecticut Health Center, Farmington, Connecticut. Maureen Berg, Desktop Publishing Specialist, Market Experts, Silver Spring, Maryland. Mar&a Bernstein, Indexer, Cygnus Corporation, Rockville, Maryland. Nolvell D. Berreth, Writer-Editor, Office on Smoking and Health, National Center for Chronic Disease Pre- vention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Joyce Buchanan, Administrative Assistant, Institute for Social Research, Survey Research Center, University of Michigan, Ann Arbor, Michigan. Janine E. Bullard, Proofreader, Cygnus Corporation, Rockville, Maryland. Ralph S. Carabello, Ph.D., Epidemiologist, Office on Smoking and Health, National Center for Chronic Dis- ease Pre\yention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Jeffrey H. Chrismon, Systems Analyst, TRW Inc., Atlanta, Georgia. Paulette Clark McGee, Proofreader, Cygnus Corpora- tion, Rockville, Maryland. Coreen A. Colovos, Copy Editor, Cygnus Corporation, Rockville, Maryland. DarTid E Coole, M.S., Statistical Programmer, TRW Inc., Atlanta, Georgia. Karen M. Deasy, Associate Director, Office on Smok- ing and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Washington, D.C. Susan R. Derrick, Program Analyst, Office on Smok- ing and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Ellen C. Dreyer, R.N., M.S., Project Director, Cygnus Corporation, Rockville, Maryland. Rita Elliott, M.A., Editorial Consultant, University of New Mexico, School of Medicine, Albuquerque, New Mexico. Raymond J. Gamba, M.S., Graduate Student, The Claremont Graduate School, Claremont, California. Maritta Perry Grau, M.A., Copy Editor, The Write Touch: Editorial Services, Frederick, Maryland. is Sarah Gregory, Acting Managing Editor, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Lillian E. Hatch, M.S.L.S., Information Specialist, Cyg- nus Corporation, Rockville, Maryland. Elizabeth L. Hess, Copy Editor, Cygnus Corporation, Rockville, Maryland. Thomya Hogan, Proofreader, Cygnus Corporation, Rockville, Maryland. Reta N. Horton, M.A., Secretary, Office on Smoking and Health, National Center for Chronic Disease Pre- vention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Frederick L. Hull, Ph.D., Writer-Editor, Technical In- formation and Editorial Services Branch, National Center for Chronic Disease Prevention and Health Pro- motion, Centers for Disease Control and Prevention, Atlanta, Georgia. Mescal J. Knighton, Writer-Editor, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Anh Le, Project Coordinator, Vietnamese Community Health Promotion Project, University of California, San Francisco, California. Yun Chen W. Lin, M.P.H., Technical Information Spe- cialist, TRW Inc., Atlanta, Georgia. William T. Marx, M.L.I.S., Technical Information Spe- cialist, Office on Smoking and Health, National Cen- ter for Chronic Disease Prevention and Health Promo- tion, Centers for Disease Control and Prevention, At- lanta, Georgia. Maribet McCarty, R.N., M.P.H., Technical Information Specialist, The Orkand Corporation, Atlanta, Georgia. Margie McDonald, Word Processing Specialist, Cyg- nus Corporation, Rockville, Maryland. Linda A. McLaughlin, Word Processing Specialist, Cygnus Corporation, Rockville, Maryland. Jennifer A. Michaels, M.L.S., Technical Information Specialist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Pro- motion, Centers for Disease Control and Prevention, Atlanta, Georgia. Barbara A. Mills, Secretary, Office on Smoking and Health, National Center for Chronic Disease Preven- tion and Health Promotion, Centers for Disease Con- trol and Prevention, Atlanta, Georgia. Paul D. Mowery, M.S., Senior Research Scientist, Battelle Memorial Institute, Atlanta, Georgia. Leslie A. Norman, Public Affairs Specialist, Office on Smoking and Health, National Center for Chronic Dis- ease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Ward C. Nyholm, Desktop Publishing Specialist, Cygnus Corporation, Rockville, Maryland. Patrick O'Malley, Ph.D., Research Scientist, Institute for Social Research, Survey Research Center, Univer- sity of Michigan, Ann Arbor, Michigan. Anniette Ponce de Leon, Student, University of San Francisco, San Francisco, California. Felicia A. Powell, M.S., Statistical Programmer, TRW Inc., Atlanta, Georgia, Christopher Rigaux, Project Director, Cygnus Corpo- ration, Rockville, Maryland. Patricia L. Schwartz, Graphic Artist/Desktop Publish- ing Specialist, Cygnus Corporation, Rockville, Maryland. Matthew B. Spangler, Proofreader, Cygnus Corpora- tion, Rockville, Maryland. Catherine T. Timmerman, Chief Operating Officer, Cygnus Corporation, Rockville, Maryland. Peggy E. Williams, MS., Proofreader, Marietta, Georgia. Eve J. Wilson, Ph.D., Project Manager, Cygnus Corpo- ration, Rockville, Maryland. Beatrice K. Wolman, M.S., Project Manager, Cygnus Corporation, Rockville, Maryland. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Chapter 1. Introduction and Summary of Conclusions 3 Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups 29 Introduction 21 Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups 22 Retrospective Analyses of Smoking Prevalence Among African Americans and Hispanics 74 Effects of Education and Race/Ethnicit; on Cigarette-Smoking Behavior 83 Exposure to Environmental Tobacco Smoke 86 Comparisons Between Racial,/Ethnic Minority Groups in Current Tobacco Use 87 Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic Minority Groups 135 Introduction 137 Lung Cancer 137 Other Cancers 149 Chronic Obstructive Pulmonary Disease 7 55 Coronary Heart Disease 160 Cerebrovascular Disease 164 Smoking and Pregnancy 7 66 Summary of Health Consequences from Active Cigarette Smoking 172 Effects of Exposure to Environmental Tobacco Smoke 2 72 Effects of Smokeless Tobacco Use 174 Nicotine Addiction and Racial/Ethnic Differences 175 Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups 205 Introduction 207 Historical Context of Tobacco 208 Economic Influences 223 Advertising and Promotion 220 Psychosocial Determinants 225 Chapter 5. Tobacco Control and Education Efforts Among Members of Four Racial/Ethnic Minority Groups 257 Introduction 259 Primary Prevention Efforts 266 Smoking Cessation Programs 274 Environmental Tobacco Smoke and Clean Indoor Air Policies 287 Economic Efforts to Reduce Tobacco Use 292 Efforts to Control Tobacco Advertising and Promotion 293 Tobacco Product Regulations 298 List of Tables and Figures 311 Glossary 319 Index 321 Chapter 1 Introduction and Summary of Conclusions Introduction 5 Major Conclusions 6 Preparation of This Report 7 Terms Related to Race and Ethnicity 7 Terms Related to Tobacco Use 8 Demographic Characteristics of the Four Racial/Ethnic Minority Groups 8 Effects of Racial/Ethnic Background on Health 22 Chapter Conclusions 12 Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic Minority Groups 12 Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups 13 Chapter 5. Tobacco Control and Education Efforts Among Members of Four Racial/Ethnic Minority Groups Z-1 12 References 15 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Introduction This Surgeon General's report on tobacco use summarizes current information on risk factors and patterns related to tobacco use among members of four major racial and ethnic minority groups in the United States: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Island- ers, and Hispanics. In addition, this report presents information on national and regional efforts to curtail consumption of tobacco products among members of these four groups. Previous Surgeon General's reports on smoking and health have briefly summarized find- ings related to one or more of the racial/ethnic groups covered in this report, but this is the first Surgeon General's report to concentrate specifically on the four major racial/ethnic groups in the United States. Several factors prompted the development of this report. First, the information in this report has never before been compiled in one source. Consequently, policymakers, community leaders, researchers, and public health workers have had difficulty determin- ing the extent of the problem, identifying gaps in in- formation regarding tobacco use among members of the four groups, or being aware of existing tobacco con- trol programs that have demonstrated effectiveness. Thus, incorporating such information into the design and implementation of culturally appropriate services has been difficult. Second, the four racial/ethnic groups currently constitute about one-fourth of the population of this country, and the Bureau of the Census projects that by 2050 the non-Hispanic white population in the United States will total only 53 percent (Day 1996). Prevent- ing health problems related to tobacco use among the individuals in racial and ethnic groups will be inte- gral to achieving U.S. public health objectives, such as those proposed in Healthy People 2000: National Health Promotion and Disease Prevention Objectives (U.S. Depart- ment of Health and Human Services [USDHHS] 1991, 1995; National Center for Health Statistics [NCHS] 1994). This report contributes essential knowledge that must be incorporated into efforts to accomplish the Healthy People 2000 objectives, particularly these six goals: o Objective 3.1. Reduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age- adjusted baseline: 135 deaths per 100,000 people in 1987.) Among African Americans, reduce the number from 168 to 115 deaths per 100,000 people between 1987 and the year 2000 (Objective 3.la). o Objective 3.2. Slow the rise in lung cancer deaths to achieve a rate of no more than 42 per 100,000 people. (Age-adjusted baseline: 38.5 deaths per 100,000 people in 1987.) Among African Ameri- can males, slow the rise from 86.1 to 91 deaths per 100,000 people between 1990 and the year 2000 (Objective 3.2b). o Objective 3.4. Reduce the prevalence of cigarette smoking to no more than 15 percent among people aged 18 years and older. (Baseline: 29 percent in 1987 [31 percent for men and 27 percent for women].) Particular year 2000 objectives include lowering the prevalence of smoking to 18 percent among African Americans (Objective 3.4d), 15 per- cent among Hispanics (Objective 3.4e), and 20 per- cent among American Indians and Alaska Natives (Objective 3.4f) and Southeast Asian men (Objec- tive 3.4g). o Objective 3.5. Reduce the initiation of cigarette smoking by children and youths so that no more than 15 percent have become regular cigarette smokers by the age of 20 years. (Baseline: 30 per- cent of youths had become regular cigarette smok- ers by the ages of 20-24 years in 1987.) . Objecfive 3.9. Reduce the prevalence of smokeless tobacco use among males aged 12-24 years to no more than 4 percent. (Baseline: 6.6 percent among males aged 12-17 years in 1988; 8.9 percent among males aged 18-24 years in 1987.) A specific objec- tive is to lower the prevalence of smokeless tobacco use among American Indian and Alaska Native young adults to 10 percent by the year 2000 (Ob- jective 3.9a). o Objective 3.18. Reduce stroke deaths to no more than 20 per 100,000 people. (Age-adjusted baseline: 30.4 deaths per 100,000 people in 1987.) Among African Americans, reduce the number from 52.5 to 27.0 deaths per 100,000 people between 1987 and the year 2000 (Objective 3.18a). Introduction and Summary 5 This report of the Surgeon General also responds to the need to thoroughly analyze the smoking-related health status of racial/ethnic groups and to determine if there is a differential risk for tobacco addiction (Chen 1993). High risk might derive from personal charac- teristics but also from social factors, such as migratory patterns, acculturation, and the tobacco industry's his- torical involvement in the racial/ethnic communities and targeted advertising and promotion of tobacco products (see Chapter 4). In addition, this report is needed to document how patterns of health, disease, and illness among people in the various racial/ethnic minority groups differ from patterns in the rest of the U.S. population. These differences reflect the groups' exposure to to- bacco products, as well as the heterogeneity of the groups' lifestyles, cultural beliefs and practices, genetic backgrounds, and environmental exposures. This re- port illustrates how patterns of tobacco use differ among and within the four racial/ethnic groups (Chapter 2). It compares the groups in terms of the incidence and the prevalence of death rates for diseases commonly associated with tobacco use and presents data from case-control and cohort studies whenever possible (Chapter 3). The health status of members of racial and eth- nic groups in this country has also been the focus of previous federal reports, such as the Health Sfot~ of Minorities nrzd Lo7~~-Im~11zc Grou~75 (Health Resources and Services Administration [HRSAI 19851, the Report of the Secretnry's Task Force OH BInck mzd Minority Henlth (USDHHS 19851, and CIrroizic Disense in Mifforify Pop~l- lations (Centers for Disease Control and Prevention [CDC] 1994). This Surgeon General's report supports initiatives such as the Hispanic Health and Nutrition Examination Survey in the early 1980s; the Surgeon General's National Hispanic/Latin0 Health Initiative (Novello and Soto-Torres 1993); special funding ini- tiatives from federal agencies such as the CDC, the National Cancer Institute, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, the National Heart, Lung, and Blood Institute (1994), and the National Institute of Mental Health (National Institutes of Health 1993); the Department of Health and Human Services's 1996 Hispanic Agendn for Action: lmprouiug Stwiccs to Hispanic Americans, and the 1998 President's Race Ini- tiative, which includes special funding initiatives for the CDC, the Indian Health Service, and the Health Resources and Services Administration. Major Conclusions 1. Cigarette smoking is a major cause of disease and death in each of the four population groups stud- ied in this report. African Americans currently bear the greatest health burden. Differences in the magnitude of disease risk are directly related to differences in patterns of smoking. 2. Tobacco use varies within and among racial/ ethnic minority groups; among adults, American Indians and Alaska Natives have the highest prevalence of tobacco use, and African American and Southeast Asian men also have a high preva- lence of smoking. Asian American and Hispanic women have the lowest prevalence. 3. Among adolescents, cigarette smoking prevalence increased in the 1990s among African Americans and Hispanics after several years of substantial de- cline among adolescents of all four racial/ethnic minority groups. This increase is particularly strik- ing among African American youths, who had the greatest decline of the four groups during the 1970s and 1980s. 4. No single factor determines patterns of tobacco use among racial/ethnic minority groups; these pat- terns are the result of complex interactions of mul- tiple factors, such as socioeconomic status, cultural characteristics, acculturation, stress, biological el- ements, targeted advertising, price of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives. 5. Rigorous surveillance and prevention research are needed on the changing cultural, psychosocial, and environmental factors that influence tobacco use to improve our understanding of racial/ethnic smoking patterns and identify strategic tobacco control opportunities. The capacity of tobacco control efforts to keep pace with patterns of to- bacco use and cessation depends on timely recog- nition of emerging prevalence and cessation patterns and the resulting development of appro- priate community-based programs to address the factors involved. Preparation of This Report This report of the Surgeon General was prepared by the Office on Smoking and Health, National Cen- ter for Chronic Disease Prevention and Health Promo- tion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, as part of the Department's mandate, under Public Laws 91-222 and 99-252, to report to the U.S. Congress current in- formation about the health effects of tobacco use. The report was produced with the assistance of experts in the behavioral, epidemiological, medical, and public health fields. Initial background papers were produced by more than 25 scientists w~ho \vere selected because of their expertise and familiaritv M'ith the topics covered in this report. Their various contri- butions were summarized into five major chapters that were reviewed by 28 peer revie\vers. The entire manu- script was then sent to 13 scientists and experts, wrllo reviewed it for its scientific integritv. Subsequently, the report was reviewed by various institutes and agencies within the Department of Health and Human Services. Terms Related to Race and Ethnicity Race and ethnicity are classifications currently used for various purposes, such as tracking morbidity and mortality statistics, defining group characteristics (as is done in many studies and by most federal and state agencies, including the U.S. Bureau of the Cen- sus), and exploring the health characteristics of indi- viduals and groups. Most extant data consider four rack! groups in the United States (African American or black, American Indian and Alaska Native, Asian American and Pacific Islander, and white) as well as two etlr,ric categories (Hispanic and non-Hispanic). Specific choices have been made in selecting the labels used to identify individuals who share a given race, tradition, culture, or ethnicity. These labels dif- fer somewhat from those published in the Race and Ethnic Standards for Federal Statistics and Adminis- trative Reporting, more commonly known as Direc- tive 15 (U.S. Department of Commerce 1978). This di- rective presents rules for classifying persons into four racial groups (American Indian or Alaskan Native, Asian or Pacific Islander, black, and white) and two ethnic categories (Hispanic origin and not of Hispanic origin). The labels in this report were chosen to reflect current preferred use by many members of each group and researchers as well as to more clearly identify Tobacco Use Amo~lg U.S. Ra&l/Ethic Minority Groups members of a given group. Nevertheless, because of differences in the way in which ethnicity has been as- certained in the various studies, some overlap and misclassification may exist, particularly with regard to Hispanic origin (for example, Hispanics of African background may be classified as African Americans, or Hispanics may be classified as non-Hispanic whites). In addition, the terms used in this report do not always precisely depict the racial/ethnic group studied (for instance, this report consistently uses the term American I,diall and Alaska Ndiue, even when de- scribing studies of Nofive Americnm-a category that in some cases excludes Alaska Natives). Moreover, the terms used here do not reflect the fact that some studies were conducted in the 48 contiguous states and may exclude a substantial number of Alaska Natives and Native Hawaiians. Throughout this report, the following labels and definitions are used, with the ref- erents basically agreeing with those of Directive 15: Afrimll Americau. Individuals who trace their an- cestry of origin to Sub-Saharan Africa. Aliwricnn Idinn ~nrl AInska Nntiue. Persons who have origins in any of the original peoples of North America and who maintain that cultural identifi- cation through self-identification, tribal affiliation, or community recognition. Asin~ American amI Pacific lslnnder. Individuals who trace their background to the Far East, South- east Asia, the Indian subcontinent, or the Pacific Islands. His[JaJ7iC. Persons who trace their background to one of the Spanish-speaking countries in the Americas or to other Spanish cultures or origins. Wlzite. Persons who have origins in any of the original peoples of Europe, North Africa, or the Middle East. Throughout most of this report, white refers to non-Hispanic whites. Finally, this report avoids using such labels as /""FJk of color, spa%/ p0p741nti017s, Jntdticdtural pOp7dLP from, or diverse popzrlntinm because some people con- sider them inaccurate, improper, or pejorative. With- out question, not everyone will agree with the terms used in this report because no universally accepted labels exist. These terms will continue to evolve with time. Terms Related to Tobacco Use Throughout this report, F?rezlnle?zce of smking ces- sation is used to describe the proportion of persons who had ever smoked and who were former smokers at the time of survey (this term is used instead of quit ratio or quit rate). Definitions related to smoking status-ever smokers, never smokers, current smok- ers, and former smokers-are presented later in this report (see Chapter 2). Demographic Characteristics of the Four Racial/Ethnic Minority Groups In the 1990 U.S. Census, the four racial and eth- nic groups that are the focus of this report accounted for 24 percent of the population, or more than 60 mil- lion people (Table 1). African Americans were the larg- est group, followed by Hispanics, Asian Americans and Pacific Islanders, and American Indians and Alaska Natives. Although these groups constitute a minority of the total population, their overall growth of 32 percent between 1980 and 1990 far exceeds the 4- percent increase among whites (Table 1). Asian Ameri- cans and Pacific Islanders had the largest growth during that period, followed by Hispanics, American Indians and Alaska Natives, and African Americans. Because of this rapid growth, racial and ethnic popu- lations tend to be younger than the white majority. Demographic characteristics vary significantly when the four racial and ethnic groups are compared with whites, according to 1990 census data (Table 2; within-group variability is masked because all sub- groups th.at make up a given racial or ethnic group are considered together) (U.S. Bureau of the Census 1993~). The median ages of Hispanics (25.6 years), as well as American Indians and Alaska Natives (26.9 years), are lower than those of the other racial/ethnic group mem- bers. Hispanics have the lowest proportion of high school graduates (49.8 percent) of all groups and the highest proportion of people who speak a language other than English (77.8 percent). Asian Americans and Pacific Islanders (38.4 percent) as well as Hispan- ics (39.4 percent) have the largest proportions of indi- viduals who feel they do not speak English "very well." They also have the highest proportions of foreign-born persons. American Indians and Alaska Natives, Afri- can Americans, and Hispanics have significantly higher levels of unemployment and poverty as well as substantially lower household incomes than Asian Americans, Pacific Islanders, or whites. In all four groups, a majority of members live in urban environ- ments; however, American Indians and Alaska Natives have the lowest proportion of urban residents. Differences in the demographic characteristics of each of the various racial and ethnic groups are related to variations in national background and immigration history. Asian Americans and Pacific Islanders, for example, include approximately 32 different ethnic and Table 1. U.S. population distribution, by racelethnicity and Hispanic origin and percentage change, 1980-1990 1980 1990 (in millions) (in millions) 70 Change White* 180.26 188.42 4 African American* 26.10 29.28 12 Hispanic Asian American and Pacific Islander 3.50 7.23 107 American Indian and Alaska Native% 1.42 2.02 42 *Excludes persons of Hispanic origin. *Excludes 3.5 million Hispanics in Puerto Rico. $Includes Eskimos and Aleuts. Source: U.S. Bureau of the Census 1983,1993c. 8 Clzaytrr 1 Tobacco Use Among U.S. Racial/Ethnic Minnrity Groups Table 2. Selected demographic characteristics for the U.S. population, by racelethnicity, 1990 African American Indians/ Asian Americans/ Characteristic Americans Alaska Natives Pacific Islanders Hispanics Whites* Population 29,930,524 2,015,143 7,226,986 21,900,089 188,424,773 Women (percentage) Median age (years) Foreign born (percentage) 52.8 50.4 51.2 49.2 51.3 28.2 26.9 30.1 25.6 34.9 4.9 2.3 63.1 35.8 3.3 Education (percentage of persons aged 225 years) High school education Bachelor's degree or higher English-language ability (percentage of persons aged 25 years) Speak a language other than English Do not speak English "very well" Number of persons per family Percentage of families with own children aged ~18 years Employment statust (percentage of persons aged 216 years) Employed Unemployed Percentage of employed persons aged 216 years in a managerial/professional occupation Household income in 1989 ($) Median Mean Per capita income in 1989 ($) Poverty rate (percentage) Families Persons Urban residents (percentage) 63.1 65.5 77.5 49.8 79.1 11.4 9.3 36.6 9.2 22.1 6.3 2.4 3.5 56.5 62.7 62.1 67.5 67.5 65.3 12.9 14.4 5.3 10.4 5.0 23.8 73.3 77.8 5.7 9.2 38.4 39.4 1.8 3.6 3.7 3.8 3.0 60.7 59.5 64.5 45.2 18.1 18.3 30.6 14.1 28.5 19,758 20,025 36,784 24,156 31,672 25,872 26,602 46,695 30,301 40,646 8,859 8,328 13,638 8,400 16,074 26.3 27.0 11.6 22.3 7.0 29.5 30.9 14.1 25.3 9.2 87.2 56.0 95.4 91.4 70.9 *Excludes persons of Hispanic origin. The population figures for African Americans in Tables 1 and 2 are different because the population cited in Table 2 includes African Americans of Hispanic origin, while the African American population cited in Table 1 excludes persons of Hispanic origin. tThese figures do not include several categories of people who were not in the civilian labor force for various reasons, such as students, housewives, retired workers, seasonal workers in an off season who were not looking for work, institutionalized persons, during the reference week). and persons doing only incidental unpaid family work (less than 15 hours Source: U.S. Bureau of the Census 1993a,c. national groups and speak nearly 500 languages and dialects (Chen 1993). They trace their background to areas as diverse as Mongolia to the north, Indonesia and the South Pacific Islands to the south, India to the west, and Japan to the east. Hispanics include indi- viduals who trace their background to the original set- tlers of large areas in what is now the Southwest United States as well as recent immigrants from any of the 18 Spanish-speaking countries in Latin America. The American Indian and Alaska Native population in the United States is likewise composed of a richly diverse group of indigenous cultures of indigenous cultures, over half of whom do not live on a reservation (U.S. Bureau of the Census 1993~). More than 500 federally recognized tribes and an additional 100 nonfederally recognized tribes are concentrated primarily in 25 res- ervation states (U.S. Bureau of the Census 1992a). American Indians and Alaska Natives continue to speak more than 150 languages. (For additional infor- mation, see U.S. Bureau of the Census reports on Asian Americans and Pacific Islanders [1993a], Hispanics [1993b], and American Indians and Alaska Natives [ 1993~1.) Most African Americans in the United States can trace their ancestry to territories that include the modern states of Benin, Burkina Faso (formerly Upper Volta), Cameroon, the Congo Republic, Cote d'lvoire (Ivory Coast), the Democratic Republic of the Congo (formerly Zaire), Gabon, Gambia, Ghana, Guinea, Liberia, Nigeria, Senegal, Sierra Leone, and Togo (Ploski and Williams 1989). The mode of entry for practically all Africans who entered the United States in the seventeenth, eighteenth, and nineteenth centuries (until 1865) was as slaves (see Chapter 4 for further historical discussion). Many recent immigrants came from the Caribbean islands and Sub-Saharan Africa. This report excludes data on the 3.5 million residents of Puerto Rico as well as data on residents of other territories and associated states of the United States; however, many of the issues discussed in this report are relevant to these individuals because they have been influenced by the events taking place in the 50 states. Over the next 50 years, the population of the four groups is expected to increase dramatically, reaching close to one-half of the country's population by the year 2050 (Table 3), according to estimates from the U.S. Bureau of the Census (1992b). These estimates underscore the need to develop appropriate interven- tions to avert disturbing tobacco addiction patterns in this large segment of the population. Table 3. Estimated percentage distribution of the U.S. population, by race/ethnicity and Hispanic origin, 1990-2050 Year African American Non-Hispanic Asian American/ American Pacific Islander Indian* White Hispanic 1990 11.8 2.8 0.7 75.7 9.0 1995 12.1 3.5 0.7 73.6 10.1 2000 12.3 4.2 0.8 71.6 11.1 2005 12.6 `I.9 0.8 69.6 12.2 2010 12.8 5.5 0.8 67.6 13.2 2020 13.3 6.8 0.9 63.9 15.2 2050 15.0 10.1 1.1 52.7 21.1 *Includes Eskimos and Aleuts. Source: U.S. Bureau of the Census 1992b. 10 Chapter 2 Tblmco Uw Amorzg U.S. Rncid/Ethnic Minority Groups Effects of Racial/Ethnic Background on Health Extensive research has been conducted on the relationship between health and race/ethnicity (see, for example, Harwood 1981; Polednak 1989; Braithwaite and Taylor 1992; Young 1994). Published reports of these studies tend to show different rates of illness across racial/ethnic groups. Some of these dif- ferences may be explained by variations in each group's beliefs and attitudes, traditional health-related practices, normative behaviors, social conditions, lev- els of access to high-quality health care, experiences with discrimination and racism, living env,ironments, competing causes of death, and genetic backgrounds. Genetic factors may contribute to certain differences among groups of people; however, culture, degree of acculturation, and socioeconomic factors are probably far more significant determinants of health status in the United States (Freeman 1993; Adler et al. 1994). Culture is a broad concept (Kroeber and Kluckhohn 1963)-its influence encompasses all as- pects of daily life, including beliefs and practices about health and illness as well as norms that dictate behav- iors. Most contemporary societies include many dif- ferent cultures, which may be defined by historical, geographic, economic, social, and political elements (Helman 1985). The United States has always been a nation of immigrants and coexisting cultures. Acculturation-the process of learning the val- ues, beliefs, norms, and traditions of a new culture (Marin 1992)-allows individuals to make choices and to learn of new worldviews, while keeping their origi- nal views (biculturalism) or modifying their initial perspectives to be more consonant with those of the new culture (assimilation). In multicultural societies such as the United States, acculturation occurs among immigrants (as they learn the host culture) as well as among individuals born in the United States (as they learn the culture of immigrants). Despite the signifi- cance of acculturation's link with human behavior, few studies have focused on how acculturation might affect the health status and behavior of ethnic groups in the United States. Part of the problem has been the difficulty in designing appropriate measuring instru- ments (Marin 19921, although recent research has begun to assess the role that acculturation plays in determining the health status of members of U.S. racial/ethnic groups (Perez-Stable 1994; Vega and Amaro 1994; Williams and Collins 1995). Socioeconomic characteristics, which are power- ful determinants of health and disease (USDHHS 1985, 1991; Liberatos et al. 1988; HRSA 1991; Williams and Collins 1995), differ markedly among the racial and ethnic groups of the United States (Table 2). Levels of income and education may directly and indirectly af- fect the health status of individuals (Council on Ethi- cal and Judicial Affairs 1990; Weissman et al. 1991). Jncome, for example, often is a determinant of access to health care as well as of the quantity and quality of health care available. Persons with low incomes, re- gardless of race or ethnicity, are more likely to be uninsured (American College of Physicians 19901, to encounter delays in seeking or receiving care or to be denied care (Tallon 1989), to rely on hospital clinics and emergency rooms for health services (NCHS 19851, and to receive substandard care (Burstin et al. 1992). Level of education may influence health beliefs and behaviors, which determine whether and how indi- viduals seek health care, make treatment choices, and comply with treatment suggestions. Because the lit- erature reviewed in this report has often failed to con- sider the role of socioeconomic factors in the health status of members of racial/ethnic groups, under- standing the significance of the results is difficult. Nevertheless, these published reports indicate that access to health care and the type of care received are partly determined by the race and ethnicity of the pa- tient and that members of minority groups are less likely than whites to receive adequate care (e.g., Blendon et al. 1989; CDC 1989; Todd et al. 1993; Wil- liams and Collins 1995). The information summarized in this report re- flects the role of race, ethnicity, and culture in shaping tobacco use among members of the four population groups. Unfortunately, currently available methods do not help delineate the role of acculturation, socio- economic conditions, and societal problems such as racism, prejudice, and discrimination (e.g., Osborne and Feit 1992; Freeman 1993; Pappas 1994). Never- theless, efforts were made here to discern the possible role of these variables in explaining tobacco use among racial/ethnic minority group members. Surgeon General's Report Chapter Conclusions Following are the specific conclusions for each chapter in this report. Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups 1. 2. 3. 4. 5. 6. 7. In 1978-1995, the prevalence of cigarette smoking declined among African American, Asian Ameri- can and Pacific Islander, and Hispanic adults. However, among American Indians and Alaska Natives, current smoking prevalence did not change for men from 1983 to 1995 or for women from 1978 to 1995. Tobacco use varies within and among racial/ ethnic groups; among adults, American Indians and Alaska Natives have the highest prevalence of tobacco use; African American and Southeast Asian men also have a high prevalence of smok- ing. Asian American and Hispanic women have the lowest prevalence. In all racial/ethnic groups discussed in this report except American Indians and Alaska Natives, men have a higher prevalence of cigarette smoking than women. In all racial/ethnic groups except African Ameri- cans, men are more likely than women to use smokeless tobacco. Cigarette smoking prevalence increased in the 1990s among African American and Hispanic ado- lescents after several years of substantial decline among adolescents of all four racial/ethnic minor- ity groups. This increase is particularly striking among African American youths, who had the greatest decline of the four groups during the 1970s and 1980s. Since 1978, the prevalence of cigarette smoking has remained strikingly high among American Indian and Alaska Native women of reproductive age and has not declined as it has among African Ameri- can, Asian American and Pacific Islander, and Hispanic women of reproductive age. Declines in smoking prevalence were greater among African American, Hispanic, and white men who were high school graduates than they 8. 9. 10. were among those with less formal education. Among women in these three groups, education- related declines in cigarette smoking were less pronounced. Educational attainment accounts for only some of the differences in smoking behaviors (current smoking, heavy smoking, ever smoking, and smoking cessation) between whites and the racial/ ethnic minority groups discussed in this report. Other biological, social, and cultural factors are likely to further account for these differences. Compared with whites who smoke, smokers in each of the four racial/ethnic minority groups smoke fewer cigarettes each day. Among smok- ers, African Americans, Asian Americans and Pa- cific Islanders, and Hispanics are more likely than whites to smoke occasionally (less than daily). The data in general suggest that acculturation in- fluences smoking patterns in that individuals tend to adopt the smoking behavior of the current broader community; however, the exact effects of acculturation on smoking behavior are difficult to quantify because of limitations on most available measures of this cultural learning process. Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic Minority Groups 1. Cigarette smoking is a major cause of disease and death in each of the four racial/ethnic groups stud- ied in this report. African Americans currently bear the greatest health burden. Differences in the magnitude of disease risk are directly related to differences in patterns of smoking. 2. Although lung cancer incidence and death rates vary widely among the nation's racial/ethnic groups, lung cancer is the leading cause of cancer death for each of the racial/ethnic groups studied in this report. Before 1990, death rates from malig- nant neoplasms of the respiratory system increased among African American, Hispanic, and American Indian and Alaska Native men and women. From 12 Chapter 1 3. 4. 5 L 6. 7. 8. 1990 through 1995 death rates from respiratory can- cers decreased substantially among African Ameri- can men, leveled off among African American women, decreased slightly among Hispanic men and women, and increased among American Indian and Alaska Native men and women. Rates of tobacco-related cancers (other than lung cancer) vary widely among members of racial/ ethnic groups, and they are particularly high among African American men. The effect of cigarette smoking (as reflected by biomarkers of tobacco exposure) on infant birth weight appears to be the same in African American and white women. As reported in previous Sur- geon General's reports, cigarette smoking increases the risk of delivering a low-birth-weight infant. No significant racial/ethnic group differences have been consistently demonstrated in the relationship between smoking and infant mortality or sudden infant death syndrome (SIDS); cigarette smoking has been associated with increased risk of SIDS and remains a probable cause of infant mortality. Future research is needed and should focus on 110~ tobacco use affects coronary heart disease, stroke, cancer, chronic obstructive pulmonary disease, and other respiratory diseases among members of racial/ethnic groups. Studies also are needed to determine how the health effects of smokeless to- bacco use and exposure to environmental tobacco smoke vary across racial/ethnic minority groups. Persons of all racial/ethnic backgrounds are vul- nerable to becoming addicted to nicotine, and no consistent differences exist in the overall severity of addiction or symptoms of addiction across racial/ethnic groups. Levels of serum cotinine (a biomarker of tobacco exposure) are higher in African American smok- ers than in white smokers for similar levels of daily cigarette consumption. Further research is needed to clarify the relationship between smoking prac- tices and serum cotinine levels in U.S. racial/ ethnic groups. Variables such as group-specific patterns of smoking behavior (e.g., number of puffs per cigarette, retention time of tobacco smoke in the lungs), rates of nicotine metabolism, and brand mentholation could be explored. Tobacco Use Among U.S. Racinl/Ethnic Minority Groups Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic Minority Groups 1. 2. 3. 4. 5. 6. The close association of tobacco with significant events and rituals in the history of many racial/ ethnic communities and the tobacco industry's long history of providing economic support to some racial/ethnic groups-including employ- ment opportunities and contributions to commu- nity groups and leaders-may undermine prevention and control efforts. The tobacco industry's targeted advertising and promotion of tobacco products among members of these four U.S. racial/ethnic groups may un- dermine prevention and control efforts and thus lead to serious health consequences. The high level of tobacco product advertising in racial/ethnic publications is problematic be- cause the editors and publishers of these publica- tions may omit stories dealing with the damaging effects of tobacco or limit the level of tobacco-use prevention and health promotion information in- cluded in their publications. Although much of the original research on psy- chosocial factors that influence tobacco use reflects general processes that may apply to racial/ethnic populations, documenting such generalizability requires further research. The initiation of tobacco use and early tobacco use among members of the various racial/ethnic mi- nority groups seem to be related to numerous cat- egories of variables-such as sociodemographic, environmental, historical, behavioral, personal, and psychological-although the predictive power of these categories or of specific risk factors is not known with certainty because of the paucity of research. Cigarette smoking among members of the four racial/ethnic groups is associated with depression, psychological stress, and environmental factors such as advertising and promotion and peers who smoke, as is also the case in the general popula- tion. The role of these factors in tobacco use among members of these racial/ethnic groups deserves attention by researchers and persons who develop smoking prevention and cessation programs. Chapter 5. Tobacco Control and Education Efforts Among Members of Four Racial/ Ethnic Minority Groups 1. More research is needed on the effect of culturally appropriate programs to reduce tobacco use among racial/ethnic minority groups. Interven- tions should be language appropriate; addressing psychosocial characteristics such as depression, stress, and acculturation may increase the accep- tance of programs by members of racial/ethnic groups. 2. To be culturally appropriate, tobacco control pro- grams must reflect the targeted racial/ethnic group's cultural values, consider the group's psychosocial correlates of tobacco use, and use strategies that are acceptable and credible to mem- bers of the group. Culturally competent program staff must be aware and accepting of cultural dif- ferences, be able to assess their own cultural val- ues, be conscious of intercultural dynamics when persons of different cultures interact, be aware of a racial/ethnic group's relevant cultural charac- teristics, and have the skills to adapt to cultural diversity. 3. Numerous strategies are needed to control tobacco use among racial/ethnic youths: restricting mi- nors' access to tobacco products, establishing cul- turally appropriate school-based programs, and designing mass media efforts geared to young people's interests, attitudes, expectations, and norms. Recent provisions of the Synar Amend- ment, designed to prevent minors' access to to- bacco products, and the FDA regulations aimed at reducing the access to and appeal of tobacco products to young people are intended to reduce tobacco use among all youth, including members of racial/ethnic minority groups. 4. Members of racial/ethnic groups are less likely than the general population to participate in smok- ing cessation groups and to receive cessation ad- vice from health care providers. Barriers to ethnic group participation include limited cultural com- petence of health care providers and a lack of trans- portation, money, and access to health care. 5. Available data indicate that racial/ethnic groups support smoking restrictions, such as increasing cigarette excise taxes, banning cigarette advertise- ments, restricting access to cigarette vending ma- chines, raising the legal age of purchase, prohibiting sponsorship of events by tobacco com- panies, and establishing clean indoor air regula- tions. Additional research is needed to evaluate how best to build on this base of public opinion support to strengthen existing tobacco prevention and control programs within racial/ethnic communities. 6. Prevention and cessation efforts in racial/ethnic communities are limited by underdeveloped to- bacco control infrastructures and low levels of re- sources for research, program development, and program dissemination. Greater resources are needed in racial/ethnic minority communities to build tobacco control infrastructures and to develop initiatives. 14 Chapter 1 Tc7bacco USP Amoilg U.S. Racial/Ethnic Minority Groups References Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, et al. Socioeconomic status and health: the challenge of the gradient. Anrericarl Psychologist 1994;49(1):15-24. American College of Physicians. Access to health care [position paper]. Allllals of lizferr~a[ Medicir~e 1990;112(9):641-61. Blendon RJ, Aiken LH, Freeman HE, Corey CR. Ac- cess to medical care for black and white Americans: a matter of continuing concern. ]olllrlfl/ of th Americans Medical Associatioll 1989;261(2):278-81. Braithwaite RL, Taylor SE, editors. 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Il7troduction and Summary 17 Chapter 2 Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups Introduction 21 Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups 22 African Americans 22 Prevalence of Cigarette Smoking 22 Number of Cigarettes Smoked Daily 23 Quitting Behavior 25 Women of Reproductive Age 26 Young People 28 American Indians and Alaska Natives 44 Prevalence of Cigarette Smoking 44 Number of Cigarettes Smoked Daily 45 Quitting Behavior 46 Women of Reproductive Age 48 Young People 49 Regional and Tribal Tobacco Use 50 Asian Americans and Pacific Islanders 56 Prevalence of Cigarette Smoking 56 Number of Cigarettes Smoked Daily 56 Quitting Behavior 57 Women of Reproductive Age 57 Young People 59 State and Local Smoking Estimates 60 Cigarette Smoking in Asian Countries 65 Hispanics 66 Prevalence of Cigarette Smoking 66 Number of Cigarettes Smoked Daily 69 Quitting Behavior 70 Women of Reproductive Age 71 Young People 72 Retrospective Analyses of Smoking Prevalence Among African Americans and Hispanics 74 Prevalence of Cigarette Smoking Among Successive Birth Cohorts 74 African Americans 74 Hispanics 75 Long-Term Trends in Cigarette-Smoking Initiation 78 African Americans 78 Hispanics 78 Cigarette Brand Preferences 79 Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior 83 Current Smoking 85 Smoking Cessation 85 Heavy Smoking 85 Ever Smoking 85 Occasional Smoking 86 Exposure to Environmental Tobacco Smoke 86 Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use 87 Cigarette Smoking 87 Pipe and Cigar Use 92 Use of Smokeless Tobacco 94 Conclusions 94 Appendix 1. Sources of Data 95 National Health Interview Survey (NHIS) 95 Hispanic Health and Nutrition Examination Survey (HHANES) 9.5 Behavioral Risk Factor Surveillance System (BRFSS) 95 Adult Use of Tobacco Survey (AUTS) 96 Monitoring the Future (MTF) Surveys 96 Youth Risk Behavior Survey (YRBS) 96 Teenage Attitudes and Practices Survey (TAPS) 96 Appendix 2. Measures of Tobacco Use 97 Cigarette Smoking and Cessation 97 Number of Cigarettes Smoked Daily 97 Use of Cigars, Pipes, and Smokeless Tobacco 97 Appendix 3. Patterns of Cigarette Use Among Whites 98 Appendix 4. Patterns of Cigarette Use Among African Americans 722 Appendix 5. Validation of the Retrospective Assessment of Smoking Prevalence 122 References 12.5 TC~JOCCO Use Anrorzg U.S. Racial/Ethic Mixority Groups Introduction Over the past 15 years, the prevalence of ciga- rette smoking has generally declined among adult African Americans, Asian Americans and Pacific Islanders, and Hispanics. Nevertheless, rates of ciga- rette smoking and other tobacco use are still high among certain racial/ethnic minority groups compared with among the overall population, particularly American Indians and Alaska Natives. Designing more successful public health efforts to reduce tobacco-related diseases and deaths in racial / ethnic populations requires greater understanding of these racial/ethnic patterns of tobacco use. This chapter summarizes bon smoking beha\?ors such as current tobacco use, cigarette consumption, and quit- ting behavior among adults vary within and among racial/ethnic groups. In addition, for all racial/ ethnic groups, the prel.alence of cigarette smoking is examined for two groups of special interest, xvomen of reproductive age and adolescents. The purpose of this chapter is to summarize in one source the reported trends and patterns of tobacco use among members of the four racial/ethnic minor- ity groups, by gender, age, and level of education. In addition, newly compiled information is presented on smoking patterns by birth cohort (based on year of birth) for African Americans and Hispanics. The rela- tionship between racial/ethnic group and education as predictors of cigarette smoking is explored, and data on cigarette brand preference and exposure to environmental tobacco smoke are presented. The in- fluence of acculturation on smoking behavior is ex- amined among the two fastest growing immigrant groups to the United States-Asian Americans and Pacific Islanders and Hispanics. Although reports of the effects of acculturation vary widely in the litera- ture, it is an important correlate of behavior despite limitations in conceptualization, operationalization, and measurement. The analyses presented in this chapter incorpo- rate data from national and state-specific population- based surveys of adults, national population-based surveys of adolescents, and local and international surveys of various adult and adolescent populations. The national studies cited in this chapter include the National Health Interview Survey (NHIS) (197%1995), which garners yearly data on cigarette smoking; the Behavioral Risk Factor Surveillance System (BRFSS) (1987-1992), which collects information on behavioral risks among adults in the United States; the Adult Use of Tobacco Survey, which has been conducted periodi- cally since 1964; the Hispanic Health and Nutrition Examination Survey (HHANES), which gathered de- mographic and cigarette-smoking information from Hispanics between 1982 and 1984; the Monitoring the Future (MTF) surveys, which have been conducted in high schools annually since 1975; and the Teenage Attitudes and Practices Survey (TAPS), conducted in 1989 and 1993. Appendix 1 describes these major data sources, and Appendix 2 details the various measures of tobacco use. Appendix 3 presents data on patterns of cigarette use among whites that can be compared with the racial/ethnic group data presented in the chapter. Appendix 4 presents supplementary data on patterns of tobacco use among African Americans, and Appendix 5 describes how the authors validated one of the analytic techniques used to retro- spectively estimate smoking prevalence. The analyses in this chapter update and expand on previous Surgeon General's reports that describe tobacco use among racial/ethnic groups; most of these previous reports have focused on cigarette smoking only among African Americans (U.S. Department of Health, Education, and Welfare [USDHEW] 1979; U.S. Department of Health and Human Services [USDHHS] 1983,1988,1989,1990a). For some analyses reported here, small sample sizes limit the precision of the estimates. The patterns described in the text generally use point estimates, but confi- dence intervals presented in most tables can be referred to when the precision of the estimates needs to be defined. P~ttcrns of Tohcco Use 21 Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups African Americans Prevalence of Cigarette Smoking The overall prevalence of cigarette smoking among African Americans declined from 37.3 percent in 197881980 to 26.5 percent in 1994-1995, according to data from the NHIS (Table 1) (National Center for Health Statistics [NCHSI, public use data tapes, 1978- 1995). Between 1978 and 1995, the prevalence of cur- rent smoking among African American men fell from 45.0 to 31.4 percent, whereas the prevalence among African American women fell from 31.4 to 22.7 per- cent. Although the prevalence of smoking among African American men remained consistently higher than that among African American women, the gen- der differential in smoking prevalence narrowed over the 18-year period. Similar patterns have been observed since 1965 among both African Americans and whites (Figure 1) (Centers for Disease Control and Prevention [CDC] 1994~). Magnitudes of decline in smoking prevalence also differed by age (Table 1). Between 1978 and 1995, Table 1. Percentage of adult African Americans who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic 7% KI$ % I-c1 7% KI % KI % +c1 % fC1 Total 37.3 1.7 35.3 1.4 32.3 1.1 27.9 1.1 27.0 1.5 26.5 1.7 Gender Men Women 45.0 2.5 40.2 2.2 37.6 1.8 34.1 1.8 32.4 2.5 31.4 2.7 31.4 1.8 31.4 1.7 28.0 1.4 22.9 1.3 22.6 1.6 22.7 1.9 Age (years) 18-34 38.7 2.8 34.7 2.1 32.0 1.7 26.0 1.7 22.1 2.2 21.0 2.4 35-54 43.9 2.4 42.2 2.7 37.2 1.9 35.6 1.9 35.9 2.7 34.2 3.0 255 26.5 2.4 27.8 2.4 26.1 2.0 20.0 2.0 22.3 2.8 23.5 2.8 Education5 Less than high school 36.4 2.3 38.7 2.1 36.3 2.0 33.1 2.2 34.2 3.4 34.8 3.3 High school 42.1 2.6 39.4 2.8 38.8 2.1 33.5 1.9 31.9 2.7 31.3 3.1 Some college 36.7 5.5 34.8 3.4 33.0 2.7 28.9 2.8 27.5 3.2 26.4 3.7 College 34.6 6.7 28.4 4.3 19.7 3.2 17.8 2.9 18.2 4.2 16.7 3.8 *Excludes African Americans who reported they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. t95% confidence interval. 41ncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. African Americans 18-34 years of age experienced the largest decline in smoking prevalence, from 38.7 to 21.0 percent, whereas African Americans aged 55 years and older experienced the smallest decline, from 26.5 to 23.5 percent. In the years 1978-1980, persons 18-34 years of age were nearly 1.5 times more likely to smoke than those 55 years of age or older. By 1994 and 1995, however, because of the differential decline in smok- ing prevalence, the prevalence of smoking among younger adults was as low as that among their older counterparts. The prevalence of cigarette smoking among Af- rican Americans decreased most among college gradu- ates (Table 11-a pattern that has been found in the nation as a whole (Pierce et al. 1989). Among African American college graduates, the smoking prel'alence fell from 34.6 percent in 1978-1980 to 16.7 percent in 1994-1995. In comparison, smoking pre\.alence among African Americans with less than 12 years of educa- tion was 36.4 percent in 1978-1980 and 34.8 percent in 1994-1995. In the years 1978-1980, the prevalence of smoking varied little by level of education. However, by 1994 and 1995, an inverse relationship had emerged. As the level of education increased, the prevalence of cigarette smoking decreased. Number of Cigarettes Smoked Daily The percentage of African American smokers who reported that they were light smokers (smoking fewer than 15 cigarettes per day) increased from 56.0 percent in 19781980 to 63.9 percent in 1994-1995, ac- cording to the NHIS data (Table 2) (NCHS, public use data tapes, 1978-l 993). This upward trend was found across all sociodemographic groups, with men, per- sons less than 35 years of age, and college graduates experiencing the largest increases in light smoking. Throughout the l&year period, African Ameri- can I~~omen ~`110 smoked were consistently more likely than their male counterparts to smoke fewer than 15 cigarettes per day (Table 2). African American smok- ers 18-34 years of age were slightly more likely than Figure 1. Trends in the prevalence of cigarette smoking among African American and white men and women, National Health Interview Surveys, United States, 1965-1995 60- 0 ( 1965 I 1970 I 1975 I 1980 Year I I I 1985 1990 1995 African - American men African - American women White men 111, White women Source: National Center for Health Statistics, public use data tapes, 1965, 1966, 1970, 1974, 1976, 1977, 1978, 1979, 1980,1983,1985,1987,1988,1990,1991,1992,1993,1994, and 1995. Table 2. Percentage of adult African American smokers* who reported smoking <15,15-24, or 225 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic 7c *c1$ % KI % fC1 % +c1 % +c1 % +c1 Total < 15 cigarettes 15-24 cigarettes 225 cigarettes Gender Men < 15 cigarettes 15-24 cigarettes 225 cigarettes Women < 15 cigarettes 15-24 cigarettes 225 cigarettes Age (years) 18-34 < 15 cigarettes 15-24 cigarettes 225 cigarettes 35-54 < 15 cigarettes 15-24 cigarettes 225 cigarettes 2 55 < 15 cigarettes 15-24 cigarettes 225 cigarettes 56.0 2.2 55.4 2.5 58.8 2.0 60.6 2.2 63.3 3.0 63.9 3.5 33.6 2.2 35.2 2.4 32.8 1.9 31.9 2.1 31.1 2.8 28.4 3.2 10.4 1.7 9.4 1.6 8.4 1.2 7.5 1.2 5.6 1.3 7.6 2.1 50.4 3.2 52.3 3.8 53.2 3.1 55.2 3.1 59.3 4.5 61.1 5.1 37.1 3.6 36.3 3.4 37.0 3.1 35.6 3.1 34.4 4.2 28.6 4.7 12.5 2.3 11.4 2.6 9.8 1.7 9.2 1.9 6.3 2.0 10.3 3.7 62.2 3.2 58.6 3.1 65.0 2.7 67.1 2.6 67.9 3.8 67.1 4.2 29.8 2.8 34.1 2.8 28.2 2.4 27.5 2.5 27.4 3.6 28.3 4.0 8.1 2.3 7.3 1.5 6.8 1.3 5.4 1.3 4.7 1.5 4.6 1.7 59.8 3.6 56.9 3.7 64.1 2.9 67.2 3.4 69.5 5.1 70.0 5.5 31.7 3.3 34.4 3.3 28.5 2.7 26.6 3.2 25.5 4.8 23.3 5.3 8.5 2.3 8.7 2.3 7.4 1.7 6.2 1.8 5.1 2.1 6.7 2.7 51.2 3.4 31.0 4.1 52.1 3.1 54.6 3.4 60.4 4.3 58.9 5.2 35.6 3.7 37.7 3.9 37.7 3.1 36.9 3.2 33.2 4.1 32.2 4.8 13.2 2.7 11.3 2.5 10.2 1.7 8.5 1.9 6.3 2.1 8.9 3.6 55.3 5.4 60.4 5.6 59.1 5.2 60.4 4.8 59.0 6.5 66.7 6.6 34.8 5.6 32.3 5.9 33.6 5.0 31.9 4.7 36.3 6.4 27.3 6.0 9.9 4.8 7.4 3.1 7.3 2.5 7.7 2.7 4.7 2.7 6.0 3.8 *Excludes African Americans who reported they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $95% confidence interval. their older counterparts to be light smokers (except for the years 1983-1985). An association between edu- cation and light smoking became apparent in 1990-1991. In 1990 and beyond, among smokers, education was directly related to the proportion of smokers who smoked fewer than 15 cigarettes per day. As the level of education increased, the proportion smoking lightly also increased. Throughout the 18-year period, the prevalence of heavy smoking (smoking 25 or more cigarettes per 24 Cl7i7ytrr 2 i%bacco Use Amo7zg U.S. Racinl/Etlznic Minorify Groups Table 2. Continued 197%1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic 7c +c1* % 3x1 % +c1 7c +a Yc KI x KI Education5 Less than high school < 15 cigarettes 15-24 cigarettes 225 cigarettes High school < 15 cigarettes 15-24 cigarettes 225 cigarettes Some college < 15 cigarettes 15-24 cigarettes 225 cigarettes College < 15 cigarettes 15-24 cigarettes 125 cigarettes 53.1 4.0 56.0 4.1 57.3 3.1 57.3 3.4 57.7 5.5 56.1 6.0 33.5 3.6 32.7 4.0 32.7 3.3 33.5 3.3 33.9 5.4 32.5 5.6 13.4 3.1 11.3 3.1 10.0 2.2 9.2 2.3 8.4 3.0 11.5 4.5 53.9 4.7 52.4 4.4 58.3 3.6 59.0 3.7 62.7 4.6 64.0 5.7 34.9 4.8 40.6 4.1 33.2 3.5 34.8 3.6 33.4 4.4 29.2 4.9 11.2 3.6 6.9 2.1 8.5 1.9 6.2 1.6 3.9 1.8 6.8 3.9 49.7 7.5 48.6 6.6 56.3 4.7 60.9 5.6 63.4 7.0 63.0 8.4 37.6 6.1 37.4 6.8 34.7 4.7 32.2 5.5 31.0 6.8 32.2 8.2 12.7 5.9 14.1 5.1 9.0 3.1 6.9 2.9 5.6 3.1 4.9 2.5 57.1 10.2 50.9 9.7 55.2 9.6 65.0 9.3 74.7 10.0 79.0 9.9 34.1 9.0 35.6 10.9 38.2 9.6 24.9 7.9 20.6 9.5 18.1 9.5 8.8 5.5 13.5 9.4 6.7 3.4 10.1 6.7 4.7 4.0 2.9 3.5 gIncludes persons aged 25 vears and older. Source: National Center fir Health Statistics, public use data tapes, 1978-1995. day) was higher among African American men than among women, and it was higher among respondents 3554 years of age than among their younger and older counterparts (Table 2). No clear patterns emerged in the relationship between education and the prevalence of heavy smoking. Quitting Behavior Between 1978 and 1995, the overall prevalence of smoking cessation (the percentage of persons who have ever smoked 100 cigarettes and who have quit smoking) among African Americans increased from 26.8 to 35.4 percent, according to data from the NHIS (Table 3) (NCHS, public use data tapes, 1978-1995). The prevalence of cessation generally increased over time across all gender, age, and education categories. The largest increases were among persons 55 years of age or older and college graduates. Throughout the 18-year period, the prevalence of smoking cessation remained higher among persons 55 years of age or older than among their younger counterparts (Table 3). Since 1983, college graduates have been generally more likely to quit smoking than persons with less than 16 years of education. Attempts to quit smoking during the previous year and short-term success at quitting were measured in a multivariate analysis of the 1991 NHIS data (CDC 1993). After statistical control was made for gender, age, education, and poverty status, African Americans were more likely than whites to stop smoking for at least one day during the previous year. However, Af- rican Americans who had stopped smoking for at least one day were less likely than whites to have quit for at least one month. Data from the National Cancer Institute (NC11 Supplement of the 1992-l 993 Current Population Sur- vey (CPS) indicate that among adults who were daily smokers one year before being surveyed, African Americans who had tried to quit for at least one day were slightly more likely than whites to have relapsed to daily smoking. African Americans were also slightly more likely than whites to have become occasional smokers (i.e., to be smoking on only some days) and slightly less likely to have quit smoking (Table 4) (U.S. Bureau of the Census, public use data tapes, Patterns of Tobacco Use 25 Table 3. Percentage of adult African American ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic 9% &CIS % fC1 70 +c1 % +c1 - Total 26.8 1.7 30.0 1.8 31.8 1.6 36.1 1.8 Gender Men Women Age (years) 18-34 35-54 255 Educations Less than high school High school Some college College 28.7 2.0 33.5 2.6 33.9 2.3 36.8 2.5 24.5 2.5 26.2 2.5 29.4 2.1 35.2 2.4 17.9 2.8 20.2 2.8 18.8 2.3 21.0 2.6 27.7 2.6 29.5 2.9 33.1 2.6 35.2 2.6 42.3 4.0 47.0 3.6 49.2 3.0 57.3 3.6 32.6 2.7 32.7 2.5 35.0 2.5 38.0 3.3 24.4 3.4 28.8 3.6 27.3 2.7 32.4 2.6 32.4 5.9 35.0 4.7 36.6 4.0 38.1 4.4 29.8 8.6 37.0 6.9 50.2 6.1 51.3 6.1 % tc1 % XI 37.0 2.4 35.4 2.6 39.1 3.5 34.9 3.7 34.5 3.1 35.9 3.4 23.7 4.6 19.6 4.1 33.2 3.4 33.1 4.0 56.8 4.4 54.7 4.4 40.0 4.2 36.8 4.0 33.4 3.8 31.6 4.3 39.0 5.3 37.3 6.3 48.7 8.7 51.1 8.5 *Excludes African Americans who reported they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever smokers include current and former smokers. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $95% confidence interval. %cludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 1992-1993). Some data suggest that African Ameri- cans may be more likely than whites to be dependent on nicotine (see Chapter 3, Table 18, in the section Racial/Ethnic Differences in Self-Reported Nicotine Dependence; Royce et al. 19931, although a report by Andreski and Breslau (1993) suggests the opposite. African Americans appear to have comparatively lim- ited access to preventive health services, including smoking cessation services (USDHHS 1988; Hymowitz et al. 1991). Women of Reproductive Age Between 1978 and 1995, the prevalence of cur- rent smoking among African American women of re- productive age (18-44 years) declined from 35.4 to 23.4 percent, according to data from the NHIS (Table 5) (NCHS, public use data tapes, 1978-1995). Women who were college graduates experienced an over- ~~helming decline in smoking prevalence, from 37.0 to 10.8 percent, whereas women with less than a high school education (~12 years) experienced a slight in- crease in the prevalence of current smoking, from 41 .l to 46.3 percent. In the years 1978-1980, the prevalence of smok- ing vraried little by level of education. However, by 1994 and 1995, a marked inverse relationship between smoking and educational level had emerged. As the level of education increased, the prevalence of smok- ing decreased. This inverse relationship has also been found in other studies of women of reproductive age (CDC 1991 a, 1994b). National data on tobacco use and pregnancy are available from the 1967 and 1980 National Natality Tobacco USC ~4tno~zg U.S. Racial/Ethnic Minority Groups Table 4. Current cigarette smoking status among persons* who reported that they were daily smokers 1 year before being surveyed, Current Population Survey National Cancer Institute Supplement, 1992-1993 Currrent smoking status American Asian Indians/ Americans/ African Alaska Pacific Americans Natives Islanders Hispanics Whites Total x =I+ p% kc1 %kcI I kc1 R KI % &CI Smoke every day; did not try to quit for at least one day during the previous year Smoke every day; did try to quit for at least one day during the previous year Smoke on some days Do not smoke cigarettes; abstinent for l-90 davs Do not smoke cigarettes; abstinent for 91-364 days 59.8 I.5 62.8 5.5 57.8 4.4 59.8 2.3 63.1 0.5 62.5 0.5 29.7 1.4 28.9 5.1 32.0 4.2 28.5 2.1 26.0 0.5 26.6 0.4 5.6 0.7 3.7 2.1 4.8 1.9 5.6 1.1 3.7 0.2 4.0 0.2 2.2 0.5 1.8 1.5 2.5 1.4 2.5 0.7 3.4 0.2 3.2 0.2 2.7 0.5 2.8 1.9 2.9 1.5 3.6 0.9 3.8 0.2 3.7 0.2 "Aged 18 years and older; N = 44,272. `95% confidence interval. Source: U.S. Bureau of the Census, public use data tapes, 1992-1993. Surveys, the 1982 and 1988 National Surveys of Fam- ily Growth, the 1985 and 1990 NHISs, the 1988 Na- tional Maternal and Infant Health Survey (NMIHS), and the 1992-1993 National Pregnancy and Health Survey. Furthermore, since 1989, national trend data on smoking and pregnancy have become readily avail- able from information collected on the revised U.S. Standard Certificate of Live Birth, which is included as part of U.S. final natality statistics compiled each calendar year (NCHS 1992, 1993, 1994; Ventura et al. 1994). Among the earliest sources of national trend data on smoking during pregnancy were the National Na- tality Surveys, which were administered to a national sample of married mothers of live infants born in 1967 and 1980 (Kleinman and Kopstein 1987; USDHHS 1989). Among African American mothers ~20 years of age, smoking rates remained virtually constant over time at about 27 percent. The smoking prevalence among African American mothers aged 220 years de- clined from 33 percent in 1967 to 23 percent in 1980. The National Survey of Family Growth collected data in 1982 and 1988 on the smoking behavior of females 1544 years of age during their most recent pregnancy. In 1982,29.2 percent of African American women re- ported smoking during their most recent pregnancy, compared with 23.4 percent in 1988 (Pamuk and Mosher 1992; Chandra 1995). More recent data from U.S. final natality statistics indicate that smoking rates for African Americans during pregnancy declined from 17.1 percent in 1989 to 10.6 percent in 1995 (Table 6). Smoking rates declined for African American teen- aged mothers from 1989 through 1995 but remained virtually unchanged for African American adult moth- ers aged 2049 years during those years (NCHS 1992, 1993,1994; Ventura et al. 1994,1995,19961. In general, African American adolescent mothers were less likely to have smoked than mothers 20-49 years Table 5. Percentage of African smokers,* overall and aggregate data American women of reproductive age who reported being current cigarette by education, National Health Interview Surveys, United States, 1978-1995 Characteristic Total 1978-1980+ 1983-1985+ 1987-1988+ lPPO-lPPl+ 1992-1993+ 1994-1995+ % KIS % KI % *a % KI % _+CI % _+CI 35.4 2.3 34.1 2.0 30.6 1.8 25.4 1.6 23.8 2.1 23.4 2.4 Education5 Less than high school 41.1 5.6 52.4 5.7 48.2 4.2 44.5 4.7 45.7 6.9 46.3 7.8 High school 36.3 4.0 36.8 3.8 34.5 3.0 31.6 3.0 30.0 3.8 28.4 4.3 Some college 37.1 4.8 32.3 5.0 30.6 3.8 26.4 3.4 26.2 4.7 26.1 5.6 College 37.0 10.2 21.8 6.5 20.0 4.3 17.3 4.3 13.1 5.0 10.8 4.9 *Excludes African American women who reported they were of Hispanic origin. For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 1844 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $95% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. old-a finding that is consistent with previously published data WSDHHS 1994). Data from the 1988 NMIHS indicate that 27 per- cent of African American mothers sampled reported smoking cigarettes in the 12 months before delivery (Sugarman et al. 1994). The National Pregnancy and Health Survey, conducted between October 1992 and August 1993 and sponsored by the National Institute on Drug Abuse (NIDA), provides nationally represen- tative data on the prevalence of prenatal drug use among females of reproductive age (1544 years). Ac- cording to the National Pregnancy and Health Survey, 19.8 percent of African American women reported us- ing cigarettes during their pregnancies (NIDA 1994). In the 1985 and 1990 NHISs, questions related to smok- ing were asked of women aged 18-44 years who had given birth within the past five years. In 1985, 27.5 percent of African American women smoked during the 12 months before the birth and 22.6 percent smoked after learning of their pregnancy; in 1990, 19 percent smoked during the year before the birth and 14.1 per- cent after learning of their pregnancy (Floyd et al. 1993). Young People Cigarette Smoking In the 1970s and 198Os, the prevalence of ciga- rette smoking declined among both maIe and femaIe African American high school seniors, according to data from the MTF surveys (Figure 2) (Bachman et al. 1991b). The prevalence of daily cigarette smoking, based on two-year rolling averages (percentages cal- culated by averaging the data for the specified year and the previous year to increase racial subgroup sample sizes and stabilize estimates), among African American high school seniors was 24.9 percent in 1977, 4.1 percent in 1993, and 7.0 percent in 1996 (Figure 3) (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). Between 1974 and 1991, signifi- cant declines in the prevalence of cigarette smoking also were observed among African American adoles- cents participating in the National HousehoId Surveys on Drug Abuse (NHSDAs) as well as among African Americans 18 and 19 years of age who participated in the NHISs (Nelson et al. 1995). 28 Chrzptcr 2 T3mCL) Use Ajnong U.S. Racial/Ethic Minority Groups Table 6. Percentage of live-born infants' mothers who reported smoking during pregnancy, by year and race/ ethnicity, U.S. final natality statistics, 1989-1995 Race of mother* African American American Indian and Alaska Kative Asian American and Pacific Islander' Chinese Filipino Hawaiian and part Hawaiian %I?yzian American or Pacific Islander White 17.1 15.9 14.6 13.8 12.7 11.4 10.6 23.0 22.4 22.6 22.5 21.6 21.0 20.9 5.7 5.5 5.2 4.8 4.3 3.6 3.4 2.7 2.0 1.9 1.7 1.1 0.9 0.8 5.1 5.3 5.3 4.8 4.3 3.7 3.4 19.3 21.0 19.4 18.5 17.2 16.0 15.9 8.2 8.0 7.5 6.6 6.7 5.4 5.2 4.2 3.8 3.8 3.6 3.2 2.9 2.9 20.4 Hispanic origin of mothert Hispanic origin Cuban Central and South American Mexican American Other and unknown Hispanic Puerto Rican African American, non-Hispanic White, non-Hispanic 8.0 6.7 6.3 5.8 5.0 4.6 4.3 6.9 6.4 6.2 5.9 5.0 4.8 4.1 3.6 3.0 2.8 2.6 2.3 1.8 1.8 6.3 5.3 4.8 4.3 3.7 3.4 3.1 12.1 10.8 10.7 10.1 9.3 8.1 8.2 14.5 13.6 13.2 12.7 11.2 10.9 10.4 17.2 15.9 14.6 13.8 12.7 11.5 10.6 21.7 21.0 20.5 19.7 18.6 17.7 17.1 Total 19.5 1989 1990 1991 1992 1993 1994 1995 19.4 18.4 18.8 17.8 17.9 16.9 16.8 15.8 15.6 14.6 15.0 13.9 *Includes data for 43 states and the District of Columbia (DC) in 1989,45 states and DC in 1990, and 46 states and DC in 1991-1995. Excludes data for California, Indiana, New York (but includes New York City), and South Dakota in 1994 and 1995; Oklahoma in 1989-1990; and Louisiana and Nebraska in 1989, which did not require the reporting of mother's tobacco use during pregnancy on the birth certificate. White and African American racial groups include persons of Hispanic and non-Hispanic origin. +Maternal tobacco use during pregnancy was not reported on the birth certificates in California and New York, which together accounted for 43-66 percent of the births in each Asian subgroup (except Hawaiian) during 1989-1991. `Includes data for 42 states and DC in 1989,44 states and DC in 1990,45 states and DC in 1991-1992, and 46 states and DC in 1993-1995. Excludes data for California, Indiana, New York (but includes New York City), and South Dakota in 1994 and 1995; Oklahoma in 1989-1990; and Louisiana and Nebraska in 1989, which did not require the reporting of either Hispanic origin of mother or tobacco use during pregnancy on the birth certificate. Persons of Hispanic origin may be of any race. Sources: National Center for Health Statistics 1996; Ventura et al. 1996, 1997. `The prevalence of cigarette smoking among Af- rican American adolescents has been substantially lower than the prevalence among white and Hispanic adolescents (Figures 2 and 3) (Bachman et al. 1991b; USDHHS 1994; CDC 1996; Johnston et al. 1996). Lo- cal, more limited surveys have also shown similar differences in cigarette smoking prevalence between African American and white youths (for example, Sheridan et al. 1993; Greenlund et al. 1996). In addition to the slight increases in the 1990s in smoking prevalence among African American high school seniors (Figures 2 and 3), CDC's Youth Risk Behavior Survey (YRBS) detected an increase in the prevalence of cigarette smoking from 1991 to 1995 Patterns of Tobacco Use 29 Figure 2. 35- 25- Trends in daily smoking* among African American and white high school seniors, by gender, United States, 1977-1996 0 ; I I I I I I I I I I I I I I I I I I I I 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 Year - African American males - African American females ---- White males - . - . . White females Note: To increase racial subgroup sample sizes and stabilize estimates, the percentages were calculated by averaging the data for the specified year and the previous year. *Daily smoking is defined as smoking one or more cigarettes per day during the previous 30 days. Source: Institute for Social Research, University of Michigan, unpublished data from the Monitoring the Future surveys, 1976-1996. among male African American high school students (CDC 1996). The prevalence of previous-month smoking among African American male high school students increased from 14.1 percent in 1991 to 27.8 percent in 1995. Among female African American high school students, prevalence was 11.3 percent in 1991 and 12.2 percent in 1995 (CDC 1996). Data from the MTF surveys indicate that the prevalence of daily smoking increased more rapidly from 1993 to 1996 for male than for female African American high school seniors (Figure 2) (Institute for Social Research, University of Michigan, unpublished data from the MTF surveys, 1976-19961. Yet even with this increase, the prevalence of smoking among African American high school seniors was still lower than that for members of other racial/ethnic groups during 1990- 1994 (Table 7). The trend of lower smoking prevalences among African American adolescents observed in recent years has continued as these individuals age and become young adults, according to the NHIS data. From 1978 through 1995, the prevalence of current smoking de- clined more among African Americans aged 20-24 years than among whites of the same ages, regardless of gen- der (Table 8) or level of formal education (Table 9) (NCHS, public use data tapes, 1978-1995). In addition, among persons 25-29 and 30-34 years of age, recent declines in smoking prevalence were greater for Afri- can Americans than for whites (Table 8) (Figure 4). In addition to the recent increases seen among African American high school seniors (Figures 2 and 31, the MTF surveys indicate that previous-month smoking prevalence (based on two-year rolling aver- ages) among eighth-grade African American students 30 Chnpfer 2 Figure 3. 35- 25- Tobncco Use Among U.S. RncinllEtknic Minority Groups Trends in daily smoking* among African American, Hispanic, and white high school seniors, United States, 1977-1996 "I I I 19f9 I I I I I I I I I 19k9 I I I 19$3 I 1945 I 1977 1981 1983 1985 1987 1991 Year - African Americans - Hispanics mm-0 Whites Note: To increase racial subgroup sample sizes and stabilize estimates, the percentages were calculated by averaging the data for the specified year and the previous year. *Daily smoking is defined as smoking one or more cigarettes per day during the previous 30 days. Sources: Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data, 1996. increased from 5.3 percent in 1992 to 9.6 percent in 1996; among ninth-grade African American students, the prevalence increased from 6.6 percent in 1992 to 12.2 percent in 1996 (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). These recent pat- terns among African American adolescents suggest that the progress seen among young adults (Table 8) may reverse itself in the future. Possible biases. The accuracy of the finding that African American youths have been smoking less than white youths has been called into question. For ex- ample, trends observed may have resulted from arti- factual phenomena such as differential dropout rates OT misclassification bias. Differrntirr2 dropout rates. Some investigators have hypothesized that the data may be biased for two rea- sons. First, the data from school-based surveys exclude youths who are school dropouts. Second, because African American youths have a higher dropout rate than do white youths, the smoking prevalence rates may be more biased for African American youths than for white youths. However, this bias should only be apparent in the school surveys. The proportion of young adults (aged 25-29 years) who have completed at least four years of high school increased from 74 percent in 1976 to 83 percent in 1993 for African Ameri- cans; for whites, this proportion was 86 percent in 1976 and 87 percent in 1993 (Kominski and Adams 1994). The increasing rate of completing at least four years of high school among African American young adults, relative to whites, is not consistent with the hypoth- esis that the trend in smoking prevalence observed in school surveys is related to the dropout rate. Further- more, in household surveys, the trends in smok- ing prevalence among African Americans have also Potterm of Tobacco Use 31 Table 7. Trends in the percentage of high school seniors who were previous-month smokers, by race/ ethnicity and gender, Monitoring the Future surveys, United States, 1976-1979,1980-1984, 1985-1989,1990-1994 1976-1979 1980-1984 1985-1989 1990-1994 Males African American 33.1 19.4 15.6 11.6 American Indian and Alaska Native 50.3 39.6 36.8 41.1 Asian American and Pacific Islander 20.7 21.5 16.8 20.6 Hispanic 30.3 23.8 23.3 28.5 White 35.0 27.5 29.8 33.4 Females African American 33.6 22.8 13.3 8.6 American Indian and Alaska Native 55.3 50.0 43.6 39.4 Asian American and Pacific Islander 24.4 16.0 14.3 13.8 Hispanic 31.4 25.1 20.6 19.2 White 39.1 34.2 34.0 33.1 Note: The Institute for Social Research usually reports the N (weighted), which is approximately equal to the sample size. Cases are weighted to account for differential probability of selection and then normalized to average 1 .O. For males, the ranges of the N (weighted) for each of the cells in this table are 2,9164,393 for African Americans, 342-587 for American Indians and Alaska Natives, 242-1,166 for Asian Americans and Pacific Islanders, 893-2,808 for Hispanics, and 24,931-31,954 for whites. For females, the ranges of the N (weighted) for each of the cells in this table are 3,982-5,716 for African Americans, 299-586 for American Indians and Alaska Natives, 22%1,143 for Asian Americans and Pacific Islanders, 940-2,723 for Hispanics, and 25,627-31,933 for whites. Sources: Bachman et al. 1991a; Institute for Social Research, University of Michigan, unpublished data. become lower than those for whites (Nelson et al. 1995). Finally, data from the 1989 TAPS have shown that Af- rican American youths-both active students and dropouts-are significantly less likely than white youths to have smoked recently. Among students 17 and 18 years of age who remained in school, African Americans (5.7 percent) were less likely than whites (19.3 percent) to have smoked in the previous week (CDC 1991b). Among youths who left school, 17.1 percent of African Americans and 46.1 percent of whites had smoked in the previous week. Similarly, 1991 NHSDA data show that among youths 16-18 years old, 7.2 percent of African American high school seniors and 27.7 percent of white high school seniors had smoked in the previous month, compared with 30.4 percent of African American dropouts and 72.2 percent of white dropouts (Kopstein and Roth 1993). Thus, dropout status does not account for the lower smoking prevalence among African American youths. Differetltinl misclassifimtion bins. Other research- ers have proposed that in recent years, African Ameri- can youths may have been more likely to misclassify their smoking status when questioned. No trend data are available on differences in misclassification of smoking status over time between African Americans and whites. However, data from the 1976-1992 MTF surveys have been used to compare the trends of high school seniors' reports of smoking by their friends-a measure for which they would have little reason to underreport (Johnston et al. 1993b; USDHHS 1994). Until 1993, the percentage of African American seniors who reported that most or all of their friends smoke declined substantially more than that of white seniors. Since 1993, an increase in this measure has been ob- served for African Americans, but not for whites (Bachman et al. 1980a, 1980b, 1981, 1984, 1985, 1987, 1991a, 1993a, 1993b, 1997; Johnston et al. 1980a, 1980b, 1982,1984,1986,1991,1992,1993a, 1995b, 1997). This observation may be limited by the fact that African American and white youths have friends from several ethnic groups. Bauman and Ennett (1994) recently assessed misclassification bias in a household survey of ado- lescents 12-14 years of age, using carbon monoxide and salivary cotinine (a nicotine metabolite) as bioIogica1 32 Chapter 2 fi7bm~o USC Among U.S. Racial/Ethnic Minority Groups Table 8. Percentage of African Americans and whites 20-34 years of age who reported being current cigarette smokers,* by age group and gender, National Health Interview Surveys, United States, 1978-1995 aggregate data 197&1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic 7c +cP 7r tc1 c/c KI % fCI 7% fCI % +CI Aged 20-24 years African Americans Total Men Women Whites Total Men Women Aged 25-29 years African Americans Total Men Women Whites Total Men Women Aged 30-34 years African Americans Total Men Women Whites Total Men Women 37.3 4.3 32.0 3.6 24.7 2.9 16.8 2.7 15.0 4.1 13.7 3.9 44.8 6.8 31.6 6.2 25.4 5.0 21.3 4.8 20.3 7.6 19.6 7.3 31.8 4.4 32.3 3.8 24.1 3.3 13.1 2.5 10.7 3.4 8.9 3.3 35.6 1.6 35.5 1.6 30.4 1.5 28.4 1.5 32.0 2.3 33.3 2.5 37.2 2.2 34.1 2.3 30.5 2.3 28.0 2.3 32.2 3.1 34.9 3.6 34.0 2.0 36.X 2.2 30.3 1.8 28.8 2.0 32.4 3.1 31.6 3.3 41.5 3.9 39.0 3.9 38.3 3.4 30.5 3.3 21.7 3.6 21.0 4.3 47.6 4.9 41.6 6.2 43.1 5.5 35.9 5.7 21.3 5.9 22.6 7.6 36.5 5.8 36.8 4.6 34.3 3.7 26.1 3.6 22.1 4.5 19.6 5.3 38.4 1.4 36.2 1.5 34.7 1.3 30.8 1.3 31.2 1.9 32.2 2.1 42.3 2.0 38.3 2.2 34.5 1.8 31.2 1.9 31.9 2.7 32.6 3.1 34.7 2.0 34.1 1.9 35.0 1.7 30.5 1.7 30.6 2.5 31.9 2.8 43.0 5.1 40.8 4.5 41.0 3.1 36.5 3.0 34.2 4.2 31.9 4.3 50.2 8.2 45.5 7.1 43.6 5.1 38.9 4.8 38.3 6.9 31.2 6.8 37.5 6.0 37.1 4.6 38.9 3.6 34.5 3.6 30.8 4.9 32.5 5.7 38.6 1.8 34.4 1.5 33.1 1.3 31.1 1.2 32.9 1.7 30.7 1.8 43.1 2.5 37.3 2.2 35.9 1.8 32.7 1.7 33.1 2.4 31.3 2.6 34.2 2.3 31.5 1.9 30.4 1.6 29.6 1.5 32.7 2.2 30.2 2.6 - - *For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $95oic confidence interval. Source: National Center for Health Statistics, public use data tapes, 1978-1995. markers for tobacco use. Among adolescents who re- white adolescents were three times more likely than ported that they did not smoke, African Americans African American adolescents to test positive for car- were more likely than whites to test positive for car- bon monoxide, suggesting that whites in this study bon monoxide and for cotinine. Overall, however, were substantially more likely to smoke, regardless of Przttrrm of Tobacco Use 33 Table 9. Percentage of African Americans and whites 20-24 years of age who reported being current cigarette smokers,* by education and gender, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic % +_c1t 7c +c1 % +c1 % +c1 % +c1 Yo K-1 212 years' education African Americans Total Men Women Whites Total Men Women 41.9 5.2 49.1 7.9 35.9 6.3 45.2 1.8 47.8 2.8 42.7 2.6 213 years' education African Americans Total Men Women Whites Total Men Women 26.4 6.4 32.0 11.3 23.5 6.7 21.6 2.0 22.0 2.5 21.2 2.5 38.6 4.5 30.4 3.7 22.8 3.9 18.5 5.4 16.7 5.4 38.2 7.7 29.6 6.3 28.9 6.9 21.9 9.4 22.2 10.1 38.9 4.9 31.0 4.5 17.8 3.5 15.2 5.1 12.5 5.0 48.3 2.3 44.2 2.1 40.5 2.4 46.9 3.2 45.4 4.2 47.8 3.5 46.2 3.2 40.5 3.4 47.5 4.8 47.1 5.8 48.7 2.9 42.3 2.8 40.5 3.1 46.4 4.5 43.6 5.6 17.3 4.4 12.4 3.7 7.2 2.9 9.0 5.3 9.3 5.6 15.6 7.9 13.3 7.0 9.2 5.3 16.6 12.4 15.9 10.6 18.5 6.6 11.9 4.0 5.5 3.0 4.6 4.0 3.1 3.0 18.2 1.8 15.4 1.5 16.0 1.5 19.0 2.6 23.6 2.8 15.8 2.4 14.0 2.0 14.5 2.4 17.6 3.5 24.6 4.2 20.5 2.6 16.7 2.1 17.3 2.1 20.3 3.5 22.7 3.8 - *For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. *95% confidence interval. Source: National Center for Health Statistics, public use data tapes, 1978-1995. differential misclassification. In a study of young reports of cigarette smoking with measured carbon adults 18-30 years old, Wagenknecht and colleagues monoxide from expired air. The investigators found (1992) also found differential misclassification, with that the sensitivity for self-reports was slightly lower African Americans (5.7 percent) more likely than for African Americans than for whites, but the magni- whites (2.8 percent) to misclassify themselves as non- tude of the effect was small. When self-reported smok- smokers. However, these researchers suggested that ing rates were adjusted for carbon monoxide values, their results may have been influenced by differential at every grade level African American students had exposure to environmental tobacco smoke and by dif- significantly lower smoking prevalences than whites. ferences in nicotine metabolism. Using a sample of Although the phenomenon of differential mis- seventh- through tenth-grade New York State public classification may need further investigation, no evi- school students, Wills and Cleary (1997) compared self- dence indicates that misclassification bias explains the Tobacco Use Among U.S. Racial/Ethnic Minorify Groups Figure 4. Trends in smoking* among African Americans and whites aged 20-34 years, United States, 1978-1995 African Americans 0 I III II `1 11 11 1 " 1 ""I""""" 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year Whites lo- 0 III'1 II I I ' l `1 " " ""J""""' 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year a 8 m a Aged 20-24 - Aged 25-29 - Aged 30-34 *For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. Source: National Health Interview Surveys, National Center for Health Statistics, public use data tapes, 1978-1995; see Table 8 for corresponding data. Patterns of Tobacco Use 35 substantial decline in smoking prevalence reported by African American youths. Possible behavioral, sociodemographic, and attitudinal explanations. Exploring possible interac- tions between the use of alcohol or other drugs and changes in cigarette smoking among African American and white adolescents may yield important scientific data. Understanding the trends of smoking behavior in the context of factors such as the age when youths start smoking, background and lifestyle factors, and attitudes about smoking may help program develop- ers design better smoking prevention and control in- terventions for these and other population subgroups. Differelztinl 115~ of dwr drugs. MTF data were ana- lyzed to explore possible interactions between the use of alcohol or other drugs and changes in cigarette smoking among African American and white adoles- cents (Table 10) (Figures 5 and 6) (Institute for Social Research, University of Michigan, public use data tapes, 1976-1994). Between 1976 and 1994, the per- centage of African American adolescents who were abstinent from (i.e., did not use in the previous month) both cigarettes and other substances (Table 10) was higher than for whites and tended to increase more rapidly for African Americans than for whites in ev- ery category of drug use. For example, 41.7 percent of African American high school seniors surveyed in 1976-1979 were abstinent from cigarettes and alcohol, compared with 64.1 percent in 1990-1994. Among white seniors, 22.4 percent were abstinent from both cigarettes and alcohol in 1976-1979, compared with 37.1 percent in 1990-1994. Concurrent use (i.e., use of both substances in the past month) was lower and tended to decrease more rapidly among African Ameri- can seniors than among white seniors between 1976 and 1994. In addition, trends in the use of cigarettes, alcohol, and other substances among high school se- niors indicate that among both smokers and nonsmok- ers, African Americans were generally less likely than whites to use substances other than tobacco (Table 10). Age qfsnrokillg illitinfim. African American smok- ers initiate smoking at slightly later ages than white smokers, according to the findings of two national studies (Escobedo et al. 1990; CDC 1991~). In addi- tion, data from the 1994-1995 (combined) NHSDAs indicate that among U.S. adults aged 30-39 years who had ever smoked daily, the average ages for first try- ing a cigarette and for becoming a daily smoker were about one year higher for African American males than for white males and about two years higher for African American females than for white females (Table 11) (USDHHS, Substance Abuse and Mental Health Services Administration, public use data tapes, 1994-1995). These differences in the age of smoking initia- tion are not large enough to suggest that the differ- ences in smoking prevalence currently observed among African American and white adolescents will disappear as these populations age (CDC 1991~). The data presented in Table 11 and by Escobedo and col- leagues (1990) indicate that although African Ameri- cans are more likely than whites to begin smoking in their early 2Os, virtually all smokers in both groups have begun by age 25. Furthermore, the prevalence of cigarette smoking has decreased more rapidly for African Americans than for whites among those persons aged 20-24 years, 25-29 years, and 30-34 years (Table 8), suggesting that a birth cohort effect has occurred. Backpourzd nnd lifestyle frzctnrs. Investigations of background and lifestyle factors have not identified characteristics that might account for the greater de- cline in smoking among African American youths. Wallace and Bachman (1991) analyzed the MTF data and found that the difference was not explained by factors such as parents' education, presence of two parents in the household, location of residence, college plans, academic performance, employment status, religiousness, or political views. To assess the incidence of cigarette smoking among African Ameri- can and white adolescents, Faulkner and colleagues (1996) analyzed longitudinal data from the 1989-1993 TAPS. The analvses were restricted to 3,531 African Americans and whites aged 11-17 years who reported in 1989 that they had never tried cigarettes. After controlling statistically for variables that were snciodemographic (sex, age, and parental education), environmental (household smoking and number of same-sex friends who smoke), personal (beliefs about the perceived benefits of smoking), and behavioral (in- tention to smoke, participation in organized physical activity, and academic performance), the study found that African Americans were significantly less likely than whites to have tried cigarette smoking four years later. Lowry and colleagues (1996) analyzed cross- sectional data on 6,321 adolescents (aged 12-l 7 years) from the YRBS supplement to the 1992 NHIS. African Americans were significantly less likely than whites to have smoked in the previous 30 days. This analysis controlled statistically for the educational level of the responsible adult, for family income, for the age and sex of the adolescent, and for whether the adolescent was in or out of school. Furthermore, the major declines in smoking reported for African American high school seniors have occurred regardless of parents' education; the 36 Clmpfcr 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 10. Percentage of African American and white high school seniors who reported recently using or not using cigarettes and other selected substances,* Monitoring the Future surveys, United States, 19761994 aggregate data Cigarette use among African Americans+ Characteristic 1976-1979 1980-1984 1985-1989 1990-1994 Yes No Yes No Yes No Yes No Alcohol use Yes No Marijuana use Yes No Cocaine use Yes No Any illicit drug use* Yes No 22.7 25.9 15.2 31.2 11.0 29.5 7.2 26.2 9.7 41.7 5.3 48.4 3.1 56.4 2.6 64.1 17.2 11.9 11.2 14.2 6.4 7.8 3.1 5.8 15.0 55.9 9.3 65.3 7.6 78.2 6.6 84.5 1.4 0.6 1.4 1.3 1.0 1.0 0.3 0.2 31.7 66.3 19.7 77.6 13.3 84.8 9.6 89.8 17.6 12.9 11.4 15.2 6.6 9.3 3.3 6.8 14.0 55.5 8.8 64.6 7.0 77.1 6.2 83.7 Cigarette use among whites5 Characteristic 1976-1979 Yes No 1980-1984 Yes No 1985-1989 Yes No 1990-1994 Yes No Alcohol use Yes No 33.7 40.5 28.2 46.0 28.6 40.9 27.5 29.7 3.3 22.4 2.7 23.1 3.6 26.8 5.7 37.1 Marijuana use Yes No 22.4 13.7 16.9 12.8 14.4 8.1 11.8 4.4 14.3 49.6 13.8 56.5 17.5 60.0 21.3 62.5 Cocaine use Yes No 2.6 1.1 3.5 2.0 3.4 1.4 1.2 0.2 34.3 62.0 27.3 67.2 28.5 66.6 31.9 66.7 Any illicit drug uset Yes No 23.3 14.8 18.9 15.5 16.1 10.0 13.3 5.9 13.3 48.6 11.7 53.9 15.7 58.3 19.6 61.2 *Refers to use of these substances in the last 30 days. `Entries are percentages of the entire African American high school senior population. $Any illicit drug use includes any use of marijuana, hallucinogens, cocaine, or heroin or any use of other opiates, stimulants, barbiturates, methaqualone, or tranquilizers not under a physician's orders. Methaqua- lone is excluded from the definition of illicit drugs for the 1990-1994 survey data. gEntries ar e p ercentages of the entire white high school senior population. Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data tapes, 1976-1994. Patterns of Tobacco Use 37 Surgeon General's Reporf Figure 5. Use of cigarettes and alcohol* among African American and white high school seniors, United States, 1976-1979 and 1990-1994 1976-1979 African Americans 1 1 but no alcohol Whites Neither *In the previous month. Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data tapes, 1976-1994; see Table 10 for corresponding data. respondent's personal income; school performance; the importance of religion to the respondent; geographic region of residence; and, except for those who were raised on a farm, the locale in which the respondent grew up (Table 12) (Institute for Social Research, Uni- versity of Michigan, public use data tapes, 1976-1994). Attitudes about smoking. One possible explana- tion is that the attractiveness (or functional zdue) of cigarette smoking has decreased more rapidly among African American high school seniors than among white seniors. For example, African American seniors have, over time, become increasingly more likely than white seniors to acknowledge the health risks of ciga- rette smoking, to claim that smoking is a dirty habit, and to claim that they prefer to date nonsmokers. From 1976 through 1989, African Americans were more likely than whites to disagree with the statement, "I person- ally don't mind being around people who are smok- ing" (USDHHS 1994). African American youths also have been less likely than white youths to believe that cigarette smok- ing helps control weight. In anonymous surveys of 659 students (with an average age of 16 years) from two racially integrated high schools in the area 38 Chapter 2 Tobacco Use Among U.S. RaciallEfhnic Minority Groups Figure 6. Use of cigarettes and illicit drugs" among African American and white high school seniors, United States, 1976-1979 and 1990-1994 ) 1 no illicit drugs No cigarettes but illicit drugs Neither Whites *In the previous month. Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data tapes, 1976-1994; see Table 10 for corresponding data. of Memphis, Tennessee, 46 percent of white females, 30 percent of white males, 10 percent of African Ameri- can females, and 14 percent of African American males endorsed the statement, "Smoking cigarettes can help you control your weight/appetite" (Camp et al. 1993). When respondents who smoked at least once a week were asked whether they had smoked to control their weight, 61 percent of the white girls and 16 percent of the white boys said that they had smoked to control their weight, whereas none of the African American smokers reported that they smoked to control their weight. Further research is needed to delineate the role of weight control concerns in patterns of cigarette smoking initiation among adolescents of ethnic groups. One recent study suggests that African American ado- lescent females prefer a significantly heavier ideal body size than white adolescent females (Parnell et al. 1996), a finding consistent with the notion that the potential weight-controlling effects of cigarettes have less func- tional utility among young African American females than among white females. A previous Surgeon General's report indica- ted that parental concern about whether an adoles- cent smoked appeared to decrease the risk of that Patterns of Tobacco Use 39 Surgeon Gerzeml `s Report Table 11. Cumulative percentages of recalled age at which a respondent first tried a cigarette and began smoking daily, among African American, Hispanic, and white men and women aged 30-39, National Household Surveys on Drug Abuse, United States, 1994-1995 All men* Age (years) First tried a cigarette Began smoking daily African African American Hispanic White American Hispanic White <12 7.0 9.2 14.9 1.4 1.4 1.3 <14 17.1 20.6 32.2 3.7 4.6 4.6 <16 34.8 39.0 51.0 10.9 11.2 11.8 48 55.1 54.7 68.7 20.3 19.6 26.4 <19 59.9 62.7 74.0 25.5 26.3 34.3 <20 64.6 65.5 76.1 28.6 28.4 38.5 <25 71.5 72.9 80.9 40.5 37.2 47.4 <30 74.3 76.4 81.7 44.6 42.5 48.8 539 75.1 76.7 82.5 45.1 43.4 49.9 Mean age NA NA NA NA NA NA All women+ Age (years) <12 <14 <16 418 <19 <20 <25 <30 139 Mean age First tried a cigarette Began smoking daily African African American Hispanic White American Hispanic White 4.6 3.5 7.8 0.6 0.2 0.8 13.3 11.3 27.7 2.5 2.0 5.3 25.7 22.5 49.4 5.9 5.6 15.8 43.9 33.9 67.5 15.9 9.5 30.0 52.3 40.7 73.2 21.7 14.3 38.6 55.8 43.0 75.7 24.0 15.5 41.6 66.1 51.4 80.3 33.7 21.8 49.2 68.3 55.8 81.4 37.0 25.7 51.0 69.3 57.4 82.0 38.1 26.7 51.4 NA NA NA NA NA NA *N = 3,536 +N = 5,143 NA = data not available. adolescent becoming a cigarette smoker (USDHHS 1994). In a study conducted in Los Angeles and San Diego in 1986, African American parents placed a higher value than white parents on becoming involved in preventing their children from beginning to smoke (Flay et al. 1988; Koepke et al. 1990). Data from two surveys conducted in eight U.S. communities in 1988 and 1989 indicate that African American adults were more likely than white adults to perceive cigarette smoking as a very serious health problem in their com- munity, to favor eliminating vending machines from places where teenagers gather, and to prohibit smok- ing in their car (Royce et al. 1993). More recent findings from focus groups con- ducted at several U.S. sites suggest that African Ameri- can parents may be more likely than white parents to express clear antismoking messages (McIntosh 1995; Mermelstein et al. 1996). Findings from these focus 40 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Men who had ever smoked dailv First tried a cigarette Began smoking daily African African American Hispanic White American Hispanic White 8.9 22.7 45.7 73.7 81.1 87.0 96.1 99.9 100.0 15.9 13.6 29.7 55.4 74.1 83.4 86.9 97.0 99.6 100.0 15.3 15.7 3.0 3.2 2.7 36.7 8.3 10.6 9.2 61.0 24.2 25.7 23.7 83.9 45.0 45.1 52.9 90.5 56.4 60.7 68.8 93.0 63.5 65.4 77.1 98.4 89.7 85.7 95.1 98.9 98.9 97.9 97.7 100.0 100.0 100.0 100.0 14.6 18.4 18.6 17.6 Women who had ever smoked daily First tried a cigarette Began smoking daily African African American Hispanic White American Hispanic White 5.9 6.9 8.9 1.6 0.7 1.6 20.1 25.4 37.8 6.7 7.6 10.3 38.6 48.7 66.1 15.5 21.1 30.7 66.8 68.6 85.9 41.8 35.4 58.3 77.2 78.2 92.0 57.0 53.4 75.0 81.4 80.8 94.4 62.9 58.0 80.8 96.0 94.5 99.2 88.4 81.8 95.6 99.6 99.2 99.9 97.2 96.4 99.2 100.0 100.0 100.0 100.0 100.0 100.0 16.6 16.2 14.6 18.9 19.5 17.1 Source: Substance Abuse and Mental Health Services Administration, public use data tapes, 1994-1995. groups also suggest that smoking by African Ameri- can adolescents may be a sign of disrespect toward parents (USDHHS 1994). Additionally, African Ameri- can adolescent females appear to perceive that absti- nence from smoking enhances their image, whereas white girls are more likely to perceive that smoking empowers them (perhaps because of themes expressed in cigarette advertising) (Mermelstein et al. 1996). The responses of African American community leaders, including that of former USDHHS Secretary Louis Sullivan, against cigarette marketing campaigns that appear to target African Americans may have influ- enced young people's attitudes and behaviors about smoking (McIntosh 1995). Further research is needed to better under- stand the large decreases in smoking prevalence that occurred among African American youth in the 1970s and 1980s. Research is also needed to better Patterns of Tobacco USC 42 Surgrun General's Report Table 12. Percentage of African American and white high school seniors who reported previous-month and heavy* smoking, by selected variables, Monitoring the Future surveys, United States, 1976-1994 Previous-month smoking (%) Characteristic 1976-1979 1980-1984 1985-1989 1990-1994 African African African African Americans Whites Americans Whites Americans Whites Americans Whites Parental education Less than high school High school Some college College Some postgraduate study Personal income+ Low Medium High Very high School performance Far above average Slightly above average Average Below average Importance of religion Very important Important Not/somewhat important Region Northeast North Central South West 34.0 42.0 23.2 36.8 13.9 37.6 11.8 37.6 35.3 39.5 21.2 34.1 14.1 34.8 10.7 34.8 30.9 35.0 20.7 29.2 16.0 31.3 9.4 32.5 29.4 32.4 18.3 26.7 13.3 29.1 9.3 32.4 30.1 31.2 21.9 23.7 14.7 28.3 9.8 31.7 NA NA 16.4 24.5 12.6 24.6 7.5 24.6 NA NA 19.4 30.5 14.9 28.8 9.4 29.7 NA NA 22.8 33.3 14.1 34.5 9.8 35.5 NA NA 23.4 37.8 16.5 39.8 12.4 41.3 25.9 25.8 16.2 21.0 11.4 23.0 8.0 24.6 31.2 35.8 20.2 29.6 12.7 30.7 8.4 32.2 34.4 45.3 22.5 38.5 15.3 38.9 10.6 39.4 40.0 52.4 28.0 44.1 20.5 46.7 17.6 48.3 29.3 25.0 19.1 21.9 11.4 21.9 8.2 22.1 34.1 38.9 23.4 32.4 16.7 32.0 11.5 33.7 40.0 43.0 23.5 35.2 18.3 36.8 12.4 38.5 37.1 40.4 25.7 33.5 18.1 34.9 10.9 34.9 34.8 38.9 20.3 32.8 16.0 34.6 10.1 35.5 32.6 37.7 20.6 31.7 12.7 31.1 10.1 33.6 29.1 25.8 20.2 21.3 17.8 26.0 8.0 26.6 Locale in which respondent grew up Farm 33.6 Country 35.5 Small city 28.5 Medium-sized city 31.5 Suburb of medium- 34.5 sized city Large or very large city 36.2 Suburb of large or 34.1 very large city 37.9 24.9 31.6 26.7 33.0 22.3 31.9 38.3 23.3 30.7 14.6 33.1 12.2 32.2 37.4 20.0 30.1 14.1 31.1 12.1 32.6 37.4 20.1 31.2 14.5 32.3 8.7 34.7 36.9 18.5 32.0 16.5 32.0 6.8 34.7 38.5 22.3 32.0 13.9 33.4 8.5 33.6 32.7 20.0 29.1 14.0 30.2 9.0 33.8 *Heavy cigarette smoking is 10 or more cigarettes smoked per day reported at time of survey. `Personal income is the sum of income from employment, allowance, and other sources. Trend data are available for 1982-1994 only. NA = data not available. Tobacco Use Among U.S. Racial/Ethnic Minority Groups Heavy cigarette smoking (%I 1976-1979 1980-1984 1985-1989 1990-1994 African African African African Americans Whites Americans Whites Americans Whites Americans Whites 9.3 24.0 6.2 21.5 3.0 21.3 2.7 19.1 10.8 21.6 4.6 17.4 2.4 15.7 1.6 15.9 9.1 17.4 4.8 13.1 3.3 12.3 1.4 12.6 7.2 14.9 3.5 10.3 2.4 9.5 1.6 11.6 9.1 14.8 5.3 9.0 4.1 8.3 1.2 9.8 NA NA 3.1 10.1 2.2 8.7 1.1 8.0 NA NA 3.4 12.5 3.0 9.2 1.7 9.1 NA NA 6.1 16.3 2.4 14.2 1.2 13.5 NA NA 6.9 20.7 3.3 19.8 2.3 20.1 7.6 10.6 3.7 8.1 3.0 7.1 1.5 7.1 8.4 17.7 4.1 12.8 2.0 11.2 1.2 11.3 10.2 25.9 5.2 20.2 2.7 17.5 1.5 17.3 11.7 33.5 7.2 26.1 5.1 25.4 4.4 26.0 8.5 10.4 4.0 8.7 2.1 7.3 1.2 7.5 9.4 19.1 5.7 14.5 3.1 12.0 1.9 11.9 12.8 25.0 6.0 18.6 3.9 16.3 2.4 16.5 12.2 23.2 6.3 17.4 4.7 16.6 2.1 14.4 11.1 19.3 5.3 16.0 3.0 13.8 1.9 13.9 9.2 19.5 4.7 14.8 2.1 12.4 1.6 13.8 7.4 12.5 4.2 7.9 3.3 8.4 1.1 8.8 9.9 16.4 5.4 12.3 8.1 12.2 5.1 12.2 10.0 20.2 5.1 14.9 2.9 13.7 1.5 13.1 8.7 19.0 4.5 13.7 2.7 12.2 2.8 12.5 9.4 20.2 4.9 15.4 2.2 13.1 1.3 13.4 9.0 20.6 4.0 15.2 2.8 12.6 1.1 12.7 10.8 22.9 5.4 16.5 2.3 14.9 1.2 14.0 9.3 16.4 3.8 14.0 3.7 11.0 1.2 12.2 Source: Institute for Social Research, University of Michigan, public use data tapes, 1976-1994. Patterm of Tobacco Use 43 Surgeon Gerzeral's Reyort understand the reasons for the increase in prevalence that occurred in the early 1990s (Figures 2 and 3) (CDC 1996). Other risk behaviors. The Surgeon General's re- port Preventing Tobacco Use Among Young Peo,vle (USDHHS 1994) has concluded that "Tobacco use in adolescence is associated with a range of health- compromising behaviors, including being involved in fights, carrying weapons, engaging in higher-risk sexual behavior, and using alcohol and other drugs" (p. 9). Escobedo and colleagues (1997) have observed these associations for African American adolescent males and females. Using data from the YRBS supple- ment of the 1992 NHIS, the researchers found that af- ter their analysis controlled statistically for age, ethnicity, sex, parental educational level, region of the country, and other risk behaviors, marijuana use, binge drinking, and physical fighting were significantly as- sociated with cigarette smoking among African Ameri- can adolescent males and females. Focus group data suggest that African American youths are more likely than white youths to pair cigarette smoking with mari- juana use as a way to maintain and enhance the drug effects of each (Mermelstein et al. 1996). Smokeless Tobacco Use The prevalence of smokeless tobacco use among African American adolescents has remained fairly constant in recent years. According to the MTF sur- veys, previous-month smokeless tobacco use (based on two-year rolling averages) was reported by 1.8 percent of eighth-grade African American students in 1992 and 2.2 percent in 1996; among tenth-grade students, the prevalence was 2.9 percent in 1992 and 2.5 percent in 1996; and among high school seniors, the prevalence was 2.1 percent in 1987 and 2.7 per- cent in 1996 (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). Similarly, the YRBS data indicate that 2.1 percent of African American high school students were current smokeless tobacco us- ers in 1991 (USDHHS 1994), and 2.2 percent were so in 1995 (CDC 1996). African American adolescent males are substan- tially less likely than white adolescent males to use smokeless tobacco. Among male high school students participating in the 1995 YRBS, for example, 3.5 percent of African Americans and 25.1 percent of whites reported that they had used smokeless tobacco in the previous month (CDC 1996). Among females, 1.1 percent of Afri- can Americans and 2.5 percent of whites reported they had used smokeless tobacco in the previous month. American Indians and Alaska Natives Data assessing long-term trends in tobacco use among American Indians and Alaska Natives have been unavailable, for the most part, because national surveys and databases have only recently begun to identify persons of American Indian or Alaska Native ancestry. Studies using data from regional surveys or data on specific American Indian tribes have, however, provided useful information about tobacco use among members of these groups. Because the geographic location of American Indian and Alaska Native people reflects unique cultural and historical experiences, researchers should consider these differences when interpreting region-specific data about smoking preva- lence. Data from regional studies also may provide information that is useful in developing culturally appropriate tobacco control efforts. National surveys provide limited capability to assess the level of tobacco use and the effectiveness of tobacco control efforts among American Indians and Alaska Natives. The NHIS, for example, did not be- gin identifying American Indian and Alaska Native respondents until 1978. Because American Indians and Alaska Natives make up a small proportion of the U.S. population, data must be aggregated from several years to provide meaningful estimates. Also noteworthy is that the data on tobacco use among American Indians and Alaska Natives include some ceremonial use (e.g., in pipes) in addition to daily addictive behavior (see Chapter 4). Anecdotal infor- mation also suggests that standard definitions and classifications of smoking may not accurately reflect smoking habits among American Indians, some of whom may smoke no more than one or two cigarettes per day (Nathaniel Cobb, personal communication, 1994; Roscoe et al. 1995). Yet American Indians who smoke a few cigarettes every day are classified in the <15-cigarettes-per-day category, which may imply a higher overall consumption than actually exists. Such differences in amounts of daily smoking may have important implications for the design of culturally ap- propriate smoking cessation interventions targeting American Indians. Prevalence of Cigarette Smoking Among American Indian and Alaska Native men and women, rates of smoking have been substantially higher than smoking rates in any other U.S. subgroup. In the 1987 Survey of American Indians and Alaska Natives (SAIAN) of the National Medical Expenditure Survey, 32.8 percent of respondents reported being 44 Chapter 2 current smokers (Lefkowitz and Underwood 1991). This survey-the only nationally representative sample designed to assess the health practices of people of American Indian and Alaska Native ances- try-targets people who live on or near reservations and who are eligible for services provided by the In- dian Health Service (IHS). The NHIS rate of smoking among American Indians and Alaska Natives for 1987 and 1988 (39.2 percent) was greater than the SAIAN estimate, perhaps because of different modes of administration and sampling (tribally enrolled benefi- ciaries in the SAIAN and the general population of American Indians and Alaska Natives in the NHIS). In a more recent survey $50,000 25.5 12.0 9.5 3.9 38.7 11.1 10.3 2.1 32.1 12.6 14.7 2.7 29.9 7.2 10.1 2.0 20.0 22.4 55.0 t 36.9 7.8 10.1 1.9 t f- t t 29.5 10.1 8.3 3.3 Acculturation <25Y~ of lifetime in United States 29.8 9.8 13.0 3.7 NA NA NA NA 2 25% of lifetime in United States 26.2 13.3 22.3 15.9 NA NA NA NA Fluent in English5 % t % t 29.7 7.6 10.7 2.6 Not fluent in English5 31.8 8.8 13.3 3.1 36.6 4.6 10.0 1.1 Immigration before 1981 NA NA NA NA 32.2 5.3 10.5 1.5 Immigration in 1981 or later NA NA NA NA 37.7 6.0 9.8 1.5 *Current cigarette smokers are men who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. Because the number of current smokers who were women was too small for analysis, data for age, education, annual income, and acculturation are provided for men only. `95% confidence interval. SNumbers too small for analysis. %elf-report of ability to speak English well or fluently. NA = data not available. Source: Centers for Disease Control 1992b. higher among men (42.5 percent) than among women (5.7 percent) (Table 27). Southeast Asian men were 1.6 times as likely to smoke as were other men in Wash- ington, whereas Southeast Asian women were one- fourth as likely to smoke as were other women in the state (CDC 1992~). In a recent review of Hawaii's health surveillance data for 1975-1980, Blaisdell (1993) found that the smoking prevalence was higher among Native Hawai- ians than among persons in other racial/ethnic groups; 61.1 percent of pure Native Hawaiian men and 56.3 percent of part Native Hawaiian men were current smokers (Table 27). According to the 1985 BRFSS data, 42 percent of Native Hawaiian men and 34 percent of Native Hawaiian women were current smokers. Data from the 1989 BRFSS in Hawaii indicate that the prevalence was 28.2 percent among Native Hawaiians (Table 271, which was higher than that among Filipi- nos, Japanese, and whites (Blaisdell 1993). 62 Cl7aptcr 2 7Xvcco Use Amor7g U.S. Racial/Ethnic Mirzorify Groups Table 26. Percentage of adult Asian Americans and Pacific Islanders who reported being current smokers,* overall and by gender, age, and education, Screener Survey, California, 1990 and 1991 aggregate data+ Characteristic Chinese (% 1 Filipinos (%) Japanese (% 1 Koreans (% 1 All Asians (%`I Total Age (years) 18-24 25-44 45-64 265 Education Less than high school High school Some college College Men Total Age (years) 18-24 25-44 45-64 265 Education Less than high school High school Some college College Women Total Age (years) 18-24 2544 45-64 265 Education Less than high school High school Some college College 11.7 15.9 17.4 23.5 15.9 9.7 12.2 19.7 26.9 14.6 12.4 21.0 20.3 26.1 18.1 11.4 14.4 16.8 16.2 15.3 11.4 6.6 9.9 23.2 8.9 17.6 19.2 23.4 38.1 21.4 16.7 20.3 21.5 21.3 19.4 11.2 15.2 16.2 25.3 15.2 6.6 11.2 12.3 19.1 10.5 19.1 23.0 20.1 35.8 23.5 13.0 19.1 17.2 34.3 19.0 20.9 29.2 24.7 44.1 27.1 19.9 25.8 22.1 22.6 24.0 19.8 10.6 11.1 60.6 14.0 35.4 32.1 18.4 70.6 36.9 26.3 27.6 28.7 35.3 28.3 18.1 21.5 19.2 32.4 20.9 9.8 18.9 16.5 31.0 15.6 4.7 8.9 14.9 13.6 8.9 5.8 4.0 22.9 19.9 9.5 5.5 14.6 16.3 13.9 10.4 2.5 5.1 13.4 9.9 7.4 2.6 3.4 8.3 NA 3.8 1.7 11.6 28.8 20.9 9.4 9.8 12.7 17.5 14.4 12.6 4.8 8.7 13.4 19.4 9.5 3.2 4.9 7.0 5.2 4.9 *Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. Only English-speaking persons were interviewed. `The variables needed to compute confidence intervals were not available. NA = data not available. Source: Burns and Pierce 1992. httfW7S (If i-OhCClJ USC 63 Table 27. Summary of selected findings on the percentage of Asian American and Pacific Islander adults who smoke, overall and by gender, 1975-1995 Study Population Sources Location/Year Characteristics Total Klatsky and Armstrong 1991 California, 1978-1985 CDC 1992~ Blaisdell 1993 McPhee et al. 1993 McPhee et al. Santa Clara County, 1995 California, 1990 Wewers et al. 1995 Franklin County, Ohio, 1992 CDC 1997a Jenkins et al. 1997b Jenkins et al. Houston, Texas 1997b 1990,1992 Washington State, 1989 Hawaii, 1975-1980 Hawaii, 1975-1980 Hawaii, 1985 Hawaii, 1989 San Francisco and Alameda Counties, California, 1987,1989 Alameda County, California, 1994-1995 San Francisco and Alameda Counties, California, 1990 Adults - Current smokers Chinese Filipino ~EZeIEians NA 16.2 7.3 NA 32.9 11.4 NA 22.7 18.6 NA 30.9 12.6 Persons who smoke 21 pack/day Chinese NA Filipino NA Japanese NA Other Asians NA Southeast Asians, by age (years) 18-29 17.6 30-39 26.3 40-59 26.6 '60 28.9 Total 23.1 Pure Native Hawaiians NA Part Native Hawaiians NA Native Hawaiians NA Native Hawaiians 28.2 Vietnamese adults 1987 NA 1989 NA 4.1 1.3 7.1 1.7 8.2 4.6 6.7 1.6 29.5 3.0 53.7 5.6 54.5 8.3 55.9 7.1 42.5 5.7 61.1 NA 56.3 NA 42 34 NA NA 56 9 45 2 Vietnamese men Cambodians Laotians Vietnamese Korean adults NA 36 20.6* 34.0 (30.3)+ (38.8) 27.8 45.6 (32.9) (48.2) 27.6 43.3 (29.0) (43.3) 21 39 NA 6.6 (21.5) 4.2 (10.8) & 6 Vietnamese men Vietnamese men 1990 1992 NA NA NA 36.1 NA 39.6 NA 40.9 NA Men Women *Figures not in parentheses are from self-report. `Figures in arentheses represent cotinine-adjusted prevalences. Persons whose saliva cotinine levels were > 14 n /m P were considered to be smokers. NA = &ta not available. Data collected from several surveys (conducted in 1987,1989,1990, and 19921 of Vietnamese men and women living in California, Texas, and Ohio showed that the prevalence of cigarette smoking was substan- tially higher among Vietnamese men than among all U.S. men (Jenkins et al. 1990; McPhee et al. 1993; McPhee et al. 1995; Wewers et al. 1995; Jenkins et al. 1997b). Vietnamese women, however, were signifi- cantly less likely to smoke than were Vietnamese men or other U.S. women (Table 27). Several surveys have been conducted in San Francisco and Alameda Counties, California. In the 1987 survey, which included data from 215 randomly sampled Vietnamese, 56 percent of Vietnamese men reported smoking cigarettes, compared with 9 percent of Vietnamese women (Jenkins et al. 1990). Vietnam- ese men had twice the smoking prevalence of men in the United States. On average, however, the number of cigarettes smoked per day was smaller among Viet- namese men (13.4) than among men in the general U.S. population (23.0). In the 198Y survey of 151 Vietnam- ese adults, 45 percent of Vietnamese men and 2 per- cent of Vietnamese women reported being cigarette smokers (Table 27) (McPhee et al. 1993). The precision of the estimates of smoking prevalence from the 1987 and 1989 surveys is limited by small sample sizes. In the 1990 survey of 1,133 Vietnamese men, which served as the baseline measure in an evaluation of a community-based smoking cessation intervention, 36.1 percent were current smokers. These men smoked an average of 11.1 cigarettes per day (Jenkins et al. 1997b). Another survey of Vietnamese men (n = 1,322), which also served as the 1990 baseline measure in an evaluation of a similar smoking cessation intervention, was conducted in Santa Clara County, California. In this population, 37.9 percent were current smokers; the smokers consumed an average of 9.9 cigarettes per day (McPhee et al. 1995). The comparison data for the two evaluation studies conducted by McPhee and colleagues were obtained from surveys of Vietnamese men living in Houston, Texas (McPhee et al. 1995; Jenkins et al. 1997b). In the 1990 survey (n = 1,581), 39.6 percent of the men were current smokers; in the 1992 survey (n = 1,209), 40.9 percent were current smokers. The mean number of cigarettes smoked daily was significantly lower in 1992 (11.9) than in 1990 (13.21. The 1990 and 1992 survey data showed an asso- ciation between cigarette smoking prevalence and acculturation. In multivariate analyses that included statistical control for education, employment, and pov- erty status, the prevalence of cigarette smoking was elevated among persons with limited English-lan- guage proficiency and persons who had more recently immigrated to the United States (McPhee et al. 1995; Jenkins et al. 1997b). Data collected from 1,403 South- east Asian immigrant men and women through a household interview indicate that self-reported ciga- rette smoking prevalence is underreported, especially among women (Wewers et al. 1995). Cigarette smok- ing status among Cambodian, Laotian, and Vietnam- ese adults in Franklin County, Ohio, was verified by saliva cotinine assay; a cutoff of 14 ng/mL was used to indicate active smoking. Self-reported smoking prevalence was 40.9 percent for men and 5.6 percent for women. However, results from biochemical verification indicated that 43.7 percent of men and 14.8 percent of women were current smokers. Misclassification as a result of exposure to environmen- tal tobacco smoke is unlikely, given how high the cotinine levels were among self-reported former and never smokers (range 17-331 ng/mL). As other stud- ies have found, current smoking was substantially higher among men than women for all racial/ethnic groups in the study (Table 27) and was higher among respondents with less education. From August 1994 to February 1995, a telephone survey of 676 Korean Americans (aged 18 years and older) was conducted in Alameda County, California (Table 27) (CDC 1997a) , Overall, 39 percent reported that they had smoked at least 100 cigarettes in their lifetimes. Men (70 percent) were more likely than women (13 percent) to have smoked at least 100 life- time cigarettes. Current smoking prevalence was 39 percent for Korean American men in Alameda County-an estimate that was substantially higher than the 19 percent prevalence estimate (from the 1995 California Behavioral Risk Factor Survey) for all men in the state. Conversely, only 6 percent of Korean American women from Alameda County reported current smoking-less than the statewide estimate for women of 14 percent. Cigarette Smoking in Asian Countries Because so many Asian Americans have recently immigrated to the United States, understanding how smoking practices in Asian countries may affect smok- ing practices among Asian Americans here is impor- tant. Currently, however, data are scarce on smoking trends in the countries from which Asian Americans and Pacific Islanders have emigrated. The informa- tion that is available suggests that the prevalence of smoking among men in Asia is much higher than among Asian American men. Various studies from Asian countries indicate a very high cigarette smoking prevalence among men and a relatively low prevalence among women (Weng et al. 1987; Li et al. 1988; Hawks 1989; Koong et al. 1990; Gong et al. 1995; Jenkins et al. 1997a; World Health Organization, unpublished data). In many of these countries, the estimated prevalence of smoking among men exceeds 50 percent. However, the prevalence of smoking among women is generally below 20 percent. Some of these studies indicate that the prevalence of smoking among women increases with age (Weng et al. 1987; Koong et al. 1990). In Pacific Island nations, the prevalence of smoking among men is also very high, with estimates generally exceeding 50 percent, similar to those in Asian countries. Women in the Pa- cific Island nations are less likely to smoke than men, but they are more likely to smoke than women in Asian countries, with prevalence estimates generally exceed- ing 20 percent (World Health Organization, unpub- lished data). Studies also show that smoking prevalences are much higher among Chinese male adolescents than among female adolescents. In a 1988 survey of 8,437 junior high school students and 3,823 senior high school students in Beijing, the self-reported prevalence of ever smoking was 34.4 percent among male junior high school students and 3.9 percent among their fe- male counterparts (Zhu et al. 1992). Among senior high school students, the prevalence of ever smoking was 46.0 percent among males and 5.5 percent among fe- males (Wang et al. 1994). Hispanics No data are available on long-term trends in the prevalence of cigarette smoking among Hispanics in the United States. Before 1978, major U.S. government databases, surveys, and publications limited their clas- sifications of race and ethnicity to "white" and "black," and no information was available about persons of Hispanic ancestry. When questions about Hispanic ancestry were added to the NHIS in 1978, direct esti- mates of smoking prevalence among Hispanics were possible for the first time. Because Hispanics made up a small proportion of the U.S. population at the time of the initial surveys, survey data must be aggre- gated from several years to provide meaningful estimates. As with previous sections, data in this sec- tion are from the NHISs, which included Hispanic data aggregated as follows: (11 1978, 1979, and 1980; (2) 1983 and 1985; (3) 1987 and 1988; (4) 1990 and 1991; (5) 1992 and 1993; and (6) 1994 and 1995. Not until the HHANES was administered from 1982 through 1984 was a large enough sample of Hispanics available to assess long-term reconstructed trends in smoking through retrospective analysis of smoking prevalence among successive birth cohorts of Hispanics (Escobedo and Remington 1989; Escobedo et al. 1989a). Prevalence of Cigarette Smoking NHIS data indicate that the prevalence of smok- ing declined among Hispanics from 1978 through 1995 (Table 28) (NCHS, public use data tapes, 1978- 1995). Birth cohort data from the HHANES also reflect recent declines in the prevalence of smoking among the three subgroups of Hispanics surveyed: Cuban Americans, Mexican Americans, and Puerto Ricans (Escobedo and Remington 1989). Between 1978 and 1995, the prevalence of smok- ing among Hispanic men and women decreased, al- though smoking prevalence was consistently greater among men than among women, according to the NHIS data (Table 28). Previous analysis of the HHANES birth cohort data showed that after 1970, the prevalence of smoking declined sharply among Mexican American men and less dramatically among Puerto Rican and Cuban American men (Escobedo et al. 1989a). In contrast, the prevalence of smoking changed little or increased among most age groups of Cuban American, Mexican American, and Puerto Rican women. For men participating in the 198221984 HHANES, the smoking prevalence ranged from 41.3 percent (among Puerto Ricans) to 43.6 percent (among Mexican Americans) (Escobedo and Remington 1989), compared with 31.6 percent of Hispanic men in the 1983-1985 NHIS. For women participating in HHANES, the smoking prevalence ranged from 23.1 percent (among Cuban Americans) to 32.6 percent (among Puerto Ricans) (Escobedo and Remington 19891, compared with 20.4 percent of Hispanic women in the 1983-1985 NHIS. Several factors help explain why the HHANES estimates for men are at least 10 percentage points higher than the NHIS estimates for men for a compa- rable period and why the HHANES estimates for women also show a higher prevalence than the NHIS estimates for women. Most importantly, the HHANES was more likely to select an immigrant population than the NHIS because HHANES offered respondents the choice of English or Spanish questionnaires. In addi- tion, the HHANES sampled Cuban Americans from Dade County, Florida; Mexican Americans from Ari- zona, California, Colorado, New Mexico, and Texas; and Puerto Ricans from New York, New Jersey, and Con- necticut. On the other hand, the NHIS, administered only in English, is a national sample of the general popu- lation, which includes a wider range of racial/ethnic Table 28. Percentage of adult Hispanics who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 199%1993+ 1994-1995+ Characteristic % +c1s 9% +c1 % fC1 Yc KI % +c1 Yo fC1 Total 30.1 1.9 25.6 1.6 23.6 1.4 21.5 1.4 20.5 1.6 18.9 0.7 Gender Men Women Age (years) 18-34 35-54 255 Educations Less than high school High school Some college College 37.6 3.0 31.6 2.9 29.6 2.3 27.8 2.3 25.9 2.6 22.9 2.4 23.3 2.0 20.4 1.9 18.4 1.5 15.9 1.6 15.5 1.9 15.1 1.7 32.3 2.7 25.8 2.2 23.6 1.9 21.1 1.9 21.0 2.4 19.8 2.2 30.4 2.7 28.4 3.2 26.3 2.3 25.7 2.2 23.4 2.7 19.8 2.5 22.9 2.8 19.9 4.2 18.2 2.8 13.7 2.6 12.4 3.7 14.3 3.5 33.4 3.5 28.0 2.6 26.1 2.3 22.9 2.4 21.6 2.7 20.2 2.4 25.2 3.9 28.1 3.8 27.8 3.0 27.6 2.7 24.2 3.3 21.6 3.4 32.7 6.5 26.4 4.0 20.3 3.2 19.9 3.1 19.5 4.2 21.0 4.1 17.1 6.6 20.4 6.1 13.9 3.0 16.1 3.4 13.1 3.8 8.7 3.1 *For 19781991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $950/c confidence interval. "Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. groups and subgroups, including persons who identi- fied themselves as Puerto Rican, Cuban, Mexican, Mexicano, Mexican American, Chicano, Spanish, or of other Latin American origin. Because Hispanics with higher levels of education are less likely to smoke than other groups of Hispanics (Haynes et al. 19901, the slightly different target populations in the HHANES and in the NH&--which probably differ in educational attainment-may help explain differences in smoking prevalence between the two surveys. Hispanics aged 55 years and older consistently had the lowest rates of cigarette smoking in the NHIS (Table 28), a finding similar to that from the HHANES (Haynes et al. 1990). Rates of cigarette smoking generally have been highest among Hispanics with a high school education or less and lowest among those who have graduated from college (Table 281. This pat- tern also was observed in a smaller survey of Hispanic adults in a semirural city near Albuquerque, New Mexico (Samet et al. 1992). In the 1982-1984 HHANES, having 12 or more years of education was associated with lower rates of cigarette smoking among Cuban American, Mexican American, and Puerto Rican men (Haynes et al. 1990). Among Hispanic women, those with 7-11 years of edu- cation had the highest rates of cigarette smoking. The 1982-1984 HHANES used an eight-item scale to measure level of acculturation in Mexican Americans (Delgado et al. 1990). The variables used to construct the scale were language ability, self-identification, parents' racial/ethnic identification, and generation in the United States. Among Mexican American women, there was a dose-response relationship between the level of acculturation and Table 29. Percentage of adult Hispanic smokers* who reported smoking <15,15-24, or 225 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic % +c1$ % +c1 % fC1 % fC1 % fC1 % fC1 Total <15 cigarettes 15-24 cigarettes 225 cigarettes Gender Men <15 cigarettes 15-24 cigarettes 225 cigarettes Women <15 cigarettes 15-24 cigarettes 225 cigarettes Age (years) 18-34 Cl5 cigarettes 15-24 cigarettes 225 cigarettes 35-54 12 years). Among men, smoking prevalence varied for those with ~12 and 12 years of education; smoking prevalence was highest among whites, intermediate among Hispanics of high acculturation, and lowest among Hispanics of low acculturation. This pattern also existed for women, but in all three of the educa- tion categories. Additionally, in a multivariate analy- sis that controlled for age, gender, educational attainment, and Mexican origin, Hispanics with a low acculturation level were significantly less likely to smoke than those with a high acculturation level. Navarro suggested that level of acculturation may be related to the degree of urbanization of the person's or family's residence in the country of origin. For ex- ample, persons living in rural areas of Latin America appear to be less likely to smoke than those living in urban areas (USDHHS 1992). The relationship be- tween cigarette smoking and level of acculturation among Hispanics living in the United States may be confounded by adaptation to industrial and urban societies (Navarro 19961, especially if persons or families from rural areas acculturate more slowly than those from urban areas. Future research into this topic might ideally include information on the person's or family's residence in the country of origin. Number of Cigarettes Smoked Daily Between 1978 and 1985, trends in the number of cigarettes smoked per day by Hispanic smokers re- mained stable (Table 29) (NCHS, public use data tapes, 19781995). More recently, however, an increasing pro- portion of Hispanic smokers have been smoking fewer than 15 cigarettes per day, and a declining proportion of them have been smoking 25 or more cigarettes per day. For example, in 1978-1980, 13.3 percent of His- panic smokers smoked 25 or more cigarettes per day. By 1994-1995, this proportion was 7.7 percent. From 1978 to 1993, Hispanic men were more likely than Hispanic women to smoke 25 or more ciga- rettes per day, although these differences were not sta- tistically significant (Table 29). Consumption patterns in 1994-1995 were similar across genders. Between 1978 and 1995, the prevalence of smoking 25 or more cigarettes per day declined among Hispanics at all levels of education (Table 29), although only the decline among persons with less than a high school education was statistically significant. Patterns of Tobacco Use 69 Quitting Behavior In the NHIS, the prevalence of smoking cessa- tion among Hispanic smokers increased moderately between 1978 and 1995 (Table 30) (NCHS, public use data tapes, 1978-1995). No notable differences in smoking cessation between Hispanic men and women were observed. The prevalence of cessation was higher among persons in the older age groups and among college graduates (Table 30). Data from a recent multivariate analysis of the 1991 NHIS (CDC 1993) indicate that after the analysis controlled for gender, age, education, and poverty sta- tus, Hispanics were more likely than whites to stop smoking for at least one day during the previous year. Hispanics who had stopped smoking for at least one day were about as likely as whites to have stopped for at least one month. Overall, Hispanic smokers were slightly more likely than whites to have quit smoking for at least one month. Data from the NC1 Supplement of the 1992-1993 CPS indicate that among Hispanics aged 18 years and older who were daily smokers one year before the sur- vey, 59.8 percent reported that they were still smoking daily and that they had not tried quitting for at least one day during the previous year (Table 4). Another 28.5 percent had tried quitting for at least one day, 5.6 percent were occasional smokers (i.e., smoked only on some days), 2.5 percent had not smoked for the past l-90 days, and 3.6 percent had not smoked for the past 91-364 days. This distribution was similar to that among whites, with the exception that slightly more Hispanics had become occasional smokers. Table 30. Percentage of adult Hispanic ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 197%1980+ 1983-1985+ 1987-1988+ 1990-1991+ Characteristic 5% +c1* R +c1 % +c1 % +c1 Total 35.0 2.8 Gender Men Women Age (years) 18-34 35-54 255 Education_ Less than high school High school Some college College 35.5 3.4 40.5 4.1 43.0 3.3 43.0 3.6 45.8 4.1 48.2 4.3 34.2 4.3 37.6 4.3 42.5 3.4 45.6 3.5 41.6 4.5 43.1 4.5 27.9 4.2 32.6 3.2 33.7 3.6 34.3 3.5 31.4 4.3 32.5 4.9 37.2 3.9 39.2 5.2 44.9 3.7 45.3 3.6 46.4 4.7 49.6 4.9 51.0 5.5 57.2 7.6 60.4 5.0 67.1 5.6 70.3 6.9 68.1 6.4 30.5 3.6 37.7 4.0 43.3 3.6 45.5 4.4 42.8 5.0 47.6 5.1 45.7 7.1 40.0 6.0 41.2 4.6 41.9 4.4 44.2 6.0 44.5 6.2 38.5 9.8 47.8 6.9 55.0 6.3 52.6 6.1 52.8 8.8 49.1 7.6 59.4 14.2 52.2 10.3 59.2 7.2 56.6 7.3 64.0 8.9 71.1 9.1 - - 39.3 2.8 32.8 2.4 44.1 2.6 44.2 3.1 46.2 3.2 199%1993+ 1994-1995+ % +c1 YO fC1 *The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that thev were not smoking, and ever smokers include current and former smokers. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. t95% confidence interval. %cludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Tobacco Use Anzmig U.S. Racinl/Et/mic Minorify Group Women of Reproductive Age From 1978 to 1995, a large proportion of Hispanic women of reproductive age (18-44 years) have smoked cigarettes, although this proportion has been declining over time (Table 31) (NCHS, public use data tapes, 1978-1995). Some evidence suggests that the prevalence of smoking among women of reproductive age v7aries according to the country of origin, with Cuban Ameri- can women (22.6 percent) and Mexican American women (23.2 percent) reporting cigarette smoking in lower proportions than Puerto Rican women (33.5 per- cent) (Pletsch 1991). In a comparison of data from the HHANES and the National Health and Nutrition Ex- amination Survey (NHANES), Guendelman and Abrams (1994) found that Mexican American iTomen of reproductive age were less likely than their lz'hite counterparts to smoke cigarettes at each of the repro- ductive stages (interconception, pregnancy, lactation, and postpartum). The National Survey of Family Growth collected data in 1982 and 1988 on the smoking behavior of females 1544 years of age during their most recent pregnancy. In 1982,17.2 percent of Hispanic women reported smoking during their most recent pregnancy, compared with 13.7 percent in 1988 Wamuk and Masher 1992; Chandra 1995). More recent data from U.S. final natality statistics indicate that smoking rates for Hispanics during pregnancy declined from 8 per- cent in 1989 to 4.3 percent in 1995 (Table 6). Hispanic adolescent mothers were about as likely as older Hispanic mothers to have smoked (USDHHS 1994). Hispanic mothers report generally low rates of tobacco use, ranging from 1.8 to 4.1 percent for Mexi- can, Cuban, Central American, and South American mothers to 8.2 to 10.4 percent for Puerto Rican and "other" Hispanic mothers and those of unknown Hispanic origin (Table 6). Ventura and colleagues (1995) reported that 3 percent of foreign-born or Puerto Table 31. Percentage of Hispanic women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic 7c KIS 7% KI 5% +c1 % KI Y0 XI % KI Total 25.5 2.7 22.2 2.2 19.8 1.7 16.7 1.8 17.3 2.3 16.4 2.0 Educations Less than high school 29.2 4.3 24.4 4.4 23.5 4.0 17.6 3.7 17.0 4.4 17.0 3.7 High school 21.3 5.6 27.6 5.3 24.1 3.7 21.4 3.6 25.1 5.3 21.4 4.7 Some college 12.9 7.5 21.5 6.7 15.9 4.6 19.5 4.2 17.0 6.1 16.5 5.3 College 17.3 12.0 16.7 8.3 12.7 4.7 15.2 5.0 12.9 5.8 5.1 4.1 *For 1978-1991, current cigarette smokers include women aged 1844 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 1844 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $95% confidence interval. gIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Prrf term of Tuhncco Use 71 Rican-born Hispanic mothers smoked, compared with 9 percent of their United States-born counterparts (Ventura et al. 1995). Data on tobacco use among these mothers may be skewed because California and New York do not report this information, and together these states account for almost half of all Hispanic births (Ventura et al. 1996). The National Pregnancy and Health Survey, con- ducted between October 1992 and August 1993 and sponsored by NIDA, provides nationally representa- tive data on the prevalence of prenatal drug use among Hispanic females of reproductive age (15-44 years). According to National Pregnancy and Health Survey data, 5.8 percent of Hispanic women reported using cigarettes during their pregnancies (NIDA 1994). In the 1985 and 1990 NHISs, questions related to smok- ing were asked of women aged 1844 years who had given birth within the past five years. In 1985, 16.8 percent of Hispanic women smoked during the 12 months before the birth and 10.3 percent smoked after learning of their pregnancy; in 1990, 12.1 percent smoked during the year before birth and 8 percent af- ter learning of their pregnancy (Floyd et al. 1993). Young People Cigarette Smoking Despite the dearth of information on tobacco use among Hispanic youths, several studies have been able to identify trends in smoking initiation and patterns of tobacco use by analyzing data from the HHANES, the MTF surveys of high school seniors (Figure 3), and small local surveys (for example, Smith et al. 1991; Dusenbury et al. 1992; Vega et al. 1993). HHANES data have shown that smoking initia- tion increased rapidly among Cuban Americans, Mexi- can Americans, and Puerto Ricans between ages 11 and 15 years, peaked between ages 15 and 19 years, and declined after the age of 20 years (Escobedo et al. 1990). In all age groups, smoking initiation rates were higher among males than among females. Slight variations in smoking initiation by level of education were found when the HHANES data were combined for all three Hispanic subgroups (although these were three separate surveys, it was necessary to combine three groups to estimate trends for all three groups). Hispanics with less than a high school education had the highest rates of smoking initiation, with an earlier age of onset and a more accelerated rate of smoking initiation during young adolescence, than Hispanics with more years of schooling. Hispan- ics with a high school education had intermediate rates of smoking initiation, whereas those with more than a high school education had slightly lower smoking initiation rates. Because educational attainment is a reliable (Liberatos et al. 19881 although limited (Mont- gomery and Carter-Pokras 19931 indicator of socioeco- nomic status, these data suggest that an association between smoking initiation and socioeconomic status may exist among Hispanics, as it does for the general U.S. population. However, these differences in smok- ing initiation by educational attainment were not as large as those found among whites. In addition, data from the 1994-1995 (combined) NHSDAs indicate that among persons aged 30-39 years, Hispanic men and women were less likely to become daily smokers than whites (Table 11) WSDHHS, Substance Abuse and Mental Health Ser- vices Administration, public use data tapes, 1994- 1995). Among persons in this age group who had ever smoked daily, the initiation patterns among Hispan- ics were more like those of African Americans than those of whites. The average ages for first trying a cigarette and for becoming a daily smoker were about one year higher for Hispanic men than for white men and about two years higher for Hispanic women than for white women (Table 11). Among high school seniors who participated in the MTF in 1985-1989,23.8 percent of Mexican Ameri- can males, 22.0 percent of Puerto Rican and Latin0 males, 18.7 percent of Mexican American females, and 24.7 percent of Puerto Rican and Latina females smoked cigarettes in the previous month (Bachman et al. 1991 b). In addition, 11.6 percent of Mexican Ameri- can males, 13.3 percent of Puerto Rican and Latin0 males, 8.1 percent of Mexican American females, and 13.3 percent of Puerto Rican and Latina females smoked cigarettes daily in the previous month. The prevalence of smoking one-half pack of cigarettes or more per day was somewhat higher among males (5 to 6 percent) than among females (2 to 4 percent). Between 1976 and 1989, the prevalence of daily smoking declined among Mexican American high school seniors of both genders and among Puerto Rican and Latina females, according to the MTF data (Bachman et al. 199lb). Decreases occurred be- tween 1976 and 1984 among Mexican American males and between 1980 and 1989 among Puerto Rican and Latina females. Among Mexican American females, decreases in the prevalence of daily smoking occurred between 1976 and 1984, and no decline was observed in more recent years. In contrast, little change in the prevalence of daily smoking was observed among Puerto Rican and Latin0 males over the entire survey period (Bachman et al. 1991b). Tt~/mco Use Arnmg U.S. Racinl/Efhnic Minority Gro14ps Recent data indicate that rates of smoking are generally lower among Hispanic youths than among white youths. The 1989 TAPS showed that 11.8 per- cent of Hispanics reported some level of cigarette smoking, compared with 17.7 percent of whites and 6.2 percent of African Americans (Moss et al. 1992). However, patterns may differ for migrant and resident youths. In a recent study of 214 migrant Hispanic ado- lescents enrolled in school in San Diego, the prevalence of cigarette smoking within the 30 days preceding the survey increased by school grade, from a low of 10 percent of 9th graders to 14 percent of 10th graders, 21 percent of 11th graders, and 18 percent of 12th graders (Lovato et al. 19941. Also, acculturation may influence smoking behavrior. In a study of sixth and seventh graders in Dade County, Florida, Vega and col- leagues (1993) found that cigarette smoking \vas more frequent among United States-born Cuban American children (23.8 percent) than among foreign-born Cuban Americans (15.1 percent). According to the 1995 YRBS, 34.0 percent of His- panic high school students and 38.3 percent of white high school students smoked on one or more days during the previous month (CDC 1996). Hispanic stu- dents were significantly more likely than African American students (19.2 percent) to have smoked dur- ing the previous month. Regarding more frequent smoking, Hispanic youths (10.0 percent) and African American youths (4.5 percent) were less likely than white youths (19.5 percent) to have smoked on at least 20 days during the previous month. Lowry and colleagues (1996) analyzed cross- sectional data on 6,321 adolescents (aged 12-17 years) from the YRBS supplement to the 1992 NHIS. His- panics were significantly less likely than whites to have smoked in the previous 30 days. This analysis con- trolled statistically for the educational level of the re- sponsible adult, for family income, for the age and gender of the adolescent, and for whether the adoles- cent was in or out of school. In an analysis comparing measured carbon monoxide from expired air with self- reported smoking among a sample of seventh- through tenth-grade New York State public school students, Wills and Cleary (1997) found that the self-report sen- sitivity was slightly lower for Hispanics than for whites but that the magnitude of the effect was small. When self-reported smoking rates were adjusted for carbon monoxide values, ninth- and tenth-grade Hispanic students had significantly lower smoking prevalences than whites. Recent findings from focus groups conducted at several U.S. sites suggest that Hispanic parents may be more likely than white parents to express clear anti- smoking messages and that smoking by Hispanic ado- lescents may be a sign of disrespect toward parents (Mermelstein et al. 1996). According to the 1996 MTF surveys, the preva- lence of previous-month smoking (estimated by com- bining 1995 and 1996 data) among Hispanic high school seniors (25.4 percent) was intermediate to that among African American seniors (14.2 percent) and white se- niors (38.1 percent) (Institute for Social Research, Uni- versity of Michigan, unpublished data from the 1996 MTF surveys). A similar pattern was observed for tenth- grade students: previous-month smoking prevalences were 23.7 percent for Hispanics, 32.9 percent for whites, and 12.2 percent for African Americans. However, among eighth-grade students, the Hispanic-white difference was attenuated: 19.6 percent of Hispanics, 22.7 percent of whites, and 9.6 percent of African Ameri- cans were previous-month smokers. Trends in daily smoking among high school seniors show that rates for Hispanics have been consistently lower than for whites since 1977 and higher than for African Americans since the early 1980s (Figure 3). The MTF surveys suggest that rates of smoking among Hispanics have increased in the 1990s. The prevalence of previous-month smoking (based on two- vear rolling averages) among eighth-grade students was 16.7 percent in 1992 and 19.6 percent in 1996; among tenth-grade students, the prevalence was 18.3 percent in 1992 and 23.7 percent in 1996; and among high school seniors, the prevalence was 21.7 percent in 1990 and 25.4 percent in 1996 (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). Simi- larly, YRBS data indicate that the prevalence of previ- ous-month smoking among Hispanic high school students was 25.3 percent in 1991 (USDHHS 1994) and 34.0 percent in 1995 (CDC 1996). Other Risk Behaviors Using data from the YRBS supplement to the 1992 NHIS, Escobedo and colleagues (1997) observed asso- ciations (USDHHS 1994) between cigarette smoking among Hispanic adolescents and specific behaviors com- promising to health. Marijuana use, binge drinking, and weapon carrying were significantly associated with ciga- rette smoking among Hispanic adolescent males; mari- juana use, binge drinking, multiple sexual partners, and physical fighting were associated with cigarette use among Hispanic adolescent females. The analysis controlled statistically for age, ethnic@, gender, paren- tal educational level, region of the country, and other risk behaviors. Patferfzs of T@t7acco use 73 Smokeless Tobacco Use Recent trends in smokeless tobacco use among Hispanic adolescents have changed little. According to the MTF surveys, previous-month smokeless tobacco use (based on two-year rolling averages) was reported by 4.2 percent of eighth-grade Hispanic students in 1992 and 5.2 percent in 1996; among tenth-grade students, the prevalence was 6.2 per- cent in 1992 and 4.0 percent in 1996; and among high school seniors, the prevalence was 4.4 percent in 1987 and 8.1 percent in 1996 (Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data from the 1996 MTF surveys). YRBS data indicate that the prevalence of previous-month use among Hispanic high school students was 5.5 per- cent in 1991 (USDHHS 1994) and 4.4 percent in 1995 (CDC 1996). Hispanic adolescent males are much less likely than white adolescent males to use smokeless tobacco. Among male high school students participating in the 1995 YRBS, for example, 5.8 percent of Hispanics and 25.1 percent of whites had used smokeless tobacco during the previous month (CDC 1996). Prevalence among females was 3.1 percent for Hispanics and 2.5 percent for whites. Retrospective Analyses of Smoking Prevalence Among African Americans and Hispanics Because of the lack of long-term national survey data on smoking behavior among racial/ethnic groups, retrospective analysis is the only way to reconstruct smoking prevalences for African Americans before 1965 and for Hispanics before 1978. The retrospective method of constructing smoking prevalences for suc- cessive birth cohorts of men and women in the U.S. population was first reported by Harris (USDHEW 1979; Harris 1983). Harris's methodology later served as the basis for a report in which smoking prevalences were presented for Cuban American, Mexican Ameri- can, and Puerto Rican men and women (Escobedo and Remington 1989). Most recently, the NC1 (1991) published some results of an analysis of birth cohorts of whites and African Americans. Another type of ret- rospective analysis has also been used to estimate long- term trends in cigarette smoking. This approach has been the basis of two published reports, one that pre- sented smoking trends among Hispanics in various age groups (Escobedo et al. 1989a) and another that pre- sented smoking trends among Hispanic young adults (Escobedo et al. 1989b). For this section of the report, both types of retrospective analysis were used to gen- erate information not previously available. Prevalence of Cigarette Smoking Among Successive Birth Cohorts The following detailed analysis of smoking trends over time-according to gender and educational attainment ot defined birth cohorts (based on the year of birth)-uses data from the 1987 NHIS (for African Americans) and the 1982-1984 HHANES (for Hispan- ics). The smoking histories of respondents were con- structed according to the ages they reported cigarette smoking initiation and cessation. Information about these two smoking-related events was then used to classify each respondent as a nonsmoker, current smoker, or former smoker from birth to interview and to calculate the proportion of people smoking each year in each birth cohort. (See Appendix 5 for a discussion of the valida- tion of this methodology.) The resulting birth cohort curves (Figures 7-10) represent smoking prevalences of each cohort for each year from birth to interview (throughout childhood, adolescence, and adulthood) (NCHS, public use data tapes, 1978, 1979, 1980, 1982- 1984, and 1987 and 1988 combined). By comparing the curves among successive birth cohorts, one can examine smoking trends-over time for those cohorts. African Americans The prevalence of smoking among successive birth cohorts of African American men with at least a high school education has declined gradually, with the peak and age-specific smoking prevalences for the most recent cohort (1958-1967) being lower than the prevalences for previous cohorts' curves (Figure 4). In contrast, little progress has been made in re- ducing the prevalence of cigarette smoking among Tobacco Use Among U.S. Racial/Ethnic Minority Groups successive birth cohorts of African American men with less than a high school education (Figure 7). Although smoking prevalences declined slightly for successive cohorts, the peak prevalence for the most recent co- hort continues to be nearly as high as that for previ- ous cohorts. In addition, smoking prevalences during adolescence among African Americans with less than a high school education did not decrease between suc- cessive birth cohorts. Despite initial increases in smoking prevalence among successive birth cohorts of African American women with at least a high school education, prevalences have declined in recent years (Figure 8). The declines in prevalence among African American women with at least a high school education are not as marked as the declines observed among successive birth cohorts of African American men of a similar educational background. Smoking prevalences among African American women with less than a high school education have increased markedly, with the most recent cohort (195881967) showing the highest peak (Figure 8). Hispanics Among six successive birth cohorts of Hispanic men with at least a high school education covering the years 1908-1967, the peak prevalence of smoking in- creased gradually for the first three cohorts but declined beginning with the 1938-1947 cohort (Figure 9). In ad- dition, the rate of increase in smoking prevalence dur- ing adolescence slowed markedly for the most recent cohort compared with rates for previous cohorts. The smoking prevalence pattern among succes- sive birth cohorts of Hispanic men with less than a high school education (Figure 9) is similar to the pat- tern among African American men with a similar edu- cational background. Smoking prevalences have declined slightly since the early 195Os, when the high- est prevalence was observed for the 1918-1927 cohort. The slight decline in smoking prevalence among successive birth cohorts of Hispanic women with at least a high school education is similar to the decline among African American women with a similar edu- cational background (Figure 10). However, the decline Figure 7. Cigarette smoking prevalence among successive birth cohorts of African American men, by education, National Health Interview Surveys, United States, 1978-1980,1987, and 1988* 8o- High school 80- Less than a high 70 - education 70 - school educatio 60- 60- 2 50- 50- E 40- `i $ 40- 2 30- 2 ? 30- 20- 20- IO- 10- 0 I I I I I I I O- 1910 1920 1930 1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 Year Year Birth cohorts: - 1908-1917 -.-`. 1918-1927 1928-1937 ---- 1938-1947 - 1948-1957 - 1958-1967 *Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth to interview, they provide information about the smoking prevalence of each cohort during childhood, adolescence, and adulthood. Sources: National Center for Health Statistics, public use data tapes, 1978-1980,1987 (Cancer Control Supplement and Epidemiology Supplement), and 1988; Escobedo and Peddicord 1996. Patterm of Tobacco Use 75 Surgeon Geneyal's Report among Hispanic women began more recently, with the 1938-1947 cohort. The peak prevalence for the most recent cohort of Hispanic females with at least a high school education was similar to the peak prevalence for African American women of the same educational level (25 percent). The smoking prevalences among successive birth cohorts of Hispanic women with less than a high school education increased slightly over time and then lev- eled off (Figure 10). In addition, the prevalence of smoking during adolescence increased much more rapidly in the most recent birth cohort than in previ- ous cohorts. However, the overall pattern of smoking prevalence in this subgroup of Hispanic women does not show the dramatic increases observed in succes- sive birth cohorts of African American women with a similar educational background. The peak prevalence for the most recent birth cohort of Hispanic women with less than a high school education (34 percent) was substantially lower than the peak prevalence for the corresponding cohort of African American women (54 percent). The slight changes in smoking prevalences among successive birth cohorts of Hispanic women, regardless of educational background, may be the re- sult of the larger proportion of Mexican American women who compose these subgroups. Although few changes have been observed in the prevalence of smoking among successive birth cohorts of Mexi- can American women, in recent birth cohorts of Cuban American and Puerto Rican women, more women have smoked cigarettes than those in previ- ous cohorts (Escobedo and Remington 1989). Had more Cuban American and Puerto Rican women been included in the HHANES, the pattern may well have been different. The results of these birth cohort analyses show that educational attainment is the most powerful pre- dictor of temporal trends in smoking prevalence. In both racial/ethnic groups, men, and to a lesser extent women, with at least a high school education have made progress in reducing cigarette smoking. How- ever, men with less than a high school education, re- gardless of race/ethnicity, are as likely to smoke now as they were in previous decades. Recent cohorts of African American women with less than a high school education are now substantially more likely to smoke than their counterparts in previous decades. Figure 8. Cigarette smoking prevalence among successive birth cohorts of African American women, by education, National Health Interview Surveys, United States, 1978-1980,1987, and 1988, 80 70 60 High school education 5 50- -z i 40- 30- 20- lo- 0, I I I I I I I 80 70 60 Less than a high school education 1910 1920 1930 1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 Year Year Birth cohorts: - 1908-1917 -.-.. 1918-1927 1928-1937 ---- 1938-1947 - 1948-1957 - 1958-1967 *Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth to interview, they provide information about the smoking prevalence of each cohort during childhood, adolescence, and adulthood. Sources: National Center for Health Statistics, public use data tapes, 1978-1980,1987 (Cancer Control Supplement and Epidemiology Supplement), and 1988; Escobedo and Peddicord 1996. 76 Clzaptey 2 Tobnczo Use Among U.S. RncinIIEfh,ric Minority Groups Figure 9. Cigarette smoking prevalence among successive birth cohorts of Hispanic men, by education, Hispanic Health and Nutrition Examination Survey, 1982-1984, 80 I High school 70 education d'-.- ., 60 h,\ - I $ 50- `; &b , 50- I p: 40- E 40- , , 2 30- 2 30- , I 20- 20- .' 10- .' 10- 0 ,* I I I I 0 I I I 1910 1920 1930 1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 Year Year Birth cohorts: - 1908-1917 -.-`. 1918-1927 1928-1937 - - - - 1938-1947 - 1948-1957 - 1958-1967 *Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth to interview, they provide information about the smoking prevalence of each cohort during childhood, adolescence, and adulthood. Sources: National Center for Health Statistics, public use data tapes, 1982-1984; Escobedo and Peddicord 1996. Figure 10. Cigarette smoking prevalence among successive birth cohorts of Hispanic women, by education, Hispanic Health and Nutrition Examination Survey, 1982-1984* 8o- High school 80- Less than a high 70 - education 70 - school education 60- 60- 5 50- E 40- 2 $ 50- 40- 2 30- 2 8 30- 20- 20- 10- 10- 0 I O- 1910 1920 1930 1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 Year Year Birth cohorts: - 1908-1917 -`-" 1918-1927 1928-1937 ---- 1938-1947 - 1948-1957 - 1958-1967 *Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth to interview, they provide information about the smoking prevalence of each cohort during childhood, adolescence, and adulthood. Sources: National Center for Health Statistics, public use data tapes, 1982-1984; Escobedo and Peddicord 1996. Pnfterns of Tobncco Use 77 Long-Term Trends in Cigarette-Smoking Initiation Another type of birth cohort analysis was con- ducted to determine long-term trends in smoking among young adults (2G29 years of age) by gender and educa- tional attainment. Information on smoking history was determined during the years that each person was 2G29 years of age. For each year, the prevalence of smoking was determined by dividing the number of smokers aged 20-29 years by the total number of persons aged 2C-29 years in that year. Unlike the birth cohort analysis de- scribed in the preceding section of this chapter, in this analysis the group for which prevalences are computed changes from year to year because new respondents en- ter the group when they are 20 years old and leave it when they become 30 years old. The information for African Americans was ob- tained from NHIS data collected in 1978, 1979, 1980, 1987, and 1988, whereas the information for Hispan- ics was obtained from HHANES data collected in 1982-l 984. Figure 11. BO- 70- 60- 5O- !+ 2 40- 8 z o 30- 20- lo- African Americans Up until the early 197Os, African American men had substantially higher rates of smoking initiation than African American women (Figure 11). Within each gender group, significant education-related differences were not observed until the 195Os, when rates of smoking initiation among male high school graduates began to decline sharply and rates among females with less than a high school education began to increase. Rates among less educated females surged drama tically between 1970 and 1980. After 1980, rates of smoking have consistently declined among each of these subgroups of African Americans except males with less than a high school education. Hispanics Significant education-related differences in rates of smoking initiation have been evident only among Hispanic males. Around 1940, Hispanic males who graduated from high school began showing Reconstructed prevalence of smoking among African American adults aged 20-29 years, by gender and education, National Health Interview Surveys, United States, 1910-1988 Men with less E%% 3~ation Men with a high school education Women with less ZXZ %kation Women with a high school education 0 ; I I I I I I I I 1910 1920 1930 1940 1950 1960 1970 1980 1990 Year Source: National Center for Health Statistics, public use data tapes, 1978,1979,1980,1987, and 1988 combined. Tobacco Use Among U.S. Racinl/Efhic Minority Groups appreciably lower smoking rates than Hispanic males with less than a high school education (Figure 12). These differences increased in the 1960s and even more rapidly in the mid-1970s. No consistent differences in smoking rates by education were observed among Hispanic females. Cigarette Brand Preferences Knowing what influences cigarette brand.prefer- ence among smokers is belie\red to be important be- cause this information can be used to develop counteradvertising strategies. In the late 1970s and the 198Os, the 12 most commonly used brands of ciga- rettes-Marlboro, Winston, Salem, Kool, Pall Mall, Kent, Benson & Hedges, Camel, Merit, Vantage, Virginia Slims, and Newport-were used by at least 76 percent of all current U.S. smokers, according to data from the 1986Adult Use of Tobacco Survey (AUTS) and the 1978- 1980 and 1987 NHISs (Table 32). Brand use varied some- what by race/ethnicity. For example, the top brands preferred by African Americans were Kool, Newport, Salem, and Winston, whereas whites preferred Marlboro, Winston, Salem, and Benson & Hedges. These differences in part reflect the greater use of mentholated cigarettes by African Americans (Cummings et al. 1987; USDHHS 1989). Fifty-five percent of all African American smokers reported us- ing one of three brands that were available only in mentholated form (Newport, Kool, and Salem). Simi- lar patterns and percentages of brand preferences were observed in the 1987 NHIS (Table 32). Hymowitz and colleagues (1995) recently stud- ied menthol cigarette smoking among adults who par- ticipated in a stop-smoking study. Among African Americans who smoked menthol cigarettes (n = 1741, the top reasons given for smoking menthols were as follows: 83 percent said that menthol cigarettes tasted better than nonmenthol cigarettes, 63 percent said that they had always smoked menthol cigarettes, 52 per- cent said that menthol cigarettes were less harsh to the throat than nonmenthol cigarettes, 48 percent found inhalation to be easier with menthol cigarettes, and 33 Figure 12. Reconstructed prevalence of smoking among Hispanic adults aged 20-29 years, by gender and education, Hispanic Health and Nutrition Examination Surveys, 1920-1984 Men with less - ZnOOa !Z&ation Men with a high 11-v. school education Women with less %Z," ZEation Women with a - high school education I I I 1950 1960 ld70 1980 1490 Year Source: National Center for Health Statistics, public use data tapes, 1982-1984. Pafferm of Tobacco Use 79 Table 32. Percentage of self-reported cigarette brand use among adult current cigarette smokers, overall and by race/ethnicity and gender, National Health Interview Surveys (NHIS) 1978-1980 com- bined, Adult Use of Tobacco Survev (AUTS) 1986, and NHIS 1987 Survey Sample Size* Benson & Hedges Camel Kent Kool Marlboro % KIS % XI %X1 % %I % &CI NHIS 1978-1980 African Americans Total Men Women 1,540 6.0 1.6 1.3 0.7 1.6 0.6 28.0 4.0 3.8 1.3 750 4.0 1.7 2.3 1.2 1.1 0.8 31.3 4.7 4.2 1.7 790 8.1 2.4 0.3 0.4 2.2 0.8 24.4 4.5 3.3 1.6 Whites Total Men Women AUTS 1986 African Americans Total Men Women Whites Total Men Women NHIS 1987 African Americans Total Men Women Whites Total Men Women 13,228 4.2 0.6 4.4 0.5 4.8 0.5 6.3 0.6 17.5 1.1 6,675 2.7 0.5 6.9 0.7 4.0 0.6 6.8 0.8 20.3 1.5 6,553 5.8 0.8 1.7 0.4 5.7 0.6 5.8 0.7 14.4 1.2 388 9.2 3.5 0.9 1.2 0.6 0.6 19.9 4.9 6.7 3.1 176 4.6 3.8 1.2 2.0 0.5 0.5 19.6 7.2 10.2 5.5 212 13.8 5.7 0.5 1.2 0.7 0.7 20.3 6.7 3.2 2.9 3,693 4.1 03 4.9 0.9 2.7 2.7 4.2 0.8 28.3 1.8 1,883 2.9 0.9 7.9 1.5 2.3 2.3 4.7 1.2 32.4 2.6 1,810 5.5 1.3 1.5 0.7 3.2 3.2 3.5 1.0 23.7 2.4 428 6.3 2.7 2.6 2.0 2.5 2.3 24.8 5.4 2.7 1.5 174 2.2 1.8 3.4 3.3 2.1 2.8 30.3 8.6 3.1 2.2 254 11.2 5.1 1.7 2.2 3.0 3.7 18.4 5.5 2.3 1.9 1,860 5.8 1.2 3.8 1.1 3.1 0.9 3.7 1.0 31.1 2.6 934 3.8 1.4 5.7 1.6 2.1 1.0 3.6 1.3 38.8 3.5 926 8.1 2.1 1.6 1.7 4.3 1.6 3.7 1.4 22.0 3.1 *Unweighted sample size. `In the NHIS, "other" includes other brands, no particular brand, and roll-your-own cigarettes; in the AUTS, "other" includes other brands. percent said that they could inhale menthol cigarettes always smoked menthol cigarettes, and 21 percent found more deeply. Among a small sample (n = 39) of whites inhalation to be easier with menthol cigarettes. who smoked menthol cigarettes, 74 percent said that Evaluating changes in young smokers' brand menthol cigarettes tasted better than nonmenthol ciga- preferences is especially important because it can rettes, 51 percent said that menthol cigarettes were more help identify factors that influence their choices and soothing to the throat, 39 percent said that they had may suggest ways to discourage them from starting Totmcco Use Ammo U.S. RacidjEthnic Minority Groups Merit Newport Yc kc1 % kc1 Pall Virginia Mall Salem Vantage Slims Winston Other+ % kc1 7r kc1 x kc1 Yc kc1 Yc kc1 7% XI 1.4 0.6 5.2 2.3 6.9 1.5 15.9 2.0 0.9 0.5 2.6 0.9 11.9 2.1 14.5 2.0 1.3 0.9 5.6 2.7 9.6 2.5 12.7 2.8 0.7 0.2 0.2 0.3 13.4 3.3 13.6 2.5 1.4 0.9 4.7 2.8 4.0 1.3 19.4 2.7 1.1 0.8 5.2 1.9 10.3 2.1 15.6 3.2 4.3 0.4 1.2 0.4 5.4 0.4 9.0 0.7 3.5 0.4 2.2 0.3 13.3 0.9 23.9 1.1 4.0 0.6 1.2 0.4 6.4 0.6 7.9 0.8 3.5 0.6 0.2 0.1 15.5 1.2 20.6 1.4 4.7 0.6 1.2 0.4 4.2 0.5 10.3 1.0 3.5 0.5 4.4 0.5 10.8 1.0 27.5 1.4 0.1 0.4 23.4 3.2 2.3 1.8 0.0 0.0 26.2 8.0 2.8 3.0 0.1 0.5 20.5 6.7 1.8 2.2 4.9 0.9 2.4 0.6 3.5 0.7 4.6 1.2 2.7 0.9 3.9 1.1 5.3 1.3 2.1 0.8 2.9 0.9 17.4 3.6 0.4 15.2 6.5 0.5 19.7 6.4 0.4 8.2 1.1 3.6 6.4 1.4 3.5 10.4 1.7 3.8 1.3 1.1 19.6 5.7 2.2 1.2 12.7 3.8 0.5 0.8 1.2 21.9 9.1 2.1 1.6 11.9 5.4 0.0 1.9 2.0 16.9 5.3 2.3 1.7 13.5 4.7 1.0 4.5 1.0 2.8 0.9 2.5 0.8 7.0 1.4 2.6 4.1 1.4 2.5 1.2 3.2 1.2 5.4 1.9 2.8 4.9 1.3 3.2 1.3 1.5 0.8 8.9 2.1 2.4 0.8 3.4 2.2 6.5 3.0 9.4 3.6 1.3 0.3 1.0 8.8 5.1 10.2 5.5 1.0 6.4 4.0 4.2 3.3 8.5 4.6 0.7 3.0 0.7 11.0 1.2 19.2 1.6 1.0 0.4 0.4 13.0 1.9 15.4 2.0 1.1 6.0 1.3 8.8 1.6 23.6 2.4 0.5 1.9 1.2 11.7 4.0 11.2 3.5 0.0 0.5 0.8 12.9 6.3 8.8 4.4 1.2 3.4 2.4 10.3 4.8 14.1 5.0 0.8 3.8 0.9 12.3 1.9 17.0 1.9 1.0 0.1 0.2 13.6 2.7 14.3 2.5 1.1 8.2 2.0 10.7 2.6 20.5 2.8 $9570 confidence interval. Sources: National Center for Health Statistics, public use data tapes, 1978-1980 and 1987; Centers for Disease Control, public use data tapes, 1986. to smoke (Hunter et al. 1986; Pierce et al. 1991a). Data (10.9 percent), and Salem (9.7 percent) were preferred from the 1989 TAPS show that among adolescents who by African Americans (Table 33) (CDC 1992d). In the usually bought their own cigarettes (61.9 percent), 1993 TAPS, the most popular brands were still Marlboro was the most popular brand among whites Marlboro among whites (63.5 percent) and Hispanics (71.4 percent) and Hispanics (60.9 percent), and the (45.4 percent) and Newport among African Americans mentholated brands of Newport (61.3 percent), Kool (70.4 percent) (Table 33). Table 33. Percentage of self-reported cigarette brand use among adolescent current cigarette smokers,* by race/ethnicity, Teenage Attitudes and Practices Surveys (TAP%), 1989 and 1993 Benson & Sample Hedges Camel Kool Marlboro Merit Newport Survey Size+ R &CIS % ?CI % XI % ?CI % ?CI TAPS 1989 Race African American White 41 3.3 6.4 3.1 6.2 10.9 9.1 8.7 9.7 807 1.3 1.2 8.4 2.2 0.6 0.5 71.4 3.4 46 3.7 4.9 7.6 8.6 5.8 6.1 60.9 15.0 817 1.3 1.2 8.1 2.1 0.8 0.6 69.1 3.5 41 1.7 3.3 0.0 0.0 11.9 10.9 8.5 8.5 646 0.2 0.4 14.4 3.1 0.5 0.8 63.5 4.3 50 0.0 0.0 10.1 7.7 4.5 8.6 45.4 14.9 647 0.3 0.4 13.6 3.1 0.9 0.8 60.9 4.3 Salem Sample Size+ 7r &CI Vantage Virginia Slims Winston 0.0 0.0 0.5 0.5 0.0 0.0 0.5 0.5 61.3 15.7 5.6 1.6 12.8 9.5 8.0 1.9 $ ? 70.4 14.1 NA NA 8.7 2.4 NA NA 34.0 15.1 NA NA 11.0 2.5 Other Ethnicity Hispanic Non-Hispanic TAPS-II 1993 Race African American White Ethnicity Hispanic Non-Hispanic Survey % KI 7c kc1 TAPS 1989 Race African American 41 9.7 7.2 0.0 0.0 NA NA 0.0 0.0 2.9 5.8 White 807 1.0 0.7 0.1 0.2 NA NA 3.4 1.3 7.6 2.0 Ethnicity Hispanic Non-Hispanic 46 2.8 5.4 0.0 0.0 NA NA 0.0 0.0 6.5 7.6 817 1.5 0.8 0.1 0.2 NA NA 3.3 1.3 7.3 1.9 TAPS-II 1993 Race African American 41 1.4 2.7 NA NA 0.5 1.0 0.0 0.0 5.5 6.0 White 646 1.0 0.8 NA NA 1.0 1.0 1.2 0.1 9.4 2.8 Ethnicity Hispanic Non-Hispanic 50 0.0 0.0 NA NA 0.0 0.0 6.0 8.1 0.0 0.0 647 1.1 0.8 NA NA 1.1 1.0 0.8 0.7 10.4 2.9 *Current smokers are adolescents aged 12-18 years who reported smoking cigarettes on 1 or more of the 30 days preceding the survey. +Unweighted sample size. t95% confidence interval. "Numbers are too small for meaningful analysis; this brand is included in the "other" category. NA = data not available. Sources: National Center for Health Statistics, public use data tapes, 1989; Centers for Disease Control and Prevention, public use data tapes, 1993. Tdmso USC Avmr~ U.S. Rncial/Ethnic Minority Groups A notable change in brand preferences occurred between 1989 and 1993, however. The percentage of adolescents purchasing Marlboro cigarettes decreased 13 percent, whereas the percentage of those purchas- ing Camel cigarettes increased 64 percent and the percentage of those purchasing Newport cigarettes increased 55 percent (CDC 1994a). The declining pref- erence for Marlboro cigarettes was greatest among Hispanics (CDC 1992d). Increases in brand preference were greatest among white adolescents who preferred Camel cigarettes and among Hispanic adolescents who preferred Newport cigarettes. In 1993, the brands of cigarettes most commonly smoked among a small sample of Vietnamese middle and high school students in Worcester, Massachusetts, were Marlboro (71 .O per- cent) and Camel (9.7 percent) (Wiecha 1996). Data from the 1989 and 1993 TAPSs indicate that brand preference is more concentrated among adoles- cents than among adults. In both surveys, the three most popular brands for each racial/ethnic group were purchased by at least 80 percent of adolescent smok- ers. Both surveys identified very small numbers of smokers among African American adolescents (41 in 1989 and 45 in 1993) and Hispanic adolescents (46 in 1989 and 50 in 1993); thus, brand preference estimates for these groups are imprecise. Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior In this chapter, smoking prevalence has been shown to vary by racial/ethnic minority group and by educational attainment. Because educational at- tainment varies among racial/ethnic groups and is related to smoking prevalence, the question arises as to whether racial/ethnic differences in smoking can be explained by differences in educational attainment. A previous analysis of the 1985 NHIS data showed that controlling for selected measures of so- cioeconomic status, such as employment status and poverty level, reduced differences in the smoking prevalence between African Americans and whites (Novotny et al. 1988). Although education, together with such variables as income and occupation, is often used to create a composite measure of socioeconomic status, many researchers have used education as a single proxy in- dicator of socioeconomic status because education is often associated with many lifestyle characteristics (Liberatos et al. 1988). In addition, education data are usually more accurate and easier to collect than income and occupation data (Liberatos et al. 1988). Findings in this report indicate that the prevalences of cigarette smoking, smoking cessation, and heavy smoking are all associated with race/ ethnicity and educational attainment. Because racial/ ethnic group and educational attainment are often in- terrelated, multivariable models were used in this analysis to distinguish how each variable influences smoking behavior. Data were derived from the NHISs for 1987,1988,1990, and 1991 (Table 34) (NCHS, pub- lic use data tapes, 1987, 1988, 1990, and 1991). The multivariable logistic regression technique was used to assess the odds ratios of smoking behaviors for African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics compared with whites, before and after ad- justing for the effects of educational attainment.' Four separate logistic regression models were constructed for different measures of smoking behavior: current smoking, ever smoking, heavy smoking (among cur- rent smokers), and smoking cessation (among ever smokers). Four design variables were created to rep- resent the racial/ethnic groups (African Americans, American Indians and Alaska Natives, Asian Ameri- cans and Pacific Islanders, and Hispanics), with whites serving as the reference group. Similarly, two design ' Let p,,, = logistic regression coefficient for the ith ethnicity group h~$rr education was included, and p,, = logistic regression coefficient for the ith ethnicity group after education was included. Then p,,, - p,, measures education's confounding effect on the relationship between smoking and ethnicity. The variance of p,,, - p,, can be approximated as var(p,,,) + var(p,,); and the standard error, SE(P,,, p,,), is the square root of the variance. In terms of the more commonly used measure, odds ratio (OR), the following relationship exists: ORI,,/OR,, = exp(!3,, - p,,). The 95 percent confidence interval for OR,,,/OR,, can then be computed as exp[@,$, - p,,) + 1.96 X SE@,, o,,)]. Education's confounding effect on the relationship between smoking and ethnicity is determined to be statisticalIy significant if the 95 percent confidence interval for OR,,,/OR,, does not include 1.0. Pattcms of Tobacco Use 83 Table 34. Relationship between smoking status and race/ethnicity among adults,* before and after controlling for education,+ National Health Interview Surveys, United States, 1987,1988,1990, and 1991 aggregate data Race/ethnicity Not controlling for education ORoS CIS Controlling for education 0% CI Effect of educationt OR,,/ORl CI CurrenP Former1 Heavy** Ever'+ African Americans Hispanics Asian Americans and Pacific Islanders American Indians and Alaska Natives Whites African Americans Hispanics Asian Americans and Pacific Islanders American Indians and Alaska Natives Whites African Americans Hispanics Asian Americans and Pacific Islanders American Indians and Alaska Natives Whites African Americans Hispanics Asian Americans and Pacific Islanders American Indians and Alaska Natilres Whites 1.11 1.06,1.16 0.74 0.70, 0.79 0.51 0.45, 0.58 1.46 1.16, 1.85 1.0 referent 0.65 0.61, 0.70 0.97 0.90, 1.05 0.95 0.80,1.13 0.66 0.47,0.92 1.0 referent 0.19 0.16,0.21 0.25 0.21,0.30 0.17 0.11,0.26 0.74 0.58, 0.95 1.0 referent 0.82 0.79,0.86 0.63 0.60, 0.67 0.39 0.35, 0.43 1.21 1.05, 1.40 1.0 referent 0.96 0.91, 1.00 1.16 1.08, 1.24 0.58 0.54, 0.62 1.29 1.18, 1.42 0.54 0.47, 0.62 0.94 0.78, 1.14 1.20 0.95, 1.51 1.22 0.88, 1.70 1.0 referent 1.0 referent 0.74 0.69, 0.78 1.16 1.07, 1.26 0.88 0.74, 1.05 0.74 0.53, 1.02 1.0 referent 0.89 0.81,0.97 0.84 0.75,0.94 1.08 0.85, 1.38 0.89 0.56, 1.41 1.0 referent 0.18 0.16, 0.20 0.23 0.20,0.28 0.17 0.11,0.27 0.70 0.55,0.90 1.0 referent 1.04 0.87, 1.25 1.08 0.84, 1.38 0.97 0.52,1.83 1.05 0.74,1.49 1.0 referent 0.76 0.72, 0.79 0.55 0.52, 0.58 0.40 0.36, 0.44 1.09 0.93, 1.27 1.0 referent 1.09 1.02, 1.16 1.15 1.06, 1.24 0.97 0.83, 1.13 1.11 0.90, 1.38 1.0 referent *Includes persons aged 25 years and older. `Education was evaluated at three levels: less than high school education, high school education, and at least some college. SO& = odds ratio not controlling for education; OR, = odds ratio controlling for education. Odds ratios were calculated as follows: OR JOR,, = exp@,,, - pi,), where p,,, is the logistic regression coefficient for the ith ethnic group before controlling for education, and pII is the coefficient after controlling for education. Other variables in the logistic models include age, gender, marital status, geographic region, and year of survey. 595% confidence interval. `Current cigarette smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. The association presented is for current smoking compared with former and never smoking. _Former smokers are those who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking cigarettes. The association presented is for former smoking compared with current smoking. **Heavy smokers include current smokers who reported at the time of survey that they were smoking 25 or more cigarettes per day. The association presented is for heavy smoking compared with current smoking of l-24 cigarettes per day. "Ever smokers are those who reported at the time of survey that they had smoked at least 100 cigarettes in their lives, regardless of their current smoking status. The association presented is for ever smoking compared with never smoking. Sources: National Center for Health Statistics, public use data tapes, 1987,1988,1990, and 1991; Escobedo et al. 1995. Tobacco Use Amo~~g U.S. Rncid/Ethnic Minority Groups variables were created to represent persons with and without a high school education, with persons having at least some college education serving as the refer- ence group. In addition to including race/ethnicity and education, the logistic regression models included the year of the survey, age, gender, marital status, and geographic region. Education was first omitted from and then en- tered in these models. The difference in estimated co- efficients before and after the inclusion of education was computed for each of the four design lrariables representing the different racial/ethnic groups. The variance of this difference was estimated to be the sum of the variances of the two coefficients. The 95 per- cent confidence interval of the difference was com- puted by using this variance estimate. The difference in coefficients was translated into the ratio of the odds ratios before and after adjusting for education (Table 34) (Escobedo et al. 1995). Current Smoking Before adjustment for education, the data indi- cated that African Americans as well as American Indians and Alaska Natives were more likely than whites to be current smokers (Table 34). Hispanics as well as Asian Americans and Pacific Islanders were substantially less likely than whites to be current smok- ers. After adjustment for the confounding effects of education, the odds ratios for current smoking among African Americans and Hispanics decreased signifi- cantly (Table 34). Thus, when the data were adjusted for educa- tion, current smoking among African Americans did not differ from whites-an indication that the differences in the unadjusted rates were probably attributable to factors related to differences in educa- tional attainment. For Hispanics, current smoking was lower than for whites, and adjustment for the confounding effects of education further accentuated these differences. Smoking Cessation African Americans as well as American Indians and Alaska Natives who had ever smoked were sub- stantially less likely than whites to have quit smoking (Table 34). When education was included in these models, the odds ratio for smoking cessation increased, suggesting that lack of education accounts for some but not all of the low rates of quitting in these two groups. Before adjustment for education, the data showed that Hispanics were as likely as whites to quit smoking. However, after adjustment for education, the data showed that Hispanics were more likely than whites to quit smoking. Thus, the unadjusted smok- ing cessation rate was lower among both African Americans and Hispanics than among whites partially because of confounding by educational attainment. A similar magnitude of change was observed among American Indians and Alaska Natives, but this differ- ence was not statistically significant. Educational at- tainment does not explain why African Americans are less likely than whites to quit smoking. Heavy Smoking Members of all four racial/ethnic groups were less likely than whites to be heavy smokers, before and after the data were adjusted for the effects of educa- tion (Table 34). These differences were greatest between whites and Asian Americans and Pacific Is- landers and were smallest between whites and Ameri- can Indians and Alaska Natives. Because the odds ratio of heavy smoking changed little after adjustment for education, the differences in heavy smoking between racial/ethnic groups appear to be independent of factors associated with educational attainment. Ever Smoking Before the data were adjusted for the effects of education, all racial/ethnic groups except Ameri- can Indians and Alaska Natives were substantially less likely than whites to have ever smoked (Table 34). After adjustment for education, the odds ratios for ever smoking among African Americans and Hispanics de- clined even further, and these declines were statisti- cally significant. This finding suggests that if African Americans and Hispanics had socioeconomic status more comparable with that of whites, they would be even less likely ever to smoke than whites. Differences in current smoking, quitting, and ever smoking between whites and Asian Americans and Pacific Islanders also were found. Asian Americans and Pacific Islanders were less likely than whites to be current smokers, substantially less likely to be ever smokers, but also slightly less likely to have quit smok- ing. After adjustment for education, the odds ratios associated with these smoking behaviors changed little (Table 34). Thus, the lower smoking prevalences among Asian Americans and Pacific Islanders may be related to factors other than education-presumably cultural factors associated with being an Asian Ameri- can or a Pacific Islander in the United States. Pnttrrm of Tobncco Use 85 Occasional Smoking In addition to smoking more cigarettes each day whites who currently smoke are generally more likely than members of other racial/ethnic groups to smoke on a daily basis. According to the 1993,1994, and 1995 combined NHISs, 15.2 percent of whites who smoked were occasional (i.e., nondaily) smokers, compared with 26.0 percent of African Americans, 22.2 percent of American Indians and Alaska Natives, 33.1 percent of Asian Americans and Pacific Islanders, and 35.5 per- cent of Hispanics. Only the estimate for American In- dians and Alaska Natives did not differ significantly from that for whites (data not shown) (NCHS, public use data tapes, 1993, 1994, 1995). Husten and Exposure to Environmental Tobacco Smoke colleagues (1998) used data from the 1991 NHIS to study persons who had ever smoked 100 lifetime ciga- rettes but who had never smoked on a daily basis. Among the ever smokers, African Americans (12.0 percent), American Indians and Alaska Natives (15.0 percent), Asian Americans and Pacific Islanders (12.1 percent), and Hispanics (16.8 percent) were all signifi- cantly more likely than whites (6.2 percent1 never to have smoked daily. In gender-specific multivariate analyses that controlled for income, age, and educa- tion, African Americans, Hispanics, and others (Ameri- can Indians and Alaska Natives combined with Asian Americans and Pacific Islanders) were significantly more likely never to have smoked daily. Data on exposure to environmental tobacco smoke (ETS) among members of U.S. racial/ethnic minority groups are extremely limited. In the 1991- 1993 NHIS, nearly one-third of all respondents indi- cated exposure to ETS at home three or more days per week (Table 35) (NCHS, public use data tapes, 1991- 1993). African Americans (37.6 percent) and Ameri- can Indians and Alaska Natives (36.9 percent) were more likely than other groups to report such levels of exposure to ETS at home. These findings are consis- tent with smoking prevalence data presented earlier in this chapter. Similar patterns exist among nonsmok- ers, although the occurrence of higher levels of expo- sure (three or more days) is reduced by 40 to 60 per- cent among nonsmokers compared with the total population. Among Asian American, Pacific Islander, American Indian, and Alaska Native nonsmokers, women had substantially more prolonged exposure than men. Using 1988-1991 NHANES III data on persons aged 17 years and older who did not use tobacco, Pirkle and colleagues (1996) found that 36.9 percent of Afri- can Americans, 35.1 percent of Mexican Americans, and 37.4 percent of whites reported that they were exposed to ETS either at home or at work. Wagen- knecht and colleagues (1993) analyzed data collected in 1985 and 1986 from 3,300 persons aged 18-30 years who were recruited in four urban centers (Birming- ham, Chicago, Minneapolis, and Oakland). African Americans were more likely than whites to report home exposure to ETS and to report that they spent time mostly with smokers. Using 1988 NHIS data on the number of smokers in the home, Overpeck and Moss (1991) estimated that 42.4 percent of US. children aged five years and younger were living in a household with a smoker. In 1988, African American children were more likely to be living with a smoker (51.3 percent) than were white children (41.6 percent), and non-Hispanic chil- dren (43.2 percent) were more likely to be doing so than were Hispanic children (35.8 percent). In recent years, small-scale studies have reported on potential exposure to ETS among young people in U.S. racial/ethnic groups. For example, in two rural Alaska villages, an analysis of saliva samples from chil- dren in the Alaska Native Head Start program showed that 44 percent of the children (3-6 years of age) had cotinine concentrations indicative of exposure to ETS (Etzel et al. 19921. Recent research has compared levels of cotinine (a metabolite of nicotine) in biological flu- ids and hair of children, young adults, and adults Pattishall et al. 1985; Wagenknecht et al. 1993; Crawford et al. 1994; Knight et al. 1996; Pirkle et al. 1996). Most of these investigations (Pattishall et al. 1985; Crawford et al. 1994; Knight et al. 1996; Pirkle et al. 1996) reported that African Americans who did not use tobacco had higher cotinine levels than whites, even after ETS exposure and other factors were taken into account. Further factors, including possible racial differences in nicotine absorption and metabolism (Pattishall et al. 1985; Benowitz et al. 1995; Clark et al. 1996; Knight et al. 1996) and measurement issues, need to be consid- ered (see Racial/Ethnic Differences in Nicotine Metabo- lites in Chapter 3 for further discussion of this topic). Table 35. Percentage of all adults and nonsmokers who reported levels of exposure to environmental tobacco smoke in the home, by racejethnicity and gender, National Health Interview Surveys, United States, 1991-1993 aggregate data Home exposure* African Asian Americans/ American Indians/ Americans Pacific Islanders Alaska Natives Hispanics Whites 7c ,c1+ 7% +CI 7c +CI % +CI % +CI Total(%)* All adults O-2 days Tootal Men Women >3 days Total Men Women Nonsmokers O-2 days Total Men Women >3 days Total Men Women 60.8 1.3 78.5 2.8 60.9 4.5 74.4 1.7 66.9 0.6 67.1 57.3 2.0 76.7 3.7 67.3 6.4 72.4 2.3 66.1 0.7 66.1 63.5 1.5 80.4 3.9 54.9 5.6 76.0 2.1 67.5 0.7 68.0 37.6 0.7 20.5 2.9 36.9 4.4 24.5 1.6 31.9 0.6 31.7 41.1 2.0 21.9 3.7 30.8 6.1 26.3 2.2 32.7 0.7 32.7 34.8 1.5 19.0 3.8 42.7 5.9 22.7 2.1 31.3 0.7 30.8 80.4 1.3 87.6 L.3 3' 83.6 1.5 86.6 1.4 85.7 0.5 85.3 80.1 2.1 92.0 2.8 90.0 4.9 87.2 2.0 85.2 0.7 85.1 80.6 1.5 84.0 3.7 78.8 7.0 86.1 1.9 86.2 0.6 85.4 18.3 1.2 11.7 2.5 13.5 4.3 12.6 1.4 13.5 0.5 13.9 18.6 2.0 7.0 2.7 9.5 4.8 12.0 1.9 14.0 0.7 14.0 15.1 1.5 15.5 3.6 17.8 6.4 13.0 2.0 13.1 0.6 13.8 *Home exposure was the average number of days per week that anyone was inside the home, as reported by respondents answering "yes" to the question, "Does anyone smoke cigarettes, cigars, or pipes anywhere inside this home?" However, these percentages include persons who indicated no exposure. Percentages exclude "don't know" and "not ascertained" responses regarding the number of days; therefore, the sum may not total 100%. `95% confidence interval. tTotal includes persons of other, unknown, or multiple ethnicities and unknown Hispanic origin. Source: National Center for Health Statistics, public use data tapes, 1991-1993. Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use Cigarette Smoking The most recent data from the 1994 and 1995 com- bined NHISs show that the age-adjusted prevalence of current cigarette smoking was highest among American Indians and Alaska Natives (36.0 percent), intermediate among African Americans (26.5 percent) and whites (26.4 percent), and lowest among Hispan- ics (18.0 percent) and Asian Americans and Pacific Is- landers (14.2 percent) (Table 36) (NCHS, public use data tapes, 1994-1995). Among all racial/ethnic groups except American Indians and Alaska Natives, men had significantly higher rates of cigarette smoking than women. Using data from the NC1 Supplement of the 1992-1993 CPS, Shopland and colleagues (1996) re- ported patterns similar to those seen in the NHIS for African Americans, Asian Americans and Pacific Is- landers, Hispanics, and whites (data on American In- dians and Alaska Natives were not included in their report). From 1978 through 1995, the age-adjusted prevalence of smoking declined for African Americans, Asian Americans and Pacific Islanders, and Hispanics- overall and for both men and women (Figures 13-15) (NCHS, public use data tapes, 1978-1995). A differ- ent picture emerges for American Indians and Alaska Natives. Although a fairly substantial decline in prevalence was observed, particularly among men, for American Indians and Alaska Natives from 1978- 1980 to 1983-1985, prevalence did not change overall or for men from 1983-1985 to 1994-1995 or for women from 1978-1980 to 1994-1995. Table 36. Age-adjusted prevalence of current cigarette smoking" among adults, overall and by race/ ethnicity and gender, National Health Interview Surveys, United States, 1994 and 1995 aggregate data African American Indians/ Americans Alaska Natives Characteristic % %I+ % XI Asian Americans/ Pacific Islanders % ?CI Hispanics % XI Whites % %I Total 26.5 1.7 36.0 6.0 14.2 2.7 18.0 1.5 26.4 0.7 Men 31.4 2.6 39.3 9.5 23.8 5.1 21.7 2.3 28.1 1.0 Women 22.2 1.8 32.9 8.0 5.4 2.1 14.6 1.8 25.0 0.9 *Current cigarette smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. Data were age-adjusted to the 1990 U.S. census population. `95% confidence interval. Source: National Center for Health Statistics, public use data tapes, 1994-1995. Figure 13. Trends in the age-adjusted prevalence of current cigarette smoking among African American, American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white adults, National Health Interview Surveys, United States, 1978-1995 aggregate data 70 60 African - Americans American Indians and Alaska Natives Asian Americans and Pacific Islanders 10- ----- Hispanics Whites 0 I I I I I I II 1 II I I I I I 11 11 11 11 11 11 II 1 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year Note: Data were age-adjusted to Ihe 1990 U.S. census population. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Figure 14. Trends in the age-adjusted prevalence of current cigarette smoking among African American, American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white men, National Health Interview Surveys, United States, 1978-1995 aggregate data 70- . 60- `%, o ? ?? o ? ?? 50- *, o ? o ? 5 40- `=: 6 ; 30 c 20- 10 -I African - Americans American - n - I. Indians and Alaska Natives Asian Americans and Pacific Islanders De-D Hispanics - Whites O,,,l,l,l l,l,,/l/ll/llIlIIIII IllI 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year Note: Data were age-adjusted to the 1990 U.S. census population. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Figure 15. Trends in the age-adjusted prevalence of current cigarette smoking among African American, American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white women, National Health Interview Surveys, United States, 1978-1995 aggregate data African - Americans American 1111. Indians and Alaska Natives Americans and Pacific t Islanders 20 -. ---D Hispanics - Whites 0fl,ll,ll,,,l,l,l,ll,llllllllllll 1978-80 1983-85 1987-88 1990-91 1992-93 1994-95 Year Note: Data were age-adjusted to the 1990 U.S. census population. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patferns of Tobacco Use 89 Table 37. Cigarette smoking status *+ and number of cigarettes smoked per dayt among adults, overall and by race/ethnicity and gender, National Health Interview Surveys, United States, 1987, 1988,1990, and 1991 aggregate data Characteristic African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Total Never smokers Former smokers Current smokers Cigarettes smoked per day <15 cigarettes 15-24 cigarettes 225 cigarettes 54.4 41.1 70.6 15.4 21.9 13.4 30.1 37.1 16.0 59.6 39.7 58.1 32.4 40.4 35.3 8.0 19.9 6.5 Men Never smokers Former smokers Current smokers Cigarettes smoked per day <15 cigarettes 15-24 cigarettes 225 cigarettes 44.6 36.1 56.8 19.6 26.0 19.6 35.9 38.0 23.6 54.1 27.5 56.1 36.3 49.7 37.8 9.6 22.8 6.1 Women Never smokers 62.6 46.0 85.3 Former smokers 12.0 17.9 6.9 Current smokers 25.4 36.2 7.8 Cigarettes smoked per day <15 cigarettes 65.8 52.3 64.6 15-24 cigarettes 27.9 30.9 27.6 225 cigarettes 6.3 16.8 7.9 Note: For racial/ethnic-specific data on cigars, pipes, chelving tobacco, snuff, or any form of tobacco, see Table 38. *Never smokers are those who reported that they had never smoked at least 100 cigarettes; former smokers are those who reported smoking at least 100 cigarettes in their lives but ~.ho reported at the time of survey that they did not currently smoke; and current smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. `95% confidence intervals for cigarette smoking status do not exceed 10.6% for whites, +1.4% for African Americans, *3.1% for Asian Americans and Pacific Islanders, f6.6'k for American Indians and Alaska Natives, i-0.5% for all non-Hispanics, ?1.7% for all Hispanics, *2.3% for Mexican Americans, k5.2R for Puerto Ricans, +6.5% for Cuban Americans, ?3.3% for other Hispanics, and +0.5% for the total population. Analyses of aggregated NHIS data from the 1987, Pacific Islanders (16.0 percent). The prevalence of 1988,1990, and 1991 surveys indicate differing patterns never smoking cigarettes was highest among Asian in the prevalence of current smoking, never smoking, Americans and Pacific Islanders (70.6 percent) and former smoking, and cigarette consumption among lowest among American Indians and Alaska Natives members of the four racial/ethnic groups (Table 37) (41 .l percent). Rates of former cigarette smoking were (NCHS, public use data tapes, 1987, 1988, 1990, and highest among whites (26.0 percent) and lowest among 1991). The prevalence of current cigarette smoking was Asian Americans and Pacific Islanders (13.4 percent). highest among American Indians and Alaska Natives Overall, men were more likely than women to be cur- (37.1 percent) and lowest among Asian Americans and rent or former smokers, whereas women were more Hispanics All Hispanics Cuban Americans Puerto Ricans Mexican Americans Other Hispanics Whites Total5 60.3 61.9 58.7 61.0 59.3 46.7 49.2 17.2 17.5 16.3 16.8 18.4 26.0 23.8 22.5 20.7 25.0 22.2 22.4 27.3 27.0 61.4 43.3 52.2 68.4 57.9 26.8 33.4 30.0 40.1 36.7 25.7 44.8 32.0 42.3 8.6 16.6 11.1 5.9 10.1 28.3 24.3 49.8 49.6 52.4 38.9 50.6 38.9 40.7 21.6 24.1 19.4 22.1 20.8 32.1 29.6 28.6 26.3 28.3 29.0 28.6 29.1 29.6 58.8 38.5 52.1 65.9 52.4 21.7 29.1 30.9 39.9 31.7 27.2 35.7 42.9 41.2 10.3 21.6 16.2 6.9 11.9 35.4 29.7 69.5 71.1 63.3 72.7 66.5 53.9 56.8 13.4 12.5 14.0 11.7 16.3 20.4 18.6 17.0 16.4 22.7 15.5 17.2 21.7 24.6 65.2 49.2 52.3 72.8 65.9 32.1 38.1 28.8 40.4 41.1 23.2 26.6 46.9 43.5 6.0 10.5 6.6 4.0 17.5 21.1 18.4 t95% confidence intervals for the number of cigarettes smoked dailv do not exceed +0.8% for whites, +2.2% for African Americans, f9.7% for Asian Americans and Pacific Islanders, *10.4% for American Indians and Alaska Natives, +0.9%' for all non-Hispanics, f3.4% for all Hispanics, *4.7% for Mexican Americans, f8.6% for Puerto -Ricans, f12.4% for Cuban Americans, f6.8% for other Hispanics, and +O.S% for the total population. "Includes persons of other, unknown, or multiple ethnicities and of unknown Hispanic origin. Source: Centers for Disease Control and Prevention 1994~. likely than men never to have smoked. Among Afri- can Americans, Asian Americans and Pacific Island- ers, and all Hispanics except Cuban Americans, the majority of current smokers reported smoking fewer than 15 cigarettes per day, whereas whites, American Indians and Alaska Natives, and Cuban Americans were more likely than others to report smoking 25 or more cigarettes per day. For all groups except Puerto Ricans, women were much more likely than men to report smoking fewer than 15 cigarettes per day. Pipe and Cigar Use The prevalence of current pipe or cigar use has been higher among American Indians and Alaska Na- tives than among other racial/ethnic groups, accord- ing to aggregated data from the 1987 and 1991 NHISs (Table 38) (NCHS, public use data tapes, 1987 and 1991). Current pipe or cigar use occurred primarily among men; use was negligible among women of all racial/ethnic groups. The prevalence of cigar or pipe Patftws of Tobacco Use 91 Table 38. Percentage of adults tobacco, overall and who reported using cigars, pipes, chewing tobacco, snuff, or any form of by race/ethnicity and gender, National Health Interview Surveys, United States, 1987 and 1991 aggregate data* Characteristic African American Indians/ Americans Alaska Natives Asian Americans/ Pacific Islanders Cigar smoking+ Total Men Women Pipe smoking* Total Men Women Cigar or pipe smoking+t Total Men Women Any tobacco smoking' Total Men Women Use of chewing tobacco1 Total Men Women Use of snuff** Total Men Women Use of chewing tobacco or snuffl*' Total Men Women Use of any tobacco product++ Total Men Women 1.8 2.7 1.1 3.9 5.3 2.2 0.1 0.2 0.1 1.1 3.5 2.4 6.9 0.0 0.0 2.5 4.9 1.7 5.6 9.8 3.3 0.1 0.2 0.1 32.6 36.4 16.0 40.2 37.3 24.0 26.5 35.6 7.8 2.0 3.1 0.2 2.7 5.3 0.4 1.5 0.8 0.0 1.4 1.8 0.5 0.9 3.2 0.9 1.9 0.4 0.0 3.0 4.5 0.6 3.1 7.8 1.2 2.9 1.2 0.0 35.2 40.2 16.8 42.4 43.9 25.6 29.3 36.6 7.9 1.2 5:; Note: For racial/ethnic-specific data on cigarette smoking, see Table 37. *95% confidence intervals do not exceed +0.7% for whites, *2.1% for African Americans, f4.0% for Asian Americans and Pacific Islanders, f9.6% for American Indians and Alaska Natives, f0.7% for all non- Hispanics, f2.27~ for all Hispanics, &2.9% for Mexican Americans, +_7.0% for Puerto Ricans, f8.0% for Cuban Americans, +3.9% for other Hispanics, and +0.7% for the total population. `Includes persons who reported they had smoked at least 50 cigars in their lives and who reported at the time of survey that they currently smoked a cigar. tlncludes persons who reported they had smoked a pipe at least 50 times in their lives and who reported at the time of survey that they currently smoked a pipe. gIndicates a value of >O and ~0.05. smoking among men was highest among American Indians and Alaska Natives (9.8 percent) and lowest among Puerto Ricans (1.5 percent). Unfortunately, the 1987 and 1991 NHISs did not distinguish between ceremonial and addictive daily pipe smoking, and this factor may partially account for the high prevalence of pipe smoking among American Indian and Alaska Native men. Tobrrcco USC Alnong U.S. Racinl/Ethnic Minority Groups Hispanics All Cuban Hispanics Americans Puerto Ricans Mexican Americans Other Hispanics Whites Total 1.1 1.0 0.7 0.6 1.9 2.3 2.1 2.1 1.3 1.5 3.8 4.8 4.4 0.1 0.1 0.0 0.2 0.1 0.1 0.5 1.1 0.1 0.7 0.8 1.4 1.3 1.0 2.6 0.2 1.5 1.7 2.9 2.7 0.0 0.0 0.0 0.0 0.0 0.1 o.os ::; 2.1 5.1 0.8 1.5 2.7 1.2 4.3 2.1 3.3 6.7 3.0 6.2 0.1 0.0 0.1 0.0 0.2 0.1 0.1 22.7 22.5 22.1 26.8 21.7 29.6 29.1 29.3 30.8 29.4 31.9 27.2 33.2 33.4 16.8 16.9 14.8 23.1 16.9 26.3 25.2 0.4 0.0 0.4 0.1 0.5 2.0 0.7 0.0 0.8 0.3 1.1 4.1 0.1 0.0 0.1 0.0 0.1 0.1 0.3 0.5 0.1 0.6 0.3 0.8 1.9 1.7 1.0 0.3 1.0 0.6 1.6 3.8 0.1 0.0 0.2 0.0 0.0 0.3 Z:i 0.8 0.1 0.9 0.3 1.1 3.4 3.1 1.5 0.3 1.5 0.6 2.3 6.8 5.9 0.1 0.0 0.3 0.0 0.1 0.3 0.6 23.4 22.7 22.9 27.4 22.4 32.2 31.5 30.4 31.2 30.7 32.8 28.4 38.0 37.6 17.0 17.0 15.1 23.3 17.1 26.8 26.0 -\Includes current users of cigarettes, cigars, or pipes. _Includes persons who reported thev had used chewing tobacco at least 20 times in their lives and who reported at the time of survey that they currently chewed tobacco. **Includes persons who reported they had used snuff at least 20 times in their lives and who reported at the time of survey that they currently used snuff. `+Includes users of cigarettes, cigars, pipes, chewing tobacco, or snuff. Source: Centers for Disease Control and Prevention 1994~. A 1996 survey of U.S. students aged 14-19 years found that white (28.9 percent) and Hispanic (26.2 per- cent) students were slightly more likely than African American students (19.3 percent) to report having smoked at least one cigar during the previous year. In each racial/ethnic group, males were significantly more likely than females to have smoked at least one cigar during the previous year. Use among females ranged from 13.4 percent in African Americans to 20.0 percent among Hispanics. The prevalence of more Pattcrm of Tobncco USC 93 frequent cigar use did not differ by racejethnicity; 3.6 percent of African Americans, 2.5 percent of Hispanics, and 2.3 percent of whites reported that they had smoked at least 50 cigars during the previous year (CDC 1997b). Use of Smokeless Tobacco American Indians and Alaska Natives were the most likely (4.5 percent) to use chewing tobacco or snuff, according to aggregated data from the 1987 and 1991 NHISs, whereas Asian Americans and Pacific Island- ers (0.6 percent) as well as Hispanics (0.8 percent) were the least likely to use smokeless tobacco (Table 38). Conclusions Among all racial/ethnic groups except African Ameri- cans, men were much more likely than women to use chewing tobacco or snuff. Among African American women, the use of smokeless tobacco has been high- est among those aged 65 years and older (CDC 1994~). These findings are consistent with those in published studies (Bauman et al. 1989; Novotny et al. 1989; Rouse 1989), although they differ somewhat from the 1985 CPS estimates for males aged 16 years and older; these estimates showed rates of reported snuff use among African Americans (0.7 percent) and whites (2.2 per- cent) that were significantly lower than the NHIS- based rates reported here (Marcus et al. 1989). 1. 2. 3. 4. 5. 6. In 1978-1995, the prevalence of cigarette smoking declined among African American, Asian Ameri- can and Pacific Islander, and Hispanic adults. However, among American Indians and Alaska Natives, current smoking prevalence did not change for men from 1983 to 1995 or for women from 1978 to 1995. Tobacco use varies within and among racial/ ethnic groups; among adults, American Indians and Alaska Natives have the highest prevalence of tobacco use; African American and Southeast Asian men also have a high prevalence of smok- ing. Asian American and Hispanic women have the lowest prevalence. In all racial/ethnic groups discussed in this report except American Indians and Alaska Natives, men have a higher prevalence of cigarette smoking than women. In all racial/ethnic groups except African Ameri- cans, men are more likely than women to use smokeless tobacco. Cigarette smoking prevalence increased in the 1990s among African American and Hispanic ado- lescents after several years of substantial decline among adolescents of all four racial /ethnic minor- ity groups. This increase is particularly striking among African American youths, who had the greatest decline of the four groups during the 1970s and 1980s. Since 1978, the prevalence of cigarette smoking has remained strikingly high among American Indian 7. 8. 9. 10. and Alaska Native women of reproductive age and has not declined as it has among African Ameri- can, Asian American and Pacific Islander, and Hispanic women of reproductive age. Declines in smoking prevalence were greater among African American, Hispanic, and white men who were high school graduates than they were among those with less formal education. Among women in these three groups, education- related declines in cigarette smoking were less pronounced. Educational attainment accounts for only some of the differences in smoking behaviors (current smoking, heavy smoking, ever smoking, and smoking cessation) between whites and the racial/ ethnic minority groups discussed in this report. Other biological, social, and cultural factors are likely to further account for these differences. Compared with whites who smoke, smokers in each of the four racial/ethnic minority groups smoke fewer cigarettes each day. Among smok- ers, African Americans, Asian Americans and Pa- cific Islanders, and Hispanics are more likely than whites to smoke occasionally (less than daily). The data in general suggest that acculturation in- fluences smoking patterns in that individuals tend to adopt the smoking behavior of the current broader community; however, the exact effects of acculturation on smoking behavior are difficult to quantify because of limitations on most available measures of this cultural learning process. Appendix 1. Sources of Data Most of the data reported in this chapter were collected through a number of large-scale sur\reys conducted by the federal go\`ernment or private researchers. When data from one period were insuffi- cient (e.g., because of small sample size) for estimat- ing the prevalence of a risk factor or a behaI,ior, thev were combined with similar data for several periods, provided the prevalence under consideration had not changed rapidly over the periods being aggregated. This process, used in some of the NHIS and BRFSS analyses, increased the reliabilitlr and stabilitv of preva- lence estimates (CDC lY92e). The data reported in this chapter are limited in several ways. For example, because some racial/ ethnic groups were underrepresented in the data sources, the small number of responses ma\' not be representativre of the group as a whole. Moreo\.er, most surveys haire been conducted in English only, thus limiting the validitv of the responses of indi\pidu- als with limited proficiency in English, particularly among Asian Americans, Pacific Islanders, and His- panics. In addition, some surveys ha\,e used tele- phone surveys (excluding persons who lack telephone service) or school surveys (excluding youths who dropped out of school or who were frequently absent from class); these survreys have thus excluded a num- ber of respondents who may be at increased risk for cigarette smoking. Despite these limitations, the pat- terns described in this chapter are the first and largest effort to present a comprehensive perspective on ciga- rette use among members of racial/ethnic minority groups in the United States. National Health Interview Survey (NHIS) Since 1965, the CDC's NCHS has collected data on tobacco use through the NHIS, which uses a prob- ability sample of noninstitutionalized adult civilians in the United States (NCHS 1975,1985a, 1989). Some NHISs have excluded adults 18 and 19 years of age; however, this report uses data from surveys that have included respondents who were aged 18 years and older (i.e., 1978,1979,1980,1983,1985,1987,1988,1990, 1991,1992,1993,1994, and 19951. Most interviews were conducted in the home; when respondents could not be interviewed in person, telephone interviews were conducted. The overall NHIS response rate for surveys on smoking has remained at least 85 percent (NCHS 1985a). Overall, sample sizes have ranged from 10,342 in 1980 to 86,332 in 1966. In this report, data have been adjusted for nonresponse and have been weighted to provide national estimates. Confidence intervals have been calculated by using standard er- rors generated by the Professional Software for Survey Data Analysis (SUDAAN) (Shah et al. 1991). Responses from various administrations of the NHIS have been aggregated to produce more stable results for Hispanics, Asian Americans and Pacific Islanders, and American Indians and Alaska Natives. Hispanic Health and Nutrition Examination Survey (HHANES) The NCHS conducted the HHANES from 1982 through 1984 to assess the health and nutritional status and needs of Cuban Americans, MexicanAmeri- cans, and mainland Puerto Ricans. No other equiva- lent source of recent data is available for Hispanics. This survey sampled Mexican Americans from Ari- zona, California, Colorado, New Mexico, and Texas; Cuban Americans from Dade County, Florida (Miami); and Puerto Ricans from New York, New Jersey, and Connecticut. Demographic and cigarette smoking in- formation were collected from Hispanics aged 20-74 vears. All interviews were conducted in the home or i in a mobile examination center. NCHS estimates that the HHANES data represent approximately 76 percent of the 1980 Hispanic-origin population. All data in this report have been adjusted and weighted for the complex sample design, nonresponse bias, potential noncoverage bias, and regional nature of the sample (NCHS 1985b). Behavioral Risk Factor Surveillance System (BRFSS) The CDC's National Center for Chronic Disease Prevention and Health Promotion coordinates the state surveillance of behavioral risk factors through the BRFSS, initiated in 1981 (Gentry et al. 1985; Remington et al. 1988). Each state that participates in the BRFSS provides estimates of numerous risk behaviors for the state's population of persons aged 18 years and older. Paftcnls of rolJncc0 Use 95 States collect data through random digit-dialed telephone interviews. BRFSS sample sizes have ranged from 476 in Indiana in 1984 to 3,988 in California in 1992. Since 1991, at least 1,178 persons have been sampled in each state. In this report, the data have been weighted to reflect the age, race/ethnicity, and gender distribution of each participating state. Ninety- five percent confidence intervals have been calculated by using the Standard Errors Program for Computing of Standardized Rates from Sample Survey Data (SESUDAAN) (Shah 1981). Adult Use of Tobacco Survey (AUTS) Since 1964, the AUTS has been conducted peri- odically to determine rates of tobacco use as well as descriptive information on smoking patterns among representative samples of the U.S. population. Infor- mation gathered has included a history of individual use of any tobacco product as well as attitudes and beliefs about smoking-related issues. The AUTS was conducted in 1964, 1966, 1970, and 1975 by the USDHEW's National Clearinghouse for Smoking and Health, and the most recent survey was conducted in 1986 by the CDC's Office on Smoking and Health. In the 1986 AUTS, a computer-assisted telephone inter- view protocol (random-digit dialing) was used to sur- vey 13,031 noninstitutionalized civilian U.S. adults (217 years of age). Population estimates were obtained by weighting the sample according to smoking status, age, race/ethnicity, gender, education, and geographic region (USDHHS 1990b). Monitoring the Future (MTF) Surveys Each spring since 1975, the University of Michigan's Institute for Social Research, with grants from NIDA, has surveyed nationally representative samples of high school seniors as part of the MTE Sample sizes have ranged from 15,850 to 18,448. The data in this report have been weighted to provide na- tional estimates. Analyses were conducted on data collected for 1976-1994. Data from subsequent years were obtained from published reports (e.g., Johnston et al. 1996) and from the University of Michigan's In- stitute for Social Research. Since 1991, data have been collected for eighth- and tenth-grade students. Some data from these surveys are cited in this report (Johnston et al. 1993b, 1995a, 19961. Youth Risk Behavior Survey (YRBS) The CDC developed the Youth Risk Behavior Sur- veillance System to measure six categories of priority health-risk behaviors, including tobacco use, among adolescents. Data were collected through national, state, and local school-based surveys of high school stu- dents, conducted during the spring of odd-numbered years, and a national household-based survey of youths aged 12-21 years, conducted during 1992 (Kolbe 1990; Kolbe et al. 1993; CDC 1996). Data from the 1991 and 1995 national school-based surveys and the 1992 na- tional household survey are cited in this report (USDHHS 1994; CDC 1996; Lowry et al. 1996). The national school-based YRBSs each used a three-stage cluster sample design to draw a nationally representative sample of ninth- to twelfth-grade stu- dents in public and private schools in all 50 states and the District of Columbia. Schools having a substantial proportion of African American and Hispanic students were oversampled. The questionnaire was adminis- tered in the classroom by trained data collectors. The data were weighted to provide national estimates. The 1992 YRBS was a follow-back survey to the 1992 NHIS. The sample of young people aged 12-21 years was drawn from families who were interviewed for the 1992 NHIS. Participants responded in person. Respondents listened through a headset to an audio- cassette containing previously recorded questions. Respondents recorded their responses on answer sheets, which were returned to the interviewers in sealed envelopes. The data were weighted to provide national estimates. Teenage Attitudes and Practices Survey (TAPS) In 1989 and 1993, the U.S. Public Health Service conducted the TAPS to collect data on knowledge, at- titudes, and practices regarding tobacco use from a national household sample of adolescents (aged 12-18 years) through telephone interviews. The 1993 TAPS included a longitudinal component (TAPS-II) in which 7,960 (87.1 percent) of the 9,135 respondents to the 1989 TAPS were reinterviewed; these respondents were 15- 22 years of age during TAPS-II. TAPS-II also included 4,992 persons from a new probability sample. In this report, data on 9,135 TAPS respondents and 7,311 TAPS- II respondents have been analyzed. Data have been weighted to provide national estimates, and confidence intervals have been calculated by using the standard errors generated by the SUDAAN (Shah et al. 1991). Tobacco Use Among U.S. Racinl/Efhnic Mi~orify Grcmps Appendix 2. Measures of Tobacco Use Several measures of tobacco use among members of racial/ethnic groups can be derived from state and national surveys and other data sources. The most common measures include cigarette smoking and ces- sation; the number of cigarettes smoked daily; and the use of cigars, pipes, and smokeless tobacco. Cigarette Smoking and Cessation The NHIS gathers information on a range of ciga- rette smoking behaviors, using some of the following terms and measurements: For 197881991, ci~~~zt srr~okcrs are defined as those who have smoked 100 or more cigarettes in their lifetime and who report at the time of survey that they currently smoke. For 1992-1995, current smokers are defined as those who have smoked at least 100 cigarettes in their lives and who report at the time of survey that they currently smoke ev ery day or on some days. Former smokers are those who have smoked 100 or more cigarettes in their lifetime and who do not currently smoke. Netler smokers are those who have smoked fewer than 100 cigarettes in their lifetime. Ezler smokers consist of current smokers and former smokers. The prevalence ofcessafi~ (or quit ratio) is defined as the percentage of ever smokers who are former smokers (Fiore et al. 1989; USDHHS 1989,199Oa). NHIS data on age at initiation of regular smok- ing and on duration of abstinence for former smokers have been used to reconstruct the prevalence of ciga- rette smoking for the decades in this century before systematic surveillance of cigarette smoking was conducted (NC1 1991). Information such as the respondent's date of birth, age at initiation of smok- ing, and age at cessation for former smokers can be used to assess the smoking status of a respondent for any given year. Similar analyses have been reported in previous Surgeon General's reports (USDHHS 1980, 1985) and in the literature (Harris 1983; Escobedo and Remington 1989; Pierce et al. 1991b). The BRFSS has routinely reported estimates of "regular" cigarette smoking. Current regular smok- ers are defined as those (1) who report that they have smoked 2100 cigarettes and that they currently smoke and (2) who do not respond that they are occasional smokers when asked to report the average number of cigarettes they smoke daily. The use of a measure of current regular smoking generally results in median prevalence estimates that are about 0.7 to 1.0 percent- age points lower than those estimates that include current occasional smokers (CDC 1994~). The BRFSS defines and calculates the prevalence of smoking ces- sation in the same manner as is done in the NHIS. In the MTF surveys, current cigarette use patterns are defined as any use of cigarettes within the 30 days preceding the survey. This same definition was used for current alcohol, marijuana, cocaine, and any other illicit drug use. Number of Cigarettes Smoked Daily Cigarette consumption traditionally has been reported in three categories: (1) smoking fewer than 15 cigarettes per day, (2) smoking between 15 and 24 cigarettes per day, and (3) smoking 25 or more ciga- rettes per day. In the NHISs and the BRFSS surveys, respondents were asked to report the actual number of cigarettes smoked per day. In the 1978-1991 NHISs, cigarette consumption was defined as the average number of cigarettes that current smokers reported smoking each day. Starting in 1992, however, current smokers who reported that they smoked only on some days were asked to report the number of days out of the past 30 days that they smoked any cigarettes and the average number of ciga- rettes they smoked on the days that they smoked. The MTF survey asks respondents how fre- quently they have smoked during the previous 30 days. Possible responses are "not at all," "less than one cigarette per day, " "one to five cigarettes per day," "about one-half pack per day," "about one pack per day," " about one and one-half packs per day," and "two packs or more per day." Use of Cigars, Pipes, and Smokeless Tobacco The 1987 and 1991 NHISs defined current cigar smokers as those who had smoked 50 or more cigars in their lifetime and who were current cigar smokers, and they defined current pipe smokers as those who had smoked 50 or more pipes full of tobacco and who were current pipe smokers. Current snuff users were defined as those who had used snuff 20 or more times and were currently snuff users. The same logic was used to classify chewing tobacco users. In the BRFSS surveys, smokeless tobacco users were defined as those who said that they had ever used smokeless tobacco (such as chewing tobacco or snuff) and who were current users of any smokeless tobacco products. Appendix 3. Patterns of Cigarette Use Among Whites Table 39. Percentage of white adults who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic 7c kC1t % XI % IfrcI % %I Total 42.1 0.6 42.4 0.5 37.0 0.7 36.4 0.8 Gender Men Women 51.1 0.8 51.8 0.8 43.2 0.8 41.9 1.0 34.0 0.7 33.9 0.7 31.6 1.0 31.7 1.1 Age (years) 18-34 35-54 255 48.6 1.0 48.3 0.9 48.5 0.9 48.7 0.9 26.3 0.9 27.4 0.9 41.3 42.8 25.1 0.9 40.7 1.6 41.9 1.1 24.9 1.1 Education5 Less than high school High school Some college College 4?% NA 0.7 NA NA 40.4-' 1.3 41.3 0.9 37.1 1.0 36.9 1.3 44.3 1.0 39.0 0.9 38.1 1.3 44.4 1.8 38.5 1.4 37.9 2.0 35.2 1.8 28.6 1.5 28.2 1.7 1985 1987 1988 1990 Characteristic YC kC1 5% !CCI 7c KI YC XI Total 29.9 0.7 29.0 0.7 28.2 0.6 25.9 0.6 Gender Men Women 31.8 1.0 30.6 0.9 30.3 0.9 27.8 0.9 28.2 0.9 27.5 0.8 26.3 0.7 24.1 0.8 Agleg!y;rs) 35-54 33.6 1.2 32.2 1.1 31.9 1.1 29.7 1.0 33.7 1.2 33.7 1.0 32.1 1.0 29.9 1.0 21.5 1.0 20.2 0.9 19.7 0.8 16.8 0.8 255 Education_ Less than high school High school Some college College 33.7 1.6 34.8 1.6 33.7 1.3 32.0 1.5 33.1 1.2 32.6 1.1 32.6 1.0 30.0 1.0 30.3 1.6 28.5 1.3 27.8 1.3 24.9 1.2 18.3 1.2 16.9 1.0 16.2 1.0 13.7 0.9 *Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data exclude those whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 1976+ 1977+ 1978 1979 1980 1983 35.0 0.7 34.0 1.2 33.4 0.8 33.0 1.1 32.3 0.7 39.0 1.0 37.3 1.9 36.6 1.0 36.5 1.6 34.6 1.1 31.8 1.1 31.1 1.3 30.6 1.0 29.8 1.5 30.2 0.9 38.9 1.5 37.0 1.8 37.3 1.3 35.2 1.8 36.0 1.2 41.1 1.1 40.5 2.0 38.4 1.3 38.8 2.0 37.4 1.3 25.1 1.1 23.6 1.7 23.6 0.9 24.3 1.6 22.5 1.1 35.7 1.3 35.6 2.2 35.1 1.5 35.5 2.0 35.3 1.6 37.8 1.4 37.0 1.9 35.3 1.3 34.9 2.0 34.8 1.3 37.0 1.8 34.1 3.1 35.7 1.8 33.9 3.1 32.8 1.9 25.9 1.7 23.8 2.6 23.2 1.6 24.4 2.3 20.1 1.5 35.9 40.7 31.9 40.0 41.2 25.0 36.6 37.6 37.6 27.2 0.7 1.1 1.0 1.2 1.4 1.1 1.5 1.4 2.1 1.7 1991 1992 1993 1994 1995 YC XI YC %I Yc KI 5% XI YC ASI 26.0 0.6 27.5 0.9 24.6 0.7 29.8 1.0 30.0 1.0 17.3 0.8 33.3 1.5 30.6 0.9 24.9 1.2 13.8 0.9 27.2 0.8 25.4 0.8 25.5 0.7 25.6 1.0 28.6 1.2 27.0 1.2 28.2 1.1 27.1 1.5 25.9 1.1 24.0 1.0 23.1 0.9 24.1 1.3 32.8 1.5 30.1 1.4 29.3 1.4 29.7 1.8 30.1 1.3 29.3 1.4 28.9 1.2 28.3 1.6 17.5 1.2 15.8 1.1 16.2 1.1 17.8 1.3 32.0 2.0 31.8 2.6 31.9 1.8 33.3 2.6 31.9 1.4 29.1 1.3 29.8 1.3 30.2 1.7 25.9 1.7 24.9 1.7 25.7 1.7 24.1 1.9 14.8 1.3 13.5 1.3 12.3 1.1 14.0 1.6 `The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for whites aged 18 years and older. Estimates for ersons in the 18-34 year old age category were statisti- i$ cally adjusted to produce estimates that approximate thos t95'% confidence interval. for whites aged 18-34 years. 51ncludes persons aged 25 years and older. `Levels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Pnffer~ls of l-dm-co Use 99 Table 40. Percentage of adult white smokers* who reported smoking <15,1>24, and 2 25 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 Characteristic Total <15 cigarettes 15-24 cigarettes 2 25 cigarettes Gender Men <15 cigarettes 15-24 cigarettes 225 cigarettes Women <15 cigarettes 15-24 cigarettes 225 cigarettes Age (years) 18-34 <15 cigarettes 15-24 cigarettes 2 25 cigarettes 35-54 <15 cigarettes 15-24 cigarettes 225 cigarettes 255 <15 cigarettes 15-24 cigarettes 225 cigarettes Educations Less than high school <15 cigarettes 15-24 cigarettes 225 cigarettes High school cl5 cigarettes 15-24 cigarettes 225 cigarettes Some college <15 cigarettes 15-24 cigarettes 225 cigarettes College cl5 cigarettes 15-24 cigarettes 225 cigarettes 1965 1966 1970 1974 YC KI 33.1 1.1 31.7 0.8 29.7 0.9 27.7 1.2 45.3 0.8 45.9 0.9 45.0 0.9 44.7 1.2 21.6 0.7 22.4 0.7 25.4 0.9 27.6 1.1 26.6 1.0 25.8 1.0 24.4 1.2 21.5 1.6 46.7 1.1 47.2 1.2 45.2 1.2 44.5 1.9 26.7 0.9 27.0 1.0 30.4 1.2 34.1 1.7 41.8 1.3 39.5 1.2 35.9 1.1 34.5 1.7 43.4 1.3 44.3 1.3 44.7 1.1 45.0 1.6 14.8 0.9 16.2 1.0 19.4 0.9 20.5 1.2 34.7 1.4 33.9 1.3 31.6 1.2 30.9 1.8 47.4 1.5 48.2 1.3 46.9 1.2 46.3 1.8 17.9 1.1 17.9 1.0 21.6 1.2 22.8 1.6 29.0 1.1 26.7 1.1 24.7 1.1 21.4 1.6 45.1 1.2 45.5 1.3 44.2 1.2 42.9 1.8 28.0 1.2 27.8 1.1 31.1 1.1 35.7 1.7 40.1 1.9 38.8 1.9 36.3 1.6 32.7 2.4 41.5 1.9 42.2 1.9 42.7 1.4 44.7 2.4 18.4 1.5 18.8 1.5 21.1 1.5 22.7 2.3 NA NA 30.7 1.3 28.6 1.5 25.7 2.0 NA NA 45.8 1.3 44.3 1.2 45.1 2.1 NA NA 23.5 1.2 27.0 1.4 29.2 1.8 31.1l 1.0 28.5 1.4 26.2 1.4 25.7 2.0 15.9l 1.1 46.9 1.7 47.3 1.4 44.7 2.3 23.0' 0.9 24.6 1.4 26.5 1.3 29.6 1.9 NA NA 29.4 2.7 27.1 2.4 23.1 3.1 NA NA 44.6 3.0 43.1 2.8 42.7 3.3 NA NA 26.0 2.6 29.8 2.2 34.2 2.6 33.2A 2.0 35.0 3.1 31.7 2.1 27.9 3.9 42.3' 2.2 39.2 3.2 40.2 2.8 43.0 3.8 24.5' 2.0 25.9 2.8 28.1 3.1 29.1 3.4 *Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data exclude those whites who indicated they were of Hispanic origin. For 1965-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Tdacco Use Amot~g U.S. Racial/Ethnic Minority Groups 1976+ YC %I 27.8 1.2 26.9 1.2 23.7 1.5 24.4 45.2 1.3 43.6 1.4 44.7 1.7 44.7 27.0 1.2 27.5 1.4 31.6 1.6 30.9 23.2 1.6 23.8 1.2 44.6 1.9 46.8 1.4 32.2 1.9 29.4 1.3 22.0 45.2 32.8 1.6 1 .6 1 .7 20.5 1.3 17.8 1.9 20.0 41.6 1.7 43.6 2.5 43.1 33.5 1.8 38.6 2.3 36.9 1.0 1.3 1.2 1.2 1 .7 1 .7 .6 .9 .5 17.7 2.2 17.8 1.5 44.3 2.7 45.1 2.0 38.0 2.7 37.1 1.6 34.0 45.1 21.0 .7 .8 5 .L 33.7 1.6 30.1 2.4 29.2 45.8 1.9 45.8 2.3 46.5 21.0 1.6 24.1 2.3 24.4 29.3 2.1 30.1 1.7 44.8 2.6 48.4 1.9 25.9 2.3 21.5 1.6 30.0 47.3 22.6 .8 .9 .9 29.9 1.7 25.2 2.2 26.5 45.9 1.9 47.8 2.6 47.4 21.9 2.1 27.0 2.7 26.1 .7 25.2 2.7 27.5 1.9 .8 48.0 2.9 49.9 2.0 .5 26.9 2.6 22.7 1.7 22.7 1.7 21.2 1.8 19.0 2.3 19.2 1.5 17.6 2.6 18.0 1.7 43.3 2.0 42.6 2.0 41.5 2.7 41.8 2.2 40.5 2.9 42.6 2.2 34.0 1.8 36.3 2.0 39.5 2.4 39.0 2.2 41.9 3.4 39.4 2.2 32.0 2.5 31.6 2.6 28.9 3.6 28.8 2.6 28.7 3.2 26.0 2.5 43.8 2.7 42.9 2.9 43.9 4.1 44.1 3.0 44.7 3.7 47.3 2.9 24.2 2.3 25.6 2.5 27.2 3.7 27.2 2.5 26.6 3.3 26.7 2.5 26.7 1.9 26.2 2.1 23.3 2.9 23.1 2.0 21.2 3.0 20.4 2.2 44.5 2.2 43.3 2.7 44.1 3.3 44.0 2.6 44.9 3.7 45.4 2.9 28.8 2.2 30.5 2.3 32.7 2.4 32.9 2.2 33.9 3.6 34.3 2.7 24.2 1.8 22.7 1.7 22.4 2.5 20.5 1.7 21.0 2.7 21.3 1.8 46.3 2.3 45.6 2.1 43.8 2.7 46.0 2.3 44.6 3.5 46.0 2.3 29.5 2.2 31.7 2.1 33.8 2.9 33.5 2.1 34.4 3.4 32.7 2.2 26.2 3.6 27.8 3.2 18.9 3.2 22.0 3.0 18.0 4.2 21.2 2.9 41.8 3.4 41.4 3.6 44.2 5.7 42.1 3.2 45.9 5.5 46.3 3.6 32.0 3.4 30.8 3.1 37.0 5.5 35.9 3.0 36.0 4.7 32.5 3.4 30.4 3.7 30.4 3.1 25.8 5.2 29.6 3.7 27.7 5.0 28.4 3.8 41.2 4.4 40.2 3.8 41.1 5.9 37.2 3.9 35.2 5.4 40.9 4.2 28.4 3.3 29.4 3.7 33.2 4.7 33.2 3.6 37.1 5.7 30.7 4.2 1977+ 1978 1979 1980 1983 YC ASI 5% ASI YC ?CI YC KI 70 KI +The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for whites aged 18 years and older. Estimates for persons in the 18-34 year old age category were statisti- cally adjusted to produce estimates that approximate those for whites aged 18-34 years. 195% confidence interval. SIncludes persons aged 25 years and older. `Levels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. Patterns of Tobacco Use 101 Surgem Gerzeral'.s Xcport Table 40. Continued Characteristic 1985 1987 1988 1990 % KIS % 3.3 % WI % %I 26.1 1.1 25.4 1.0 24.7 1.0 27.9 1.1 43.6 1.3 43.7 1.1 45.7 1.1 45.2 1.2 30.3 1.2 30.9 1.1 29.6 1.0 26.9 1.2 20.1 1.6 20.6 1.4 20.4 1.3 21.7 1.4 42.6 1.9 40.6 1.6 43.9 1.6 43.9 1.8 37.3 1.8 38.8 1.6 35.7 1.6 34.5 1.9 32.1 1.6 30.3 1.5 29.3 1.5 34.5 1.6 44.7 1.7 46.9 1.6 47.5 1.6 46.6 1.6 23.2 1.4 22.8 1.4 23.3 1.2 19.0 1.4 31.1 1.9 29.8 1.7 29.3 1.7 34.9 1.9 45.2 2.0 45.6 1.8 47.7 1.8 47.3 1.9 23.8 1.7 24.6 1.5 22.9 1.5 17.8 1.6 19.0 1.7 20.1 1.6 18.1 1.5 20.4 1.6 41.1 2.1 41.3 1.8 43.7 1.8 43.4 2.0 39.9 2.1 38.6 1.5 38.3 1.8 36.2 2.0 Total <15 cigarettes 15-24 cigarettes 225 cigarettes Gender Men <15 cigarettes 15-24 cigarettes 225 cigarettes Women <15 cigarettes 15-24 cigarettes 225 cigarettes Age (years) IS-34 <15 cigarettes 15-24 cigarettes 225 cigarettes 35-54 cl5 cigarettes 15-24 cigarettes 225 cigarettes 255 <15 cigarettes 15-24 cigarettes 225 cigarettes Educations Less than high school cl5 cigarettes 15-24 cigarettes 225 cigarettes High school <15 cigarettes 15-24 cigarettes 225 cigarettes Some college <15 cigarettes 15-24 cigarettes 225 cigarettes College <15 cigarettes 15-24 cigarettes 225 cigarettes x95% confidence interval. $Includes persons aged 25 years and older. 27.7 2.4 26.3 1.6 27.7 2.0 29.1 2.5 44.7 2.6 44.6 1.8 45.0 2.2 44.5 2.5 27.6 2.3 29.2 1.9 27.2 2.1 26.4 2.3 19.5 2.2 19.9 2.1 19.1 1.8 19.5 2.2 44.3 2.7 44.2 2.4 44.5 2.4 48.6 2.9 36.2 2.7 35.8 2.4 36.5 2.4 31.9 2.7 23.1 1.8 22.8 1.5 20.5 1.4 24.5 1.7 44.5 2.1 43.4 1.8 47.7 1.8 45.8 1.9 32.4 1.9 33.8 1.8 31.8 1.6 29.6 1.8 26.3 2.8 24.9 2.3 25.6 2.3 27.8 2.6 42.0 3.1 43.0 2.8 43.2 2.7 43.5 3.1 31.7 2.9 32.2 2.7 32.2 2.4 28.7 2.8 30.5 3.4 31.0 3.1 32.4 2.9 35.1 3.3 37.9 3.7 39.9 3.4 39.5 3.2 39.6 3.4 31.6 3.6 29.2 3.0 28.1 2.9 25.3 3.3 Tobrrcco USE Among U.S. Racial/Ethic Minority Groups 1991 1992 1993 1994 1995 7c KI R kc1 c kC1 5% %I 70 XI 29.8 1.2 31.7 1.5 32.5 1.7 35.6 1.8 35.0 2.0 45.0 1.3 43.3 1.6 44.9 1.7 44.4 1.9 41.8 2.1 25.2 1.2 25.0 1.4 22.6 1.4 20.0 1.4 23.2 1.8 24.6 1.6 25.8 1.9 27.5 2.4 30.5 2.5 28.0 2.6 43.4 1.7 41.8 2.4 43.0 2.5 44.3 2.7 41.6 3.0 31.9 1.8 32.4 2.2 29.5 2.3 25.1 2.2 30.4 2.8 35.0 1.6 37.7 2.3 37.6 2.3 40.8 2.5 42.3 2.8 46.6 1.7 44.9 2.2 46.8 2.4 44.5 2.4 41.9 2.8 18.4 1.3 17.4 1.6 15.6 1.8 14.6 1.9 15.8 2.0 36.5 2.0 37.4 2.6 39.5 3.0 42.5 3.0 44.3 3.4 46.1 2.1 43.9 2.5 45.6 2.8 45.4 3.1 41.1 3.4 17.5 1.7 18.6 2.2 15.0 2.0 12.1 1.7 14.6 2.9 23.9 1.6 26.8 2.3 27.6 2.6 29.6 2.6 31.0 3.0 43.4 1.9 42.3 2.8 44.1 2.5 42.9 2.6 41.6 3.0 32.7 1.9 30.9 2.4 28.3 2.4 27.6 2.5 27.4 2.6 29.1 2.1 29.9 3.2 30.0 3.4 34.6 3.6 27.0 3.4 46.2 2.4 44.2 3.6 45.2 4.1 45.9 4.1 43.2 4.2 24.7 2.2 25.9 2.9 24.8 3.1 19.5 3.2 29.8 4.2 21.4 2.2 24.6 3.2 25.3 3.5 25.6 3.5 19.9 3.7 43.8 2.6 41.5 3.7 45.9 4.0 44.5 4.5 45.4 4.8 34.8 2.7 33.9 3.7 28.8 3.7 29.9 4.1 34.7 4.6 25.7 1.6 26.7 2.3 28.2 2.5 30.5 2.7 29.2 2.8 47.7 1.9 46.3 2.8 46.2 2.7 46.8 2.9 45.0 3.1 26.6 1.9 27.0 2.4 25.6 2.4 22.7 2.3 25.8 3.0 33.0 2.7 33.7 3.7 34.0 3.7 36.8 43.6 2.9 42.0 3.6 44.3 4.3 44.0 23.4 2.4 24.3 3.5 21.8 3.4 19.2 4.4 4.0 3.3 5.4 5.3 3.7 40.2 4.6 39.2 4.6 20.6 3.8 35.3 3.4 43.2 4.5 42.1 5.4 48.7 42.9 3.4 37.6 4.6 37.7 5.0 36.9 21.8 2.9 19.2 4.1 20.2 3.8 14.4 50.6 5.6 34.0 5.5 15.4 3.8 - Patterns of Tobacco Use 103 Surgeon Gmt~ral `s Report Table 41. Percentage of adult white ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 Characteristic % ?-cIS % XI % kc1 % kc1 Total 25.2 0.6 25.3 0.6 34.3 0.8 36.1 0.9 Gender Men Women 28.9 0.8 28.9 0.8 39.0 1.0 41.0 1.1 19.6 0.9 19.6 0.9 27.8 0.9 29.6 1.4 Age (years) 18-34 35-54 255 17.6 0.9 16.9 0.9 25.9 1.1 26.2 1.7 24.5 1.0 25.0 0.9 33.5 1.1 35.2 1.2 38.3 1.6 38.2 1.5 47.5 1.3 51.0 1.8 Education5 Less than high school NA NA 26.4 1.0 34.6 1.2 36.2 1.6 High school 25.4' 0.8 25.1 1.2 34.5 1.0 36.3 1.5 Some college NA NA 28.4 2.2 37.1 1.6 39.5 2.5 College 33.2+ 1.6 38.5 2.3 49.7 2.3 50.6 2.4 Characteristic 1985 1987 1988 1990 % ASI 7c kc1 % KI 70 KI Total 46.6 1.0 46.2 0.9 47.7 0.9 50.9 1.0 Gender Men Women 51.0 1.3 50.5 1.2 51.1 1.2 54.2 1.3 41.0 1.3 40.9 1.3 43.5 1.1 47.0 1.2 Age (years) 18-34 35-54 255 32.4 1.5 31.4 1.4 32.3 1.5 35.1 1.6 46.2 1.6 44.6 1.5 45.9 1.4 48.6 1.5 62.2 1.6 63.1 1.5 65.0 1.3 68.9 1.3 Education5 Less than high school 46.5 2.1 44.3 1.9 45.7 1.7 47.8 2.0 High school 44.5 1.6 44.8 1.4 45.0 1.4 48.2 1.5 Some college 48.7 2.3 48.9 1.9 50.7 1.9 54.0 1.9 College 63.7 2.2 63.0 2.1 64.6 1.8 68.7 1.9 *Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data exclude those whites who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever smokers include current and former smokers. `The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for whites aged 18 years and older. Estimates for persons in the 18-34 year old age category were statisti- cally adjusted to produce estimates that approximate those for whites aged 18-34 years. Tohncco Use Amolzg U.S. XaciallEthnic Mhorify Groups 1976+ 1977+ 1978 1979 1980 1983 36.5 41.3 30.4 25.3 36.5 51.6 37.1 36.6 39.7 49.4 1.0 36.3 1.3 41.4 1.5 30.0 1.3 26.8 1.7 35.2 1.9 50.7 1.9 36.8 1.7 36.1 2.8 39.4 2.7 50.2 1.0 39.5 1.7 40.5 1.2 40.8 1.1 44.7 2.1 45.3 1.3 45.2 1.5 32.8 2.0 34.3 1.7 35.0 1.8 29.1 2.3 29.4 1.5 30.5 1.5 36.7 2.6 39.7 1.8 39.8 1.9 56.0 2.7 55.5 1.6 54.5 1.7 39.1 2.7 41.2 1.9 39.7 1.9 39.0 2.3 40.2 1.8 40.7 2.2 44.9 3.9 41.7 2.4 43.5 2.8 54.5 3.9 55.6 2.7 54.2 1.7 42.0 2.1 46.6 2.4 36.2 2.3 29.1 2.6 40.3 2.9 59.0 3.0 41.5 2.7 41.9 4.3 44.6 3.9 57.9 1.4 1.4 1.5 1.7 1.8 2.1 1.7 2.6 2.7 1991 1992 1993 1994 1995 7c KI R %I 7c 2321 7c XI % 321 50.5 0.9 48.5 1.3 51.6 1.3 51.0 1.3 50.5 1.6 54.2 1.2 52.0 1.7 54.6 1.7 53.7 1.7 52.9 2.2 46.2 1.3 44.4 1.8 48.1 1.7 47.8 1.9 47.6 2.1 31.9 1.5 27.4 2.0 31.4 2.0 29.0 2.2 31.5 2.6 48.7 1.4 48.0 1.9 48.6 2.0 49.3 1.9 48.6 2.4 68.8 1.3 68.1 2.0 71.8 1.8 72.1 1.8 68.0 2.2 46.0 2.0 49.1 2.7 49.2 3.4 47.1 2.8 46.5 3.3 48.0 1.4 45.6 2.0 49.8 1.9 48.5 2.1 47.2 2.4 54.9 1.9 53.6 2.7 55.1 2.6 54.7 2.8 55.7 3.0 67.8 1.8 64.2 2.6 68.1 2.6 70.8 2.6 66.1 3.4 t95% confidence interval. kcludes persons aged 25 years and older. `Levels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Paftcms of Tobacco Use 105 Surgeolr Genernl's Report Table 42. Percentage of white women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1965-1995 1965 1966 1970 1974 1976+ Characteristic % +CIS % +CI % +CI YO +CI % +CI Total 42.2 1.1 41.5 1.1 36.8 1.2 37.3 1.7 36.4 1.5 Educations Less than high school NA NA 48.0 2.2 46.7 2.0 50.5 3.1 49.4 4.4 High school 44.2 1.4 41.3 1.8 36.6 1.8 38.2 2.5 38.0 2.5 Some college NA NA 43.8 3.8 37.5 3.2 35.2 4.3 34.8 4.4 College 41.3 2.9 34.6 4.4 27.2 2.6 25.5 3.3 25.0 3.4 1977+ 1978 1979 1980 1983 R +CI % *CI % +CI % +CI % +CI Total 36.8 1.5 35.6 2.1 36.0 1.4 33.2 1.9 35.5 1.3 Educations Less than high school 47.6 3.9 56.1 5.9 52.0 3.9 53.9 7.0 53.6 4.6 High school 37.3 2.5 38.4 3.2 37.3 2.4 33.4 3.6 39.4 2.4 Some college 35.3 3.6 31.8 5.8 36.3 4.3 32.2 5.3 30.8 3.2 College 24.7 3.6 20.1 4.3 21.9 2.7 22.8 4.4 17.8 2.5 1985 1987 1988 1990 1991 % +CI % +CI % +a Yo +CI 70 +CI Total 32.5 1.3 31.1 1.1 30.3 1.0 27.9 1.1 28.7 1.1 Educations Less than high school 55.1 4.4 60.6 3.7 57.9 3.9 58.4 4.3 59.6 3.8 High school 37.1 2.1 36.5 1.8 35.7 1.8 34.4 1.8 36.5 2.0 Some college 28.8 2.7 29.2 2.2 29.2 2.3 24.5 2.1 25.1 2.0 College 14.9 2.2 15.1 1.7 14.2 1.6 10.9 1.5 11.8 1.5 1992 1993 1994 1995 x +CI w +CI % +CI % +CI Total 30.7 1.6 29.1 1.4 30.6 1.6 28.2 1.8 Educations Less than high school 55.5 6.0 60.1 6.2 56.1 7.2 51.7 7.8 High school 38.3 2.8 38.6 2.7 40.2 2.9 37.0 3.4 Some college 28.3 2.9 23.4 2.8 27.2 3.2 26.0 3.6 College 14.3 2.2 11.5 2.0 11.6 2.3 15.3 2.9 *Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data exclude those whites who indicated they were of Hispanic origin. For 1965-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statisticallv adjusted to produce estimates that approximate those for white women aged 18-44 years. $95% confidence'interval. SIncludes persons aged 25 years and older. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. 1 Oh Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 43. Percentage of white adults who reported being current cigarette smokers," overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic % fCIS Yc KI % +c1 70 +c1 Yo +c1 Yo +c1 Total 33.5 0.7 30.9 0.6 28.6 0.5 25.9 0.5 Gender Men Women Age (years) 18-34 35-54 255 Education_ Less than high school High school Some college College 36.8 1.0 32.9 0.8 30.5 0.7 27.6 0.7 30.5 0.8 29.0 0.7 26.9 0.6 24.4 0.6 36.7 1.1 34.6 0.9 32.0 0.8 29.8 0.8 39.0 1.0 35.1 1.0 32.9 0.7 30.0 0.7 23.7 0.8 21.9 0.7 19.9 0.7 17.1 0.6 35.3 1.2 34.4 1.3 34.2 1.1 32.6 1.1 35.6 1.1 33.8 0.9 32.6 0.8 30.3 0.7 34.8 1.3 31.2 1.3 28.2 1.0 24.9 0.9 23.6 1.2 19.0 1.0 16.5 0.7 13.8 0.7 26.4 0.6 25.9 0.7 27.8 0.8 27.6 0.9 25.0 0.8 24.4 0.8 31.6 1.1 31.3 1.2 29.7 1.0 28.7 1.1 16.7 0.8 16.8 0.9 31.9 1.6 33.8 1.7 30.6 1.0 30.3 1.1 25.4 1.2 24.7 1.3 14.2 0.9 13.3 1.0 *These data exclude whites who indicated thev were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $95% confidence interval. 51ncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Pafterns of Tobacco Use 107 Surgeon General's Report Table 44. Percentage of adult white smokers* who reported smoking <15,15-24, or 225 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic % *cc Yo fC1 R +c1 % +c1 % fC1 % fC1 Total Cl5 cigarettes 15-24 cigarettes 225 cigarettes Gender Men Cl5 cigarettes 15-24 cigarettes 225 cigarettes Women Cl5 cigarettes 15-24 cigarettes 225 cigarettes Age (years) 18-34 Cl 5 cigarettes 15-24 cigarettes 225 cigarettes 35-54 Cl5 cigarettes 15-24 cigarettes 225 cigarettes 255 Cl5 cigarettes 15-24 cigarettes 225 cigarettes 24.0 0.7 25.1 0.8 25.0 0.7 28.9 0.8 32.1 1.1 35.3 1.3 44.7 0.9 44.9 0.9 44.7 0.8 45.1 0.9 44.0 1.2 43.1 1.4 31.4 0.9 30.0 0.9 30.3 0.8 26.1 0.9 23.9 1.1 21.6 1.1 18.9 0.9 19.1 1.2 20.5 1.0 23.2 1.1 26.6 1.6 29.3 1.8 43.5 1.3 43.7 1.3 42.3 1.1 43.6 1.3 42.3 1.8 43.0 2.0 37.6 1.3 37.2 1.4 37.3 1.2 33.2 1.3 31.1 1.6 27.7 1.8 29.4 1.1 45.9 1.3 24.7 1.1 25.9 1.3 47.6 1.2 26.5 1.3 18.8 1.0 18.6 1.4 19.1 1.1 22.2 1.1 27.2 1.7 30.3 2.0 41.4 1.6 41.7 1.7 42.5 1.3 43.4 1.5 43.1 1.8 42.2 2.0 39.8 1.5 39.7 1.7 38.4 1.3 34.4 1.5 29.7 1.6 27.5 1.8 28.8 1.7 27.0 1.7 27.0 1.4 29.1 1.6 29.9 2.5 30.5 2.5 44.2 2.0 45.8 1.8 44.8 1.6 45.4 1.7 44.7 2.7 44.4 2.9 27.1 1.7 27.2 1.7 28.2 1.5 25.5 1.6 25.4 2.2 25.0 2.7 46.2 1 22.5 1 29.6 1 47.1 1 23.3 1.2 29.8 1.0 47.2 1.1 23.0 0.9 29.6 1.2 46.7 1.3 23.8 1.1 46.6 1 18.7 1 35.7 1 46.7 1 17.6 1.2 37.7 1.6 41.6 1.9 45.7 1.6 43.2 1.8 16.6 1.2 15.2 1.4 38.3 2.0 43.3 2.2 44.6 1.9 43.4 2.3 17.1 1.5 13.3 1.6 *These data exclude those whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 308 Chapter 2 7%mxn Use Allzollg U.S. Racial/Ethnic Miuority Croup Table 44. Continued 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic - R fCIS % KI % XI % +c1 % fC1 x +c1 Education5 Less than high school <15 cigarettes 15-24 cigarettes 225 cigarettes High school <15 cigarettes 15-24 cigarettes 125 cigarettes Some college <15 cigarettes 15-i-24 cigarettes 225 cigarettes College <15 cigarettes 15-24 cigarettes 225 cigarettes 22.7 1.4 19.9 1.6 19.5 1.4 20.5 1.6 24.9 2.3 22.8 2.6 44.2 1.9 44.8 2.0 44.3 1.7 46.1 1.9 43.5 2.8 45.0 3.3 33.1 1.6 35.4 1.9 36.1 1.7 33.4 1.9 31.6 2.7 32.2 3.1 21.1 1.2 45.1 1.9 33.8 1.7 20.4 1.9 24.3 2.3 25.3 1.6 30.5 1.9 33.8 2.7 38.5 3.2 43.5 2.1 43.7 2.5 43.1 2.0 43.5 2.2 43.1 2.8 41.7 3.1 36.2 2.4 32.0 2.4 31.7 1.7 26.0 1.8 23.1 2.3 19.9 2.5 28.2 2.8 29.6 2.7 31.7 2.3 35.2 2.4 42.7 3.4 49.7 3.9 37.6 2.9 39.2 2.7 39.7 2.3 41.3 2.3 37.6 3.3 35.3 3.8 34.2 2.5 31.2 2.6 28.6 2.1 23.5 2.2 19.6 2.7 15.0 2.6 22.4 1.3 21.6 1.0 25.1 1.2 27.4 1.6 29.9 2.0 45.1 1.5 45.6 1.3 46.8 1.4 46.2 1.9 45.9 2.1 32.5 1.5 32.8 1.2 28.1 1.4 26.4 1.7 24.2 1.9 `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $95'% confidence interval. %cludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patterns of Tobacco Use 109 Table 45. Percentage of adult white ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic % KIT 7r fC1 % +c1 % fC1 % KI % KI Total 40.3 1.1 44.7 0.8 46.9 0.7 50.7 0.7 50.0 0.9 50.7 1.0 Gender Men Women 45.1 1.2 49.3 1.0 50.8 0.9 54.2 0.9 53.2 1.2 53.3 1.4 34.1 1.4 39.1 1.0 42.2 0.9 46.6 0.9 46.1 1.3 47.7 1.4 Age (years) 18-34 35-54 255 29.6 1.3 31.1 1.1 31.8 1.1 33.5 1.1 29.2 1.5 30.2 1.7 39.0 1.3 43.9 1.3 45.3 1.1 48.6 1.1 48.3 1.3 49.0 1.5 55.4 1.4 60.9 1.2 64.1 1.0 68.9 0.9 69.9 1.3 70.1 1.4 Education5 Less than high school 40.3 1.4 44.5 1.8 45.0 1.4 46.9 1.5 49.1 2.1 46.8 2.2 High school 40.0 1.5 43.5 1.1 44.9 1.1 48.1 1.0 47.6 1.5 47.9 1.6 Some college 42.9 1.8 47.1 1.8 49.8 1.4 54.5 1.3 54.3 1.8 55.2 2.0 College 55.0 2.2 61.6 1.7 63.8 1.4 68.2 1.4 66.1 1.9 68.4 2.2 *These data exclude those whites who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not current smokers, and ever smokers include current and former smokers. `1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. t95% confidence interval. %cludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Table 46. Percentage of white women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980+ 1983-1985+ 1987-1988+ 1990-1991+ 1992-1993+ 1994-1995+ Characteristic 7c fCIS % KI % KI 7c fC1 % fC1 % fC1 Total 35.3 1.2 33.7 1.0 30.7 0.8 28.3 0.8 30.0 1.2 29.4 1.2 Education Less than high school 53.4 3.0 54.5 3.4 59.2 2.7 59.0 3.0 57.5 4.2 53.9 5.2 High school 36.6 1.8 38.0 1.7 36.1 1.4 35.5 1.3 38.5 2.1 38.6 2.3 Some college 34.2 2.8 29.6 2.1 29.2 1.7 24.8 1.5 26.0 2.1 26.6 2.4 College 21.7 1.9 16.0 1.6 14.6 1.2 11.4 1.0 13.0 1.4 13.5 1.8 *These data exclude whites who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currentIy smoked every day or on some days. `1978,1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. $95% confidence interval. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Appendix 4. Patterns of Cigarette Use Among Among African Americans Table 47. Percentage of adult African Americans who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 Characteristic 1965 1966 1970 1974 % XI* % KI % KI % ASI Total 45.8 1.5 45.9 1.7 41.4 1.8 44.0 2.2 Gender Men Women Age (years) 18-34 35-54 255 Educations Less than high school High school Some college College 60.4 2.8 60.1 2.5 52.9 2.0 54.4 3.9 33.7 2.3 34.2 2.3 32.2 2.5 36.4 2.6 53.2 2.8 52.4 2.9 46.0 2.8 46.2 3.5 50.3 3.0 52.6 2.9 47.0 2.2 53.3 3.8 27.0 3.2 24.8 3.1 25.1 2.3 28.0 3.8 44.6 2.4 41.0 2.1 43.3 3.2 51.9 4.6 45.4 3.8 49.1 4.3 52.9 7.8 43.0 6.0 37.3 8.6 39.6 8.5 34.2 6.4 44.9 9.1 44.6A 2.0 37.5A 5.8 1985 1987 1988 1990 Characteristic % KIS R KI % kc1 % XI Total 35.0 1.8 32.9 1.6 31.7 1.6 26.2 1.5 Gender -Men Women 39.9 3.0 38.7 2.8 36.6 2.5 32.6 2.4 31.2 2.2 28.2 1.8 27.8 1.9 21.2 1.6 Age (years) 18-34 35-54 255 34.0 2.8 32.6 2.4 31.5 2.4 25.0 2.2 42.3 3.4 38.6 2.8 36.0 2.6 32.6 2.7 27.7 3.0 25.9 2.9 26.4 2.7 19.2 2.4 Educations Less than high school High school Some college College 39.6 3.0 37.7 2.9 35.0 2.5 30.6 2.8 39.1 3.4 38.7 2.9 38.8 2.9 31.9 2.5 35.0 4.9 34.2 4.0 31.9 3.7 25.7 3.8 28.4 6.1 18.3 3.9 20.9 4.6 17.5 3.8 `Data collected before 1978 do not distinguish between blacks of Hispanic origin and non-Hispanic blacks; these data exclude those African Americans who indicated they were of Hispanic origin. For 197&1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. `The 1976 and 1977 survevs collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce e&mates for the total population, males, and females that approximate those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year old age category were statistically adjusted to produce estimates that approximate those for African Americans aged 18-34 years old. Tobacco Use Among U.S. Racial/Ethic Minority Gruuys 1976+ 1977+ 1978 1979 1980 1983 70 KI 7c kc1 % kc1 % KI % KI % AXI 2.1 40.7 3.3 47.3 3.1 35.9 3.1 44.4 3.7 46.9 3.3 29.9 2.8 40.2 4.7 48.2 7.5 41.8 10.3 37.1 2.5 37.5 3.7 37.3 2.4 37.1 3.3 35.8 2.2 4.0 3.1 3.9 4.2 4.3 46.1 5.5 44.5 3.7 44.9 4.4 40.8 3.5 31.1 4.5 31.6 2.5 31.0 4.3 31.8 2.6 39.1 5.8 38.0 3.2 39.9 4.5 35.8 3.2 46.0 6.1 44.4 3.9 40.5 6.9 42.1 4.1 24.4 5.2 27.0 4.0 27.5 6.6 27.9 4.2 3.9 36.7 4.8 37.3 3.6 33.7 6.5 37.4 3.9 4.9 40.6 5.1 40.5 4.8 47.6 7.2 39.4 4.3 7.4 46.0 9.9 35.5 6.4 30.8 8.7 34.4 6.3 8.4 37.3 13.5 36.3 7.5 29.4 8.8 28.4 7.3 40.8 49.3 34.6 44.2 46.9 27.5 38.9 44.5 49.4 36.3 1991 1992 1993 1994 1995 % kc1 5% kc1 % KI 7% KI 7e kc1 29.4 1.6 27.8 2.0 26.0 2.0 27.2 2.3 25.8 2.6 35.5 2.7 32.3 3.5 32.4 3.4 33.9 4.0 28.8 3.7 24.5 1.9 24.1 2.2 21.0 2.2 21.8 2.2 23.5 3.1 27.0 2.4 22.4 3.0 21.6 3.3 22.0 3.4 19.9 3.4 38.3 2.7 38.0 3.7 33.6 3.6 34.7 3.9 33.6 4.6 20.7 2.7 22.4 3.5 22.3 4.1 24.0 4.0 23.0 3.8 35.4 3.0 34.4 4.5 33.9 4.5 35.3 4.5 34.1 5.0 34.9 2.6 32.3 3.7 31.4 3.8 31.6 4.5 31.0 5.0 31.8 3.8 28.4 4.8 26.6 4.4 27.6 5.4 25.2 5.1 18.0 4.2 22.4 6.6 13.9 4.6 15.7 5.2 17.6 5.4 t95% confidence interval. SIncludes persons aged 25 years and older. `Levels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Pa ttems of Tobacco Use 113 Table 48. Percentage of adult African American smokers* who reported smoking <15,15-24, or 125 cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 Characteristic 1965 1966 1970 1974 % ?a* % KI % KI % 321 Total cl5 cigarettes 15-24 cigarettes 225 cigarettes Gender Men cl5 cigarettes 15-24 cigarettes 225 cigarettes Women <15 cigarettes 15-24 cigarettes 225 cigarettes <15 cigarettes 15-24 cigarettes 225 cigarettes 35-54 <15 cigarettes 15-24 cigarettes 225 cigarettes 255 <15 cigarettes 15-24 cigarettes 225 cigarettes Educations Less than high school <15 cigarettes 15-24 cigarettes 225 cigarettes High school <15 cigarettes 15-24 cigarettes 225 ci B arettes Some co1 ege <15 cigarettes 15-24 cigarettes 225 cigarettes Colle e t 5.3 6.8 5.3 7.6 7.3 5.1 7.1 *Data collected before 1978 do not distin uish between African Americans of His % African Americans; these data exclude t ose African Americans who indicated t R anic origin and non-Hispanic ey were of Hispanic origin. For 1965-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include fl ersons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey t at they currently smoked every day or on some days. +The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year old a were statistically adjusted to produce estimates that approximate those for African Amerrcans age B e category 18-34 years old. Tobacco Use AVZOJZ~ U.S. Racial/Efhnic Mimrify Groups 197ci+ 1977+ 1978 1979 1980 1983 7c kc1 R kC1 9% %I c &CT 7c XI % kC1 52.4 3.9 54.7 4.8 57.0 5.1 55.9 3.2 55.2 5.7 54.9 3.9 39.0 3.7 35.7 4.4 34.0 4.6 33.3 3.1 33.8 4.8 35.6 3.7 8.6 2.1 9.8 2.1 9.1 2.8 10.8 1.6 11.0 3.3 9.5 2.4 44.7 4.7 48.4 5.9 49.5 7.3 51.5 4.9 48.8 44.2 4.4 35.3 5.2 37.3 6.3 36.3 4.7 38.7 11.2 3.0 12.6 3.9 13.2 5.1 12.2 2.6 12.5 9.2 Ei 51.4 36.5 12.1 Z:i; 4.1 60.3 5.8 61.2 6.2 65.0 7.0 60.8 4.4 62.1 6.8 58.5 5.1 33.8 5.9 36.1 5.6 30.4 6.4 30.0 3.8 28.5 6.3 34.6 5.0 6.0 2.2 6.9 2.3 4.6 3.0 9.2 2.6 9.4 3.2 6.9 2.5 56.5 5.5 59.4 5.8 60.3 7.9 60.5 5.2 57.8 35.9 5.3 34.8 6.3 31.5 7.0 31.1 4.3 33.1 7.6 2.6 8.0 3.4 8.2 4.2 8.4 2.5 9.1 6.0 !:i 57.7 33.0 9.4 5.7 E 44.8 44.0 11.3 ii:; 3.4 51.6 7.3 53.0 8.4 48.4 5.1 56.1 10.5 47.6 6.4 33.4 6.2 37.2 7.5 36.2 4.5 32.1 9.2 40.6 6.1 13.0 3.6 9.8 4.8 15.4 4.3 11.8 7.1 11.9 4.4 57.4 6.4 51.1 8.6 56.1 12.6 59.1 8.7 46.5 11.9 61.7 8.8 36.9 6.8 40.2 7.5 33.9 12.5 33.3 8.6 38.9 10.6 32.9 8.6 5.8 3.7 8.7 4.5 10.0 7.2 7.6 4.1 14.7 10.4 5.4 4.0 50.4 5.8 54.1 7.0 53.4 9.2 52.8 5.7 53.9 41.2 5.1 35.2 5.6 35.4 8.3 32.9 5.2 32.6 8.3 3.3 10.7 3.2 11.3 5.4 14.3 4.2 13.6 E 7:3 52.8 34.0 13.2 2:: 5.1 48.4 6.9 53.9 44.3 6.2 34.0 7.3 3.1 12.1 7.9 2: 60.4 9.5 53.5 5.6 48.9 31.1 9.1 36.1 6.3 35.8 8.5 5.5 10.4 4.4 15.3 i. : 5:6 52.6 7.0 42.1 6.9 5.4 3.1 54.7 29.2 16.1 44.9 38.8 16.3 11.7 9.9 7.9 14.9 13.9 13.0 49.5 12.0 41.5 17.6 57.0 11.5 44.7 18.2 50.2 12.1 42.8 12.7 46.1 16.8 30.1 9.2 42.7 18.5 37.1 11.7 7.7 6.0 12.5 9.0 13.0 6.8 12.5 11.0 12.7 7.9 48.1 15.6 71.9 17.1 47.5 13.2 65.7 18.7 51.6 15.3 37.9 15.6 22.6 12.5 40.1 11.5 31.1 18.3 36.7 14.8 14.0 9.6 5.5 9.8 12.5 9.2 3.3 6.4 11.7 10.9 $95X confidence interval. Vncludes persons aged 25 years and older. "Levels presented for 1965 are for some college or were college gra 1 ersons who had a high school education or less and persons who attended uates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Table 48. Continued Characteristic 1985 1987 1988 1990 70 kCIS 5% KI % KI % kC1 Total cl5 cigarettes 15-24 cigarettes 225 cigarettes Gender Men <15 cigarettes 15-24 cigarettes 225 cigarettes Women <15 cigarettes 15-24 cigarettes 225 cigarettes Age (years) 18-34 <15 cigarettes 15-24 cigarettes 225 cigarettes 35-54 cl5 cigarettes 15-24 cigarettes 225 cigarettes 255 <15 cigarettes 15-24 cigarettes 225 cigarettes Educations Less than high school <15 cigarettes 15-24 cigarettes 225 cigarettes High school <15 cigarettes 15-24 cigarettes 225 cigarettes Some college <15 cigarettes 15-24 cigarettes 225 cigarettes College <15 cigarettes 15-24 cigarettes 225 cigarettes 55.8 3.2 61.2 2.9 56.4 2.7 59.9 3.2 35.0 2.9 31.0 2.8 34.6 2.5 34.2 3.2 9.3 1.9 7.8 1.6 9.0 1.6 6.0 1.5 52.8 5.2 55.3 4.2 51.0 4.1 52.6 4.7 36.2 4.3 35.8 4.4 38.2 3.8 40.1 4.7 11.0 3.2 8.9 2.4 10.8 2.5 7.3 2.3 58.7 3.9 67.9 3.5 62.2 3.9 68.8 3.6 33.7 3.8 25.7 3.2 30.7 3.6 26.9 3.4 7.6 2.0 6.5 1.8 7.2 2.0 4.3 1.7 56.4 5.4 66.2 4.5 62.1 4.0 67.5 4.9 35.4 4.8 27.6 4.0 29.4 3.7 25.8 4.6 8.2 3.0 6.2 2.3 8.5 2.4 6.7 2.5 53.1 4.8 54.9 4.6 49.2 4.3 51.9 4.9 35.9 4.6 34.9 4.6 40.5 4.4 42.2 4.7 11.0 3.0 10.1 2.4 10.3 2.5 5.9 2.2 59.6 6.5 61.5 7.1 56.8 7.3 60.8 6.9 31.8 6.6 31.8 6.9 35.3 6.7 34.9 6.8 8.6 4.1 6.7 3.8 7.9 3.4 4.3 2.7 57.9 5.0 62.8 4.3 51.4 4.5 54.1 5.8 31.8 4.8 27.7 4.5 38.0 4.5 39.2 5.7 10.3 3.2 9.5 2.9 10.6 3.0 6.7 2.6 52.4 5.5 57.6 5.2 58.9 4.7 60.6 5.1 39.8 5.4 34.2 4.9 32.3 4.6 34.0 5.0 7.9 2.8 8.2 2.9 8.9 2.5 5.4 2.1 47.6 8.9 57.7 7.0 55.0 7.2 57.1 7.8 37.6 8.3 35.3 6.7 34.0 6.8 37.6 7.8 14.8 6.6 7.0 3.9 11.0 4.9 5.4 3.7 50.5 12.6 56.8 12.1 54.0 13.5 67.9 11.6 35.0 11.6 34.7 11.7 40.8 13.5 28.1 11.1 14.5 12.8 8.5 5.8 5.2 4.0 4.0 4.0 f95% confidence interval. %ncludes persons aged 25 years and older. 216 Chptu 2 73baccn Use Amorlg U.S. Xllcial/Ethnic Minority Grmps 1991 1992 1993 1994 1995 % XI 7% KI R ASI % KI % XI - 61.2 3.0 61.4 4.3 65.6 4.2 65.3 4.8 62.5 5.2 30.0 2.8 33.3 3.9 28.5 4.1 27.2 4.3 29.7 4.8 8.7 1.8 5.3 1.7 6.0 2.1 7.5 3.2 7.8 2.7 57.5 4.4 55.7 6.8 63.3 6.2 64.1 7.0 57.6 7.4 31.7 4.0 39.0 6.3 29.2 5.9 25.2 5.8 32.5 7.2 10.8 2.8 5.3 2.4 7.4 3.4 10.7 5.6 9.9 4.5 65.7 3.5 67.5 4.9 68.4 5.8 66.7 5.5 69.7 9.7 28.0 3.4 27.3 4.5 27.5 5.7 29.8 5.5 22.1 8.2 6.2 1.9 5.2 2.0 4.1 2.2 3.5 1.7 8.2 6.0 66.9 4.6 68.5 6.6 70.6 7.9 71.5 7.3 68.3 8.5 27.3 4.4 27.7 6.5 22.8 7.0 22.3 7.0 24.4 8.1 5.7 2.5 3.8 2.1 6.6 3.8 6.2 3.1 7.2 4.4 56.7 4.4 59.0 6.0 62.2 6.0 60.6 7.3 57.2 7.3 32.7 4.0 34.9 5.7 31.2 6.1 31.1 6.4 33.5 7.0 10.7 2.8 6.1 2.7 6.6 3.2 8.4 5.8 9.4 4.2 60.0 6.8 54.3 8.8 64.6 10.3 66.2 9.6 67.1 9.1 29.3 6.5 39.8 8.5 32.0 10.4 26.2 8.4 28.4 8.5 10.7 4.3 5.9 3.9 3.4 3.6 7.6 6.6 4.5 3.7 60.0 5.2 56.2 8.2 59.4 8.1 59.3 8.7 52.3 8.6 28.7 4.8 36.6 8.0 30.9 8.2 32.0 7.9 33.0 8.4 11.3 3.5 7.2 3.4 9.7 5.0 8.6 6.1 14.8 6.8 57.6 4.9 61.3 6.1 64.6 6.9 63.9 8.3 64.1 7.9 35.5 4.8 34.4 5.8 32.1 6.7 28.8 7.2 29.5 7.2 6.9 2.2 4.3 2.4 3.3 2.7 7.2 6.6 6.4 4.1 63.8 7.7 62.5 9.2 64.4 10.3 66.9 11.6 58.8 11.7 28.2 7.4 32.1 9.1 29.8 9.8 27.1 11.3 37.6 11.5 8.1 4.2 5.4 4.0 5.9 4.8 6.0 4.1 3.6 2.8 62.4 13.2 72.5 12.6 78.3 17.4 73.3 17.8 83.0 11.1 22.1 10.8 21.3 11.2 19.4 17.3 26.7 17.8 12.1 9.7 15.6 11.7 6.1 6.8 2.3 3.6 0.0 0.0 4.9 6.0 Patterns of Tobacco Use 117 Table 49. Percentage of adult African American ever smokers who have quit,+ overall and by gender, age, and education, National Health Interview Surveys, United States, 1965-1995 Characteristic 1965 1966 1970 1974 % KIS % KI % KI % WI Total 15.5 1.7 14.2 1.7 20.6 1.5 19.7 2.4 Gender Men Women 16.1 2.2 15.5 2.2 22.2 2.0 21.7 3.6 14.5 2.7 12.3 2.4 18.4 2.1 17.4 2.9 Age (years) 18-34 35-54 255 8.3 2.0 7.2 1.8 12.8 1.8 13.0 3.9 16.7 2.6 14.0 2.4 21.1 2.0 16.9 3.3 29.3 5.2 32.4 5.4 37.4 3.6 38.1 5.8 Education9 Less than high school High school Some college College NA NA 17.5 2.3 23.2 2.1 23.3 3.5 18.2' 2.1 11.2 3.5 19.4 3.7 17.4 4.7 NA NA 12.8 6.5 24.2 6.8 33.2 11.8 13.2' 5.7 19.9 8.6 33.9 9.9 20.4 9.9 1985 1987 1988 1990 Characteristic % KI % 33 % XI % %I Total 31.3 2.4 31.1 2.4 32.5 2.1 39.0 2.6 Gender Men Women 34.4 3.6 32.9 3.6 34.9 3.1 39.5 3.4 27.9 3.3 29.0 2.7 29.7 3.0 38.4 3.5 Age (years) 18-34 35-54 255 21.1 3.5 18.3 3.1 19.2 3.1 24.8 3.9 30.6 3.7 31.2 3.7 34.9 3.7 39.1 3.8 48.5 4.6 50.1 4.5 48.3 4.1 58.3 4.6 Education? Less than high school High school Some college College 32.8 3.6 34.2 3.7 35.8 3.4 40.4 4.4 30.8 4.4 27.0 3.7 27.6 3.5 35.7 3.9 36.6 6.6 35.8 5 5 37.3 5.8 43.8 6.5 37.4 8.7 49.9 ii2 50.4 8.3 51.4 8.2 *Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic African Americans; these data exclude those African Americans who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are those who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking. `The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 were statistically adjusted to produce estimates for the total population, males, and females that approximate those for African Americans aged 18 years and older. Estimates for persons in the 18-34 year old age category were statistically adjusted to produce estimates that approximate those for African Americans aged 18-34 years old. 11 a Cirtlpter 2 Tohncco Use A1710rzg U.S. Rncicll/Efhnic Minority Groups 1976+ 1977+ 1978 1979 1980 1983 7r KI % kc1 `?r ASI 7i XI % ?CI % KI 24.3 2.5 22.7 2.5 26.2 4.1 26.7 2.7 27.5 3.4 28.0 2.9 26.7 3.4 26.4 4.4 28.L5 6.4 28.7 3.8 29.2 4.9 32.0 4.3 21.6 3.7 18.7 3.0 23.6 4.8 24.4 3.7 25.5 4.9 23.4 3.7 13.8 3.1 14.3 3.1 17.9 5.6 18.4 4.0 16.9 4.7 18.8 3.9 24.0 4.7 23.0 4.2 27.3 6.0 26.5 4.9 31.1 7.2 27.7 4.8 13.4 6.1 37.4 6.2 41.6 10.8 42.8 6.1 41.7 10.0 44.6 6.4 30.0 3.5 26.9 3.4 29.7 6.1 33.1 4.8 34.7 7.3 32.4 5.1 23.2 4.9 20.9 1.9 25.3 5.9 25.4 4.2 21.3 9.3 25.4 5.3 23.7 9.5 26.7 8.3 27.9 13.2 32.7 10.6 37.2 12.9 32.3 9.0 23.9 13.5 25.3 10.9 20.0 16.2 26.8 9.5 41.9 12.7 36.4 11.8 1991 1992 1993 1994 1995 % kC1 7c KI % KI % KI 33.4 2.6 36.4 3.3 37.8 3.4 34.7 3.5 36.1 3.9 34.2 3.6 40.1 5.2 37.9 4.8 34.1 5.3 35.9 5.3 32.4 3.2 31.9 4.0 37.6 4.8 35.3 4.3 36.4 5.3 17.2 3.6 23.9 7.2 23.3 5.8 16.7 5.6 22.7 6.2 31.8 3.3 31.3 4.5 35.5 5.1 34.1 5.3 32.1 5.9 56.4 5.2 57.4 5.4 56.0 6.7 53.8 6.2 55.6 6.1 35.8 4.5 38.9 5.6 41.2 6.1 34.5 5.6 39.3 5.9 29.4 3.4 33.5 5.8 33.3 5.4 32.3 6.2 30.8 6.3 33.0 5.5 37.7 7.6 40.3 7.7 37.6 8.7 37.0 9.2 51.2 9.1 43.9 11.8 55.1 12.2 50.3 13.0 51.7 11.3 t95% confidence interval. *Includes persons aged 25 years and older. `Levels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Table 50. Percentage of African American women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1965-1995 Characteristic 1965 1966 1970 1974 o/c -1% 77c KI % KI % XI Total 42.9 2.9 Education_ Less than high school High school Some college College NA NA 45.0~ 4.0 NA NA 44.7" 9.6 1985 Characteristic 7% &CI 42.6 2.9 38.6 3.1 41.1 3.5 48.1 4.7 45.4 4.6 47.1 7.7 45.9 6.7 38.9 5.4 45.4 6.4 49.6 11.7 36.6 10.4 25.6 12.6 42.9 10.9 41.2 9.2 52.7 13.3 1987 1988 1990 % 3X1 % ?CI YO &CI Total 34.0 2.8 31.4 2.5 29.8 2.4 22.7 2.1 Educations Less than high school 54.3 6.8 High school 36.9 4.9 Some college 34.0 7.1 College 21.3 7.3 49.1 6.0 47.2 6.1 38.2 6.8 35.8 4.3 33.2 4.1 30.7 4.3 32.4 5.6 28.9 5.0 21.2 4.1 19.7 6.5 20.2 6.0 14.9 5.8 *Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic African Americans; these data exclude those African Americans who indicated they were of Hispanic origin. For 19651991, current cigarette smokers include women aged 1844 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days, Yhbacco USC Awzo~g U.S. Racinl/Etknic Minority Groups 1976+ 1977+ 1978 1979 1980 1983 YO AXI % kc1 % KI % KI % KI YO KI 38.8 4.2 41.7 4.0 36.4 6.3 35.2 3.0 34.6 5.4 34.3 3.4 45.3 7.1 44.0 9.0 41.5 10.3 43.2 8.9 35.7 12.9 49.6 8.9 39.1 7.3 49.3 7.6 36.4 7.7 34.5 6.8 40.0 10.0 36.5 6.2 46.0 9.6 41.4 10.5 53.0 15.3 33.2 9.7 30.5 11.8 29.3 8.4 35.5 15.4 36.6 15.1 45.9 19.2 36.2 10.3 31.0 17.4 22.5 9.2 1991 1992 1993 1994 1995 % L-G % kC1 YC XI YC ASI % AC1 28.1 2.4 24.5 2.9 23.1 2.9 22.9 1.8 23.8 3.9 50.4 6.1 45.9 10.0 45.6 9.4 43.6 9.4 49.6 12.3 32.4 4.0 29.8 5.2 30.2 5.5 26.1 5.2 30.6 6.9 31.5 5.6 26.1 6.7 26.3 6.5 27.4 8.2 24.9 7.6 19.8 6.6 18.5 8.2 8.2 6.0 8.0 5.7 13.6 7.9 `The 1976 and 1977 surveys collected data onlv for persons aged 20 years and older. The data for 1976 and , 1977 were statistically adjusted to produce estimates that approximate those for African American women aged 18-44 years. i95'"c confidence interval. $Includes persons aged 25 years and older. `Levels presented for 1965 are for persons who had a high school education or less and persons who attended some college or were college graduates. NA = data not available. Source: National Center for Health Statistics, public use data tapes, 1965-1995. Pnttrrns of Tobacco Use 321 Appendix 5. Validation of the Retrospective Assessment of Smoking Prevalence Because the method of computing smoking prevalences retrospectively is inherent in the birth co- hort analyses described in this chapter, comparability of these estimates with accepted cross-sectional estimates was examined. At least two factors contrib- ute to the observed difference between retrospective and cross-sectional estimates of smoking prevalence: how a former smoker is defined and differences in mor- tality between smokers and nonsmokers (differential mortality). Retrospective estimates will be greater than cross-sectional ones because they are based on the age at which a smoker quits wm m~df~~nll. However, cross- sectional estimates, using the accepted definition of a former smoker (a person who has ever smoked 100 cigarettes but does not smoke UUXJ), classify ever smok- ers who are not currently smoking as quitters, even though many will relapse several times before finally quitting. Differential mortality results in retrospective estimates smaller than cross-sectional ones because smokers are less likely than others to survive and re- port their smoking history. This factor affects only the older birth cohorts (Harris 1983). Retrospective estimates of smoking prevalence were assessed by comparing them with smoking prevalence estimates from the NHISs from 1965 through 1988 and from Gallup surveys from 1944 through 1988. The NHIS and Gallup surveys both sample adults only; thus, for the comparison, retro- spective prevalences computed for each year included only respondents aged 18 years and oIder in that cal- endar year. Sample sizes for the birth cohorts in- cluded in this analysis varied widely (Table 51) (NCHS, public use data tapes, 1978, 1979, 1980, 1982-1984 [HHANES], and 1987 and 1988 combined). When this methodology was used to estimate smoking prevalences retrospectively for the national Table 51. Sample sizes for birth cohorts, by gender, race/ethnicity, and education," National Health Interview Surveys, 1978-1980,1987 and 1988 combined, and Hispanic Health and Nutrition Examination Survey, 1982-1984 Men Women African American Hispanic African American Hispanic Birth Cohort HS HS HS HS 1908-1917 401 96 142 33 601 185 229 30 1918-1927 494 222 267 111 683 444 376 113 1928-1937 370 387 387 178 531 638 508 233 1938-1947 292 622 266 226 457 1,013 392 277 1948-1957 277 1,066 322 375 555 2,006 417 462 1958-1967+ 175 755 180 255 415 1,510 224 319 *Education was identified as either ~12 years of school completed (HS). `The smoking p ex erience of this cohort is still incomplete. Source: National Center for Health Statistics, public use data tapes, 1978, 1979,1980,1982-l 984 (Cancer Control Supplement and Epidemiology Supplement), and 1987 and 1988 combined. Tobn~co Use Among U.S. Racid/Etknic Minority Groups samples of the combined 1978, 1979, 1980, 1987, and 1988 NHISs, the prevalence of smoking in the U.S. population was estimated at approximately 10 percent in 1910, and it gradually increased before peaking in 1960 at approximately 50 percent (Figure 16). The prevalence then declined gradually to 28 percent in 1988. Data from successive Gallup polls administered since 1944 show a somewhat lower smoking preva- lence than do retrospective estimates, especially be- tween 1956 and 1970. Both the NHIS and the Gallup poll estimates follow a similar trend. For most years, retrospective estimates are slightly higher than those estimated from cross-sectional surveys (Table 52) (NCHS, public use data tapes, 1978, 1979, 1980, 1982-1984 [HHANES], and 1987 and 1988 combined). In addition, the estimate for the 1955 CPS (37.6 per- cent) is slightly lower than that estimated from the ret- rospective NHIS estimates (Figure 16). These findings are probably accounted for by the surveys' differing definitions of former smoker. The overall agreement of the retrospective prevalences with cross-sectional NHIS and Gallup poll data supports the validity of the prevalence estimates among successive birth cohorts for the population sub- groups presented in this chapter. Figure 16. Comparison of smoking prevalence estimates from selected U.S. surveys, 1910-1993 80 60 20 10 111,. Gallup polls National Health Interview Surve s FL? (NH1 s) Current Population Survey (CPS) Reconstructed NHISs 1950 Year Sources: Reconstructed estimates for 1910-1988 from the 1987-1988 combined NHISs (National Center for Health Statistics [NCHS], public use data tapes, 1987-1988); 1944-1991 Gallup polls (Thomas and Larsen 1993); 1955 CPS (USDHHS 1988); and 1965-1991 NHISs (NCHS, public use data tapes, 1965-1991). Pntterns of Tobacco Use 123 Surgeon Gem~l's Report Table 52. Comparison of current smoking prevalence* (%) between reconstructed estimates from National Health Interview Surveys (NHISs), 1987 and 1988 combined, NHIS cross-sectional survey estimates, and Gallup poll estimates Year Reconstructed NHISs Cross-sectional NHISs Estimate Estimate Difference+ Gallup Polls Estimate Difference+ 1944 42.7 NA 1949 45.4 NA 1954 46.7 NA 1957 46.7 NA 1965 45.8 42.4 1966 45.3 42.6 1969 43.2 NA 1970 42.7 37.4 1971 42.3 NA 1972 41.5 NA 1974 40.8 37.1 1976 39.9 36.4 1977 39.2 36.0 1978 38.5 34.1 1979 38.0 33.5 1980 37.4 33.2 1981 36.7 NA 1983 34.4 32.1 1985 32.1 30.1 1986 30.5 NA 1987 29.2 28.8 1988 28.2 28.1 NA NA NA NA -3.4 -2.7 NA -5.3 NA NA -3.7 -3.5 -3.2 4.4 4.5 4.2 NA -2.3 -2.0 NA -0.4 -0.1 41 -1.7 44 -1.4 45 -1.7 42 4.7 NA NA NA NA 40 -3.2 NA NA 42 -0.3 43 +1.5 40 -0.8 NA NA 38 -1.2 36 -2.5 NA NA NA NA 35 -1.7 38 +3.6 35 +2.9 31 +0.5 30 +0.8 32 +3.8 *In the NHIS, current smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked; in the Gallup poll, current smokers are persons who reported at the time of poll that they had smoked any cigarettes in the past week. +Difference between the survev estimate and the reconstructed prevalence estimate. 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Warm Springs (OR): Warm Springs Confederated Tribes, Community Health Promotion Department, Human Services Branch, 1993. 134 Chapter 2 Chapter 3 Health Consequences of Tobacco Use Among Four Racial/Ethnic Minority Groups Introduction 137 Lung Cancer 137 African Americans 138 American Indians and Alaska Natives 143 Asian Americans and Pacific Islanders 1 J.5 Hispanics 147 Other Cancers 149 Cervical Cancer 252 Esophageal Cancer 2.53 Oral Cancer 153 Stomach Cancer 155 Urinary Bladder Cancer 156 Chronic Obstructive Pulmonary Disease 158 African Americans 158 American Indians and Alaska Natives 158 Asian Americans and Pacific Islanders 159 Hispanics 159 Coronary Heart Disease 160 African Americans 160 American Indians and Alaska Natives 161 Asian Americans and Pacific Islanders 2 62 Hispanics 163 Cerebrovascular Disease 164 African Americans 165 American Indians and Alaska Natives 165 Asian Americans and Pacific Islanders 165 Hispanics 166 Smoking and Pregnancy 266 Studies of Low Birth Weight 167 Studies of Infant Mortality and Sudden Infant Death Syndrome 169 Health Problems Affecting Pregnant Women 171 Implications 172 Summary of Health Consequences from Active Cigarette Smoking 172 Effects of Exposure to Environmental Tobacco Smoke 172 Effects of Smokeless Tobacco Use 274 Nicotine Addiction and Racial/Ethnic Differences 175 Nature of Addiction 175 Pharmacologic Factors in Nicotine Addiction 175 Absorption, Distribution, and Elimination of Nicotine in the Body 175 Pharmacodynamics of Nicotine 2 76 Tolerance, Withdrawal, and Addictive Tobacco Use 178 Level of Addiction 179 Racial/Ethnic Differences in Nicotine Metabolites 179 Racial/Ethnic Differences in Self-Reported Nicotine Dependence 281 Racial/Ethnic Differences in Quitting Smoking 283 Addiction to Smokeless Tobacco 183 Conclusions 185 Appendix. Methodological Issues 185 Classification of Smoking Status 285 Classification of Race/Ethnicity 186 Classification of Health Outcomes 287 References 188 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Introduction The fact that cigarette smoking causes cancer, respiratory and cardiovascular diseases, and adverse pregnancy outcomes is well established (U.S. Depart- ment of Health and Human Services [USDHHSI 1989b). Evidence of the relationship between smok- ing and lung cancer began to accumulate as early as the late 1930s (Ochsner and DeBakey 1939; U.S. De- partment of Health, Education, and Welfare [USDHEW] 1964). In 1964, the first Surgeon General's report linking smoking to disease concluded that ciga- rette smoking was a cause of lung and laryngeal can- cers in men and a probable cause of lung cancer in women. In more recent reports, the Surgeon General has concluded that cigarette smoking causes 87 per- cent of lung cancer deaths, 30 percent of all cancer deaths, 82 percent of chronic obstructive pulmonary disease (COPD) deaths, 21 percent of coronary heart disease (CHD) deaths, and 18 percent of deaths from stroke (USDHHS 1989b) as well as 21-39 percent of low-birth-weight births and 14 percent of preterm de- liveries (USDHHS 1980, 1989b). In addition, passive or involuntary smoking causes lung cancer in healthy nonsmokers and respiratory problems in young chil- dren (USDHHS 1986a; U.S. Environmental Protection Agency 1992). Despite this wealth of knowledge about the health consequences of smoking, few studies have Lung Cancer examined the relationship between tobacco use and known health effects among racial/ethnic groups in the United States. Moreover, few databases include information on sufficient numbers of persons from racial/ethnic groups to allow such analyses. Although sufficient data are often not available for these population subgroups, the objectives of this chapter are to assess the burden of smoking-related diseases among U.S. racial/ethnic groups, to examine racial/ethnic differences in tobacco-related morbidity and mortality when possible, and to review studies that have examined how the relationship between to- bacco use and selected health outcomes may differ among racial/ethnic groups. For many of the adverse health outcomes and diseases presented in this chap- ter, smoking is one of many contributing factors. The focus in this chapter is on the disease burden related to smoking among four U.S. racial/ethnic minority groups (African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Island- ers, and Hispanics); data on the contribution of cigarette smoking to any differences between groups are highlighted whenever available. A discussion of some relevant methodological issues is provided in the chapter appendix. The 1964 Surgeon General's report on smoking and health concluded that "Cigarette smoking is caus- ally related to lung cancer in men; the magnitude of the effect far outweighs all other factors. The data for women, though less extensive, point in the same di- rection" (USDHEW 1964). That conclusion was based on strong epidemiological evidence from case-control and cohort studies and supporting toxicological evi- dence. When reviewed against criteria for causality, the evidence was initially judged to be sufficient for men and a similar conclusion was subsequently reached for women (USDHHS 1980). Since the 1964 Surgeon General's report, voluminous evidence has accumulated about the relationship between smoking and lung cancer (USDHHS 1989b; Wu-Williams and Samet 1994). The epidemiological studies consistently indicate that the risk of lung cancer increases with the number of ciga- rettes smoked and with the length of time a person smokes. Furthermore, evidence shows that in com- parison with smokers of non-filtered cigarettes, smok- ers of filtered cigarettes have only slightly less risk of lung cancer (Wu-Williams and Samet 1994). Although a family history of lung cancer is associated with in- creased risk, the genetic basis for this association has not yet been determined (Economou et al. 1994). En- vironmental agents other than cigarette smoke, includ- ing certain occupational agents (Coultas and Samet Health Coilseqzlel7ccs 237 Suqeon General's Report 1992; Coultas 1994) and indoor and outdoor air pol- lutants (Samet 1993), also cause lung cancer. For ex- ample, synergism between smoking and radon and asbestos has been demonstrated in studies of worker groups (Saracci and Boffetta 1994). Because nearly all cases of lung cancer are attrib- utable to cigarette smoking, variations in lung cancer patterns between racial/ethnic groups most likely re- flect differences in smoking patterns. Whenever more detailed information is available, it is included in the appropriate sections that follow. African Americans The population-based cancer registries operated by the National Cancer Institute's (NC11 Surveillance, Epidemiology, and End Results (SEER) Program pro- vide cancer incidence data for several locations throughout the United States, including Connecticut, Hawaii, Iowa, New Mexico, and Utah and the met- ropolitan areas of Detroit, Atlanta, San Francisco/ Oakland, and Seattle/Puget Sound. SEER data show that African American men have had consistently higher lung cancer incidence rates than white men since the 1970s (Figure 1) (Kosary et al. 1995). (SEER data cover about 10 percent of the U.S. population and are used frequently to estimate national cancer rates and trends.) Between 1950 and 1960, age-adjusted death rates for malignant neoplasms of the respiratory system (composed primarily of deaths from lung can- cer) among African American men surpassed those among white men and have since remained higher, whereas death rates for African American women have remained fairly similar to those among white women, according to data from the National Vital Statistics System (Table 1) (National Center for Health Statistics [NCHSI 1997). Since 1990, respiratory cancer death rates declined substantially for African American men; among African American women, rates increased through 1990 and then leveled off. From 1992-1994, the age-adjusted death rate for cancer of the trachea, bronchus, and lung (generally referred to as lung Figure 1. Incidence of cancer of the lung and bronchus, by race/ethnicity and gender, National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, 1973-1994 10 0 I I I I I I I I I I I 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 Year of Diagnosis - African American men - a- n * * White men African American women - White women Note: Age-adjusted to the 1970 standard U.S. population. Sources: Adapted from Kosary et al. 1995: Ries et al. 1997. 338 Chapter 3 Tobacco Use Arnmg U.S. Racial/Efhnic Minority Group Table 1. Death rates uer 100,000 U.S. residents for malignant diseases of the respiratory system, by race/ ethnicity a& gender, United States, 1950-1995: selected years - Race/ethnicity and gender African American men All ages, age-adjusted All ages, crude American Indian or Alaska Native men' All ages, age-adjusted All ages, crude Asian American or Pacific Islander men5 All ages, age-adjusted All ages, crude Hispanic men' All ages, age-adjusted All ages, crude White men All ages, age-adjusted All ages, crude African American women All ages, age-adjusted All ages, crude American Indian or Alaska Native women' All ages, age-adjusted All ages, crude Asian American or Pacific Islander women5 All ages, age-adjusted All ages, crude Hispanic women' All ages, age-adjusted All ages, crude White women All ages, age-adjusted All ages, crude 1950+ 1960+ 1970 1980 1985 1990 1992 1993 1994 1995 16.9 36.6 60.8 82.0 87.7 91.0 86.7 86.0 82.8 80.5 14.3 31.1 51.2 70.8 75.5 77.8 74.7 74.7 72.5 71.2 NA NA NA 23.2 28.4 29.7 31.7 31.0 31.1 32.7 NA NA NA 15.7 19.6 21.1 23.1 23.1 23.0 25.1 NA NA NA 27.6 26.9 26.8 27.4 28.4 28.0 25.8 NA NA NA 22.9 21.3 21.7 23.0 23.8 23.9 22.4 NA NA KA NA 24.0 27.7 24.4 25.1 24.8 25.2 NA NA NA NA 13.9 17.4 15.9 16.5 16.5 16.9 21.6 34.6 49.9 58.0 58.7 59.0 56.7 56.3 54.8 53.7 24.1 39.6 58.3 73.4 77.6 81.0 79.5 79.7 78.5 77.8 4.1 5.5 10.9 19.5 22.8 27.5 28.5 27.3 27.7 27.8 3.4 4.9 10.1 19.3 23.5 29.2 30.9 30.2 30.8 31.3 NA NA NA 8.1 11.1 13.5 15.5 16.1 17.7 16.4 NA NA NA 6.4 9.2 11.3 13.4 14.6 16.5 15.5 NA NA NA 9.5 9.2 11.3 11.1 11.7 11.2 13.0 NA NA NA 8.4 8.2 10.6 11.1 11.7 11.4 13.6 NA NA NA NA 6.7 8.7 8.4 8.2 8.5 8.2 5.2 7.5 7.5 7.3 7.7 7.5 4.6 5.1 5.4 6.4 z:: 10.1 13.1 18.2 22.7 26.5 27.4 27.6 27.7 27.9 26.5 34.8 43.4 46.2 47.3 47.9 48.9 - Note: Data in the table on African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and whites include persons of Hispanic and non-Hispanic origin. Conversely, in this table, the data on Hispanic origin may include persons of any race. *Age-adjusted to the 1940 U.S. standard population. Cause-of-death data are based on classifications from the then-current Internntio~~al Classification @Diseases (e.g., cause-of-death codes 160-165 for the Ninth Revision). Data for the 1980s are based on intercensal population estimates. `Includes deaths of nonresidents of the United States, tmterpretation of trends should consider that population estimates for American Indians and Alaska Natives increased by 45 percent between 1980 and 1990 (because of better enumeration techniques in 1990 and an _ increased tendency for people to denote themselves as American Indian in 1990). %terpretation of trends should consider that the Asian population in the United States more than doubled between 1980 and 1990, primarily because of immigration. `Because of incomplete data, the National Center for Health Statistics (NCHS) reports 1985 death certificate data on decedents of Hispanic origin for only 17 states and the District of Columbia. By 1990, data for 47 states and the District of Columbia were reported. NCHS estimates that the 1990 reporting area encompassed 99.6 percent of the U.S. Hispanic population. After 1992, only Oklahoma did not provide information on Hispanic origin. NA = data not available. Source: Adapted from National Center for Health Statistics 1997. i,,nzer) WFas highest for African American men (81.6 per I r)(),oOo population) (Table 2); the lung cancer death r,lte for African American women (27.2 per 100,000) ,,.db bimilar to that for white women (27.9 per 100,000) ,),,d ljigher than that for any other racial/ethnic group. .\mc,n~ African Americans in 1993, the four leading ic1Llse5 of cancer death were lung cancer (26.1 percent (,I ;1l1 cancer deaths), cancer of the colon and rectum ( 10.4 percent), prostate cancer (9.4 percent), and can- ik'T ()f the female breast (8.3 percent) (Parker et al. 1997). The higher lung cancer incidence and death rates ~,mo~~g African American men have not been fully ex- pl,lined. Two ecological analyses of population-based in ,lccounted for the differences in lung cancer be- t\\.ct'n white and African American men, whereas the ,luthors of the other paper (Devesa and Diamond 1983) pr~~posed that cigarette smoking and other environ- tnctntal correlates of socioeconomic status, such as dietary habits or occupational exposure, may have .licounted for their findings. Data from several National Health Interview `;url-cvs (NHISs) were used to conduct birth cohort ,~n,>lyll~~\~ et al. 1991; Shopland 1995). Older white men (tho5; born before 1915) experienced higher peak \nloking rates and slightly earlier ages of initiation th,ln older African American men. For persons born ,litc>r 1915, peak smoking rates and duration of smok- ing tor African American men were slightly higher than those> ior white men. In addition, Lvhite male smokers \\`c'rt' more likely than African American male smok- l'r\ to quit smoking in the 1950s (when the early ~it~tific studies on smoking and lung cancer were n~p~~rted); African American male cohorts born after IL) 15 thus experienced a greater cumulative exposure 10 cl$lrette smoke. Reflecting these trends in smok- Ills bc+avior, lung cancer mortality rates were initially ill&t>r for white men. The combination of less cessa- tl~)n, ljigher peak prevalence, and longer duration (`1 \moking in African American men after the 1940s Ilhc'l\' cl\plains the observation that mortality rates for -\trl~-cln American men began to exceed those for white 1111'1J Illttlr in the century (Shopland 1995). Lung cancer death rates have been much lower for women than for men (reflecting historically lower smoking prevalences) and have risen more slowly with age in the older birth cohorts. As rates for men began to decline in cohorts born after 1930, rates continued to rise among women, reflecting their slower adop- tion and increasing prevalence of cigarette smoking. African American and white women indicated simi- lar patterns of smoking initiation, maintenance, and quitting; lung cancer death rates for African Ameri- can and white women also have been similar (Tolley et al. 1991; Shopland 1995). These data are consistent with the interpretation that trends in smoking behav- ior are largely responsible for 20th century lung can- cer mortality patterns for African Americans and whites. Tolley and colleagues (1991) further suggested that lung cancer rates among African American men and women may be slightly higher than those for white men and women, even after considering differences in their smoking behaviors. One study (Harris et al. 1993) showed a higher lung cancer risk among African Americans compared with whites who had the same level of cumulative exposure to cigarette smoking. In this 20-year case- control study, 2,678 cases of lung cancer were identi- fied among white men, 238 cases among African American men, 1,394 cases among white women, and 113 among African American women; after adjusting the data for cumulative tar consumption and educa- tion, the researchers found that African Americans had a significantly higher risk of lung cancer. One limita- tion of this study is that it uses the Federal Trade Commission's (FTC's) estimates of tar yield to calcu- late cumulative tar consumption. The ETC's machines are set to parameters that have not changed for de- cades. Because humans smoke cigarettes differently than the machines used by the FTC, the validity of these measures has been called into question (NC1 1996a). In the Kaiser Permanente cohort study, the relative risks of lung cancer were approximately the same for African Americans and whites (Friedman et al. 1997). Dorgan and colleagues (1993) conducted a case-control study to assess race and gender differences in lung cancer, categorizing participants according to consumption of fruits and vegetables. Lung cancer risk was significantly increased for African Americans who currently smoked (compared with never smok- ers and former light smokers), regardless of the amount of vegetables consumed. These analyses were statisti- cally adjusted for gender, age, education, occupation, passive smoking, and study phase. In a recent population-based case-control study to compare the risks of lung cancer for African 73bncco USC Amo~~g U.S. Raczhl/Ethic Minority Groups Table 2. Age-adjusted death rates* for selected smoking-related causes of death, by race/ethnicity and gender, United States, 1992-1994 Disease Category UCD-9 code)+ African American Indian/ Asian American/ American Alaska Native Pacific Islander White Hispanic Men Women Men Women Men Women Men Women Men Women Cancer Lip, oral cavity, pharynx (140-l 49) 7.7 Esophagus (150) 11.4 Stomach (151) 9.5 Pancreas (157) 11.1 Larynx (161) 4.6 Trachea, bronchus, lung (162) 81.6 Cervix uteri (180) NA Bladder (188) 3.2 Kidney, other, unspecified urinary organs (189) 4.3 Cardiovascular diseases Coronary heart disease (410414) 138.3 Cerebrovascular disease (430438) 53.1 Respiratory diseases Bronchitis, emphysema (491492) 4.7 Chronic airway obstruction, not elsewhere classified (496) 17.6 1.8 2.6 1.0 3.3 1.0 3.0 1.2 2.4 0.5 3.0 3.2 0.5 2.7 0.5 4.4 0.9 2.8 0.4 4.1 4.9 2.6 8.9 5.1 3.9 1.7 6.2 3.1 8.1 3.4 3.0 5.5 3.9 7.3 5.2 5.1 3.8 0.8 0.9 0.3 0.6 0.1 1.7 0.4 1.3 0.2 27.2 33.5 18.4 27.9 11.4 54.9 27.9 23.1 7.7 5.7 NA 3.0 NA 2.5 NA 2.2 NA 3.2 1.6 1.2 0.5 1.5 0.6 3.9 1.1 1.8 0.6 2.0 4.4 2.3 1.8 0.8 4.1 1.9 3.1 1.3 85.0 100.4 71.7 36.2 132.5 62.9 82.7 43.9 40.6 23.9 45.9 21.1 1.9 9.0 29.3 22.4 26.3 22.6 22.7 16.3 1.6 2.8 2.9 0.9 6.2 3.8 2.4 6.6 14.2 7.9 2.6 20.4 12.2 8.2 0.9 3.7 *Per 100,000, age-adjusted to the 1940 U.S. standard population. Estimates for Hispanics exclude data from New Hampshire for 1992 and from Oklahoma for 1992-1994. +I&rrzntiolzal Clnssificntim of Discans~s, Ninth Rcz~isio~~, World Health Organization 1977. NA = data not available. Sources: National Center for Health Statistics, public use data tapes, 1992-1994; U.S. Bureau of the Census 1997. Americans and whites across categories of cigarette Surveillance System, a participant in the NCI's SEER smoking status, Schwartz and Swanson (1997) exam- Program. The analyses were stratified by gender and ined incident cases from the Occupational Cancer statistically adjusted for age, education, and cigarette Incidence Surveillance Study. This study operates in smoking behaviors. The overall risks of lung cancer conjunction with the Metropolitan Detroit Cancer (of all histological types) were similar for African Health Comrqzremes 142 Americans and whites. Thus, race did not appear to be an independent predictor of lung cancer in the population as a whole. Howelrer, African Americans were more likely than whites to have developed squa- mous cell carcinoma. Additionally, African American men aged 40-54 years were 24 times more likely than white men of the same ages to have developed lung cancer (of several histological types). The authors con- cluded that the increased risks among younger African Americans may suggest a greater degree of susceptibility to lung carcinogens or greater exposure to other unidentified carcinogens and they called for further research on the topic. Investigators have postulated that the more frequent smoking of menthol cigarettes by African Americans, compared with whites, contributes to their increased rate of lung cancer (Harris et al. 1993). In a recent experimental study of 12 persons after the amount of menthol injected into experimental ciga- rettes was increased, the amount of carbon monoxide exhaled by African American smokers also increased (Miller et al. 1994). In a comparison of smoking be- havior associated with mentholated cigarettes and regular cigarettes among 29 subjects, McCarthy and colleagues (1995) found higher mean puff volume and higher puff frequency after participants smoked regu- lar cigarettes than after they smoked mentholated cigarettes; however, no differences in mean expired carbon monoxide levels were found. A\Tailable data suggest that mentholated cigarettes are not smoked more intensely than regular cigarettes (Jarlik et al. 1994; Miller et al. 1994; McCarthy et al. 1995; Ahijevych et al. 1996). Thus, mentholated cigarettes may pro- mote lung permeability and diffusibility of smoke con- stituents (Jarvik et al. 1994; McCarthy et al. 1995; Clark et al. 1996a). Recent studies have examined the possible role of genetics in determining the risk of lung cancer among African Americans. Crofts and colleagues (1993) identified a restriction fragment length polymor- phism (RFLP) in the gene (CYPIAI) that encodes the enzyme responsible for initiating metabolism of polyaromatic hydrocarbon compounds found in ciga- rette smoke (Guengerich 1992, 1993). In one study of African Americans, the risk of adenocarcinoma of the lung was higher for smokers with the CYPlAl RFLP than for smokers who did not have this RFLP (Taioli et al. 1995). Two other studies, however, did not find an association between the presence of the variant al- lele in African Americans and increased lung cancer risk (Kelsey et al. 1994; London et al. 1995). Taioli and colleagues (1995) also found that persons who had adenocarcinoma with the African American CYPZAI RFLP had lower lifetime cigarette consumption, as measured by pack-years, compared with those who had adenocarcinoma without the polymorphism. However, using a cutoff point of 35 pack-years, London and colleagues (199.5) found no association between the variant CYPZAI variant allele and lung cancer risk based on smoking history. Additionally, a homozygous rare CYPlAl allele associated with the risk of lung cancer among persons from Japan (Kawajiri et al. 1990) was found more often in African Americans than in whites (Shields et al. 1993). How- ever, in a small case-control study, no association was observed between the presence of this polymorphism and lung cancer risk (Shields et al. 1993). Despite strong research interest in this area, scientists have been unable to consistently associate variant alleles with lung cancer susceptibility. The fre- quencies of the polymorphisms of interest appear to be low in United States populations studied thus far. Low frequencies of the alleles of interest suggest that future investigations must allow for an adequate sample size of the group under study and adjustment for factors such as smoking history and age. In addi- tion, low frequency allelic affects may be negated or obscured by high tobacco exposure levels. Two phenotypes were identified in African American and white persons representing poor and extensive extremes of glucuronidation (Richie et al. 1997). Glucuronidation is considered a detoxification pathway because it increases the water solubility of a chemical substrate and facilitates excretion (Goldstein and Faletto 1993). The ratio of conjugated metabolite to free metabolite of a tobacco-specific nitrosamine was 30 percent higher in the urine of white smokers than in African American smokers. This finding suggests that African Americans are at higher risk from nitrosamine exposure during smoking because of a decreased capacity to detoxify carcinogenic tobacco-specific nitrosamines. Hence, variability in glucuronosyltransferase activity, or in clearance of glu- curonide conjugates, may represent another determi- nant of cancer risk. The genetically determined poor, intermediate, or enhanced debrisoquine metabolizer phenotype has been investigated as a risk factor for lung cancer. Homozygous dominant (extensive metabolizer) indi- viduals were found more frequently among white lung cancer patients who smoked cigarettes than white control patients with COPD who smoked cigarettes (Ayes11 et al. 1984). Caporaso and colleagues confirmed the association between the extensive debrisoquine metabolizer phenotype and lung cancer risk. In this study, almost equivalent numbers of extensive metabolizers were found among African Americans (74 percent) and whites (73 percent) (Caporaso et al. 1990). Another approach in assessing the possible role of genetics is using chromosome breaks to measure cancer susceptibility. One research group has devel- oped an in vitro cytogenic assay that measures mutagen-induced chromosome breaks in short-term lymphocyte cultures. This approach has shown a relationship between mutagen sensitivity and elevated lung cancer. However, attempts to use this method as a predictive marker of racial/ethnic differences in can- cer risk in African and Mexican Americans produced inconsistent results (Spitz et al. 1995; Strom et al. 1995; Wu et al. 1996). Carcinogenesis can in\Tolve genotoxic mecha- nisms whereby chemical interactions at critical cellu- lar sites go unrepaired. Alterations in certain genes, kno\vn as proto-oncogenes and tumor suppressor genes, are linked with cancer risk (Land et al. 1983; Marshall et al. 1984; Slamon et al. 1984; Klein and Klein 1985; Denissenko et al. 1996). Some gene alleles that are e\,aluated as markers of lung cancer risk Ivary in their distributions among African Americans and whites. For example, in a study of lung cancer cases and trauma victim controls, Weston and colleagues (1991) found rare Ha-ras-1 alleles more often in the lung tissue of African Americans (17 percent) than in whites (5 percent). For both groups, the prevalence of rare alleles among lung cancer patients was higher than among controls (23 percent for African American lung cancer cases, 15 percent for African American trauma victim controls, 6 percent for white lung cancer cases, and 2 percent for white trauma victim controls). These findings were confirmed in a second study (Weston et al. 1992). African American and white differences in distribution of alleles at the L-myc locus and ~53 genotype have also been reported. The authors con- cluded that L-myc genotypes and p53 variants do not predict lung cancer risk (Weston et al. 1992). In summary, the higher rates of lung cancer ob- served among African American men are consistent with historical patterns of cigarette smoking in this century (Shopland 1995). In addition, African Ameri- can men aged 40-54 years may be especially suscep- tible to lung carcinogens (Schwartz and Swanson 1997), perhaps because they detoxify them differently (Richie et al. 1997). A genetic role in racial and ethnic-specific risk for lung cancer cannot be ruled out, because some studies have shown that African American populations have increased frequencies of rare alleles associated with greater risks for developing lung cancer than whites. However, because of the low frequency of these alleles in the populations under study and the possibility of misclassification bias, studies have been inconclusive (Shields et al. 1993; Taioli et al. 1995). Further, African American smokers prefer mentholated cigarettes, and menthol may promote the absorption and diffusion of tobacco smoke constituents (Jarvik et al. 1994; McCarthy et al. 1995; Clark et al. 1996a). This hypothesis has received inconsistent support in the epidemiological literature. Kabat and Herbert (1991) found no relationship between menthol use and lung cancer risk; however, Sidney and colleagues (1995) suggested that smoking mentholated cigarettes in- creased the risk of lung cancer only in male smokers. Further research could clarify the nature of individual susceptibility and the possible role of mentholation. Reduction in cigarette smoking will undoubtedly lead to reduction in the risk of lung cancer for African Americans. American Indians and Alaska Natives Since the early 19OOs, many studies have docu- mented the low overall occurrence of cancer among American Indians compared with whites (Hoffman 1928; Smith et al. 1956; Smith 1957; Salsbury et al. 1959; Sievers and Cohen 1961; Kravetz 1964; Reichenbach 1967; Creagan and Fraumeni 1972; Dunham et al. 1973; Blot et al. 1975; Lanier et al. 1976; Samet et al. 1980, 1988b; Sorem 1985; Mahoney and Michalek 1991; Nut- ting et al. 1993). Investigations of lung cancer inci- dence and deaths have confirmed that lung cancer is less frequent among American Indians overall than among whites (Coultas et al. 1994). Between 1992 and 1994, age-adjusted death rates for lung cancer per 100,000 among American Indian and Alaska Native men (33.5) and women (18.4) were slightly higher than those among Asian American and Pacific Islanders as well as Hispanics, whereas they were lower than rates among African Americans and whites (Table 2) (NCHS, public use data tapes, 1992-1994; U.S. Bureau of the Census 1997). Mortality rates for malignant diseases of the respiratory system increased from 1980 through 1995 among American Indians and Alaska Natives (Table 1) (NCHS 1997). Nationally, lung cancer is the leading cause of cancer death among American Indians and Alaska Natives. Among those who died of cancer in 1993, the four leading causes of death were lung cancer (26.8 percent), cancer of the colon and rectum (8.9 percent), cancer of the female breast (6.3 percent), and prostate cancer (6.0 percent) (Parker et al. 1997). Additionally, lung cancer was the leading cause of cancer death among both men and women in 10 of the 12 Indian Figure 2. Age-adjusted lung cancer death rates among American Indian and Alaska Native men in seiecteh states compared with rates among all U.S. men, 1968-1987* 80 1 60 - All U.S. men - m - 1. Alaska North Dakota, 111 South Dakota, and Montana Michigan, m--a Minnesota, and Wisconsin - Oklahoma Arizona and New Mexico 1968-l 972 1973-l 977 Years 1978-1982 1983-1987 *Rates presented here were determined using midpoint population estimates for each 5-year time interval and were adjusted to the 1970 U.S. standard population. Source: Valway 1992. Health Service (IHS) areas (Arizona and New Mexico had low rates of lung cancer deaths) (Valway 19921. Lung cancer death rates among American Indians and Alaska Natives have been rising in most IHS areas (Fig- ures 2 and 3) (Valway 1992); national death rates from malignant diseases of the respiratory system have also been increasing (Table 1). Lung cancer death rates vary by IHS area. Spe- cifically, American Indians in the Southwest have had the lowest lung cancer death rates, whereas American Indians in Alaska, North Dakota, South Dakota, and Montana have had rates nearly as high as those in the general U.S. population (Table 3, Figures 2 and 3) (Valway 1992). These differences are associated with variations in smoking among American Indians and Alaska Natives (Centers for Disease Control [CDC] 1987; Welty et al. 1993). In an analysis of data from the 1985-1988 Behavioral Risk Factor Surveillance System (BRFSS) on 1,055 American Indians, Sugarman and colleagues (1992) determined smoking prevalence for three groups of states that contained three specific IHS areas. In this study, the Plains states (Iowa, Minne- sota, Montana, Nebraska, North Dakota, South Dakota, and Wisconsin) contained the Aberdeen, Bemidji, and Billings IHS areas; the West Coast states (California, Idaho, and Washington) contained the Portland and California IHS areas; and the Southwest states (Arizona, New Mexico, and Utah) contained the Al- buquerque, Navajo, Tucson, and Phoenix IHS areas. Cigarette smoking prevalence rates were highest in the Plains states (48.4 percent for men and 57.3 percent for women), intermediate in the West Coast states (25.2 percent for men and 31.6 percent for women), and low- est in the Southwestern states (18.1 percent for men and 14.7 percent for women). These general geo- graphic patterns of smoking prevalence paralleled patterns of lung cancer mortality (Table 3) (Valway 1992). The smoking prevalence estimates from the 1985-1988 BRFSS analyses may be imprecise because of relatively small samples. However, other analyses (American Indians and Alaska Natives, in Chapter 2; Welty et al. 1995) show similar patterns. Another TO~CCCJ USC Amng U.S. Racial/Efhnic Minorify Groups Figure 3. Age-adjusted lung cancer death rates among American Indian and Alaska Native women in selected states compared with rates among all U.S. women, 196%1987* a *, I II All U.S. women Alaska North Dakota, South Dakota, and Montana Michigan, Minnesota, and Wisconsin Oklahoma Arizona and New Mexico I I I I I I I I I I I I I I I 1968-1972 1973-1977 1978-1982 1983-1987 Years *Rates presented here were determined using midpoint population estimates for each S-year time interval and were adjusted to the 1970 U.S. standard population Source: Valway 1992. potential limitation is that American Indians living in the California and Portland IHS areas may be more likely than American Indians from other IHS areas to be misclassified on death certificates as being of other racial/ethnic categories (Valway 1992), suggesting that death rates for American Indians may be underesti- mated in these areas (Sorlie et al. 1992). Lanier and colleagues (1996) recently reported on lung cancer incidence rates for Alaska Native men and women. Lung cancer incidence was higher for Alaska Natives than it was for the general U.S. population. In addition, lung cancer was the most common inci- dent cancer among men and the third most common incident cancer among women (after breast cancer and cancer of the colon/rectum). Lung cancer incidence increased substantially among Alaska Native men (by 93 percent) and women (by 241 percent) between 1969-1973 and 1989-1993. The authors concluded, "Reduction in tobacco use would result in the greatest decreases in cancer rates in this population" (p. 751). Asian Americans and Pacific Islanders Two issues should always be kept in mind when interpreting data about the health consequences of cigarette smoking among Asian Americans and Pacific Islanders: the diversity of this group and the paucity of data. The Asian American and Pacific Islander population of the United States includes approxi- mately 32 national and racial/ethnic groups and nearly 500 languages and dialects. Although many of these persons were born in the United States, many others are recent immigrants (see Chapters 1 and 2); yet the national data do not indicate these distinctions. Envi- ronmental exposures experienced in Asia, such as women's exposure to smoke from cooking fuels, may influence lung cancer occurrence among recent immi- grants (Co&as et al. 1994). From 1980 through 1995, age-adjusted death rate for malignant neoplasms of the respiratory system (primarily deaths from lung cancer) among Asian Table 3. Death rates for lung cancer among American Indians and Alaska Natives, by Indian Health Service (IHS) area, 1984-1988 Areas Men Women N Rate* N Rate* U.S., all ethnicities Nine IHS areas*+ All 12 IHS areas Aberdeen Alaska Albuquerque Bemidji Billings California+ Nashville Navajo Oklahoma+ Phoenix Portland+ Tucson 74.2 27.3 307 38.5$ 203 27.2 562 40.1t 296 21.4i 63 68.7 41 45.01 80 75.5 62 68.5$ 12 18.8$ 5 7.8$ 41 63.4$ 24 40.71 36 65.3 33 65.7i 33 33.2' 8 6.6$ 24 41.8t 15 25.1 25 11.4i 7 4.0$ 167 46.0i 55 14.0$ 20 17.2$ 13 11.5* 55 40.5f 30 23.4 6 25.9i 3 13.5i *Per 100,000, age-adjusted to the 1970 U.S. standard population. Rates based on a small number of deaths should be interpreted with caution. `The California, Oklahoma, and Portland IHS areas appear to have a problem with underreporting Indian ethnicity on death certificates; therefore, a separate total is presented for the nine other IHS areas, excluding these three areas. iDenotes a rate significantlv different from the rate for the overall U.S. population. Source: Valway 1992. During 1988-1992, the age-adjusted (to the 1970 U.S. standard population) incidence per 100,000 popu- lation of lung cancer for men was 89.0 for Hawaiians, 70.9 for Vietnamese, 53.2 for Koreans, 52.6 for Filipi- nos, 52.1 for Chinese, and 43.0 for Japanese. For com- parison purposes, the lung cancer incidence rates were 117.0 for African American men, 76.0 for white men, and 41.8 for Hispanic men. For women, the lung can- cer incidence rates were 43.1 for Hawaiians, 31.2 for Vietnamese, 25.3 for Chinese, 17.5 for Filipinos, 16.0 for Koreans, and 15.2 for Japanese. In comparison, the lung cancer incidence rates were 44.2 for African American women, 41.5 for white women, and 19.5 for Hispanic women. American and Pacific Islander men remained fairly Age-adjusted lung cancer death rates during constant; this death rate for Asian American and Pa- 1988-1992 were, per 100,000 men, 88.9 for Hawaiians, cific Islander women increased slightly between 1980 40.1 for Chinese, 32.4 for Japanese, and 29.8 for Filipi- and 1995 but was substantially lower than for men nos; mortality estimates were not available for Kore- (Table 1) (NCHS 1997). Trends should be interpreted ans and Vietnamese of either gender. In comparison, with caution because the large numbers of immigrants the lung cancer death rates were 105.6 for African from Asia and the Pacific Islands that came to the American men, 72.6 for white men, and 32.4 for His- United States during that time may have influenced panic men. For women, the lung cancer death rates both disease prevalence in and the age structure of this were 44.1 for Hawaiians, 18.5 for Chinese, 12.9 for Japa- group. During 1992-1994, the age-adjusted death rate nese, and 10.0 for Filipinos. In comparison, the lung for lung cancer was 27.9 per 100,000 for Asian Ameri- cancer death rates were 31.9 for white women, 31.5 can and Pacific Islander men and 11.4 per 100,000 for for African American women, and 10.8 for Hispanic women (Table 2). These rates were slightly higher than women (NC1 1996b). The lung cancer rates reflect gen- those for Hispanics and slightly lower than those for der differences in smoking rates among Asian Ameri- American Indians and Alaska Natives. In 1993, the can and Pacific Islander populations, as indicated by four leading causes of cancer death among Asian 1978-1995 data from the NHISs (see Chapter 2). Americans and Pacific Islanders were lung cancer (22.3 percent of all cancer deaths), cancer of the colon and rectum (10.4 percent), cancer of the liver and intrahe- patic bile duct (8.6 percent), and stomach cancer (7.7 percent) (Parker et al. 1997). Data on lung cancer for more specific subgroups have been published in several reports (Baquet et al. 1986; Ross et al. 1991; Zane et al. 1994; NC1 1996b). The most recent data are from NCI's SEER program and provide information for 1988-1992. This report includes incidence data from the nine areas included in the annual SEER reports (e.g., Kosary et al. 1995) and from Los Angeles, San Jose/Monterey, and the Alaska Area Native Health Service. Data on Hispan- ics are predominantly from Los Angeles, New Mexico, San Francisco, and San Jose/Monterey. Most Hispan- ics represented in SEER are Mexican Americans. Data on Asian Americans and Pacific Islanders are mainly from Los Angeles, Hawaii, San Francisco/Oakland, San Jose/Monterey, and Seattle/Puget Sound. Data on American Indians are from New Mexico; data from the Alaska Native Area Health Service provide infor- mation on Alaska Natives (NC1 1996b). Tohncco Use Among U.S. Racinl/Ethic Mirzority Groups Several studies have identified high rates of lung cancer among Native Hawaiians. Data on lung cancer among Pacific Islanders from the Hawaii Tumor Regis- try indicate that Native Hawaiians have the highest lung cancer incidence rates among the islands' other racial/ethnic groups, including Japanese, Filipinos, and Chinese (Kolonell980; Hinds et al. 1981). Using medi- cal records of lung cancer patients and data from a population-based survey, Hinds and colleagues (19811 assessed the risk of developing lung cancer associated with smoking among M'omen in Hawaii. The risk for developing lung cancer among women ~~110 had e\`er smoked compared with those ~`1~0 had never smoked w'as substantially greater among Nati\-e Harvaiian women (tenfold higher) than among Japanese women (fivefold higher) and Chinese women (tlvofold higher). In a comparison of the risks of smoking among Natilre Hawaiians, Filipinos, Japanese, and Chinese in HawFaii, Le Marchand and colleagues (1992) found that Native Hawaiian men had the highest risk and that lvhite and Filipino women had higher risks than Native Hawai- ian women. The pattern of variation of smoking's effect on lung cancer \vas statistically significant for men. These differences persisted after variables for beta-carotene and cholesterol intake were included in the statistical model. The observation that the risk of lung cancer related to smoking may vary among sub- groups requires further elucidation. In a cohort study of 7,961 Japanese American men who were living in Hawaii, the incidence of lung cancer was 11.4 times higher in current smokers than in persons ~`110 had never smoked; the risk for former smokers was 3.1 times higher than for never smokers (Chyou et al. 1993). Hispanics According to NCHS data from 1985 through 1995, the age-adjusted death rate for malignant neoplasms of the respiratory system (primarily deaths from lung cancer) among Hispanic men was about three times higher than that for Hispanic women (Table 1) (NCHS 1997). Trends should be interpreted with caution, be- cause only 17 states and the District of Columbia con- tributed death certificate data on Hispanics for 1985; by 1990, however, 47 states and the District of Colum- bia, covering 99.6 percent of the U.S. Hispanic popu- lation, contributed relevant data (Table 1) (NCHS 1997). From 1992 through 1994, the age-adjusted death rate for cancer of the trachea, bronchus, and lung (gener- ally referred to as lung cancer) was 23.1 per 100,000 for Hispanic men and 7.7 per 100,000 for Hispanic women (Table 2). Overall, lung cancer is the leading cause of cancer death among Hispanics. Among those who died of cancer in 1993, the four leading causes of death were lung cancer (17.9 percent), cancer of the colon and rectum (9.6 percent), cancer of the female breast (8.2 percent), and cancer of the liver and other biliary organs (6.0 percent) (Parker et al. 1997). Among Hispanic women, however, breast cancer mortality exceeds that of lung cancer (NC1 1996b). National mortality data for 1992-1994 (Table 4) also indicate that rates of lung cancer per 100,000 were higher among Cuban men (33.7) than among Mexican American (28.3) and Puerto Rican men (21.9). Among women, little variation is evident across His- panic subgroups (Table 4). An earlier nationwide analysis limited to foreign-born Cubans, Mexicans, and Puerto Ricans provided similar results for 1979-1981 (Rosenwaike 1987). Some regional data suggest that rates of lung cancer among Hispanics increased rapidly. For ex- ample, New Mexico mortality data for 1958-1982 indicate that lung cancer death rates increased for suc- cessive birth cohorts of Hispanics (Samet et al. 1988b). Between 1958-1962 and 19781982, lung cancer death rates per 100,000 increased from 10.1 to 28.8 among Hispanic men and from 4.8 to 11.2 among Hispanic women (Samet et al. 1988b). However, lung cancer death rates among Hispanics remained below those of the general U.S. population. Moreover, be- tween 1969-1971 and 1979-1981, lung cancer incidence rates doubled for persons with Spanish surnames (not necessarily all persons were Hispanic) residing in the Denver, Colorado, area (Savitz 1986). National and regional vital statistics have shown that patterns of lung cancer incidence differ among Hispanics and whites throughout the United States (NCHS 1994). Much of the information available on lung cancer incidence has relied on the SEER Program, which for many years included only one subgroup of Hispanics-those residing in New Mexico. Since the 195Os, descriptive studies of death have documented differing patterns of lung cancer among Hispanics and whites in the western and southwestern United States. In California, during the 1950s and 196Os, age-specific death rates from lung cancer among older Mexican-born women were two to three times the rates among California women of all ages (Buechley et al. 1957; Buell et al. 1968). Lung cancer death rates for women in Texas and New Mexico during the 1960s and 1970s showed a similar pattern of age-specific rates (Lee et al. 1976; Samet et al. 1980,1988b), although Hispanic women in the West and Southwest have had lower over- all lung cancer death rates than white women (Savitz 1986; Martin and Suarez 1987; Samet et al. 1988b; Bernstein and Ross 1991). Table 4. Age-adjusted death rates* for selected smoking-related causes of death among Mexican Americans, Puerto Rican Americans, and Cuban Americans, United States, 1992-1994 Disease category (ICD-9 code)+ Mexican Men Women Puerto Rican Men Women Cuban Men Women Cancer Lip, oral cavity, pharynx (140-149) Esophagus (150) Stomach (151) Pancreas (157) Larynx (161) Trachea, bronchus, lung (162) Cervix uteri (180) Bladder (188) Kidney, other, unspecified urinary organs (189) Cardiovascular diseases Coronary heart disease (410-414) Cerebrovascular disease (430338) 2.0 0.4 5.5 0.9 3.3 0.7 2.7 0.3 6.1 1.1 2.7 0.4 6.8 3.5 7.7 3.9 3.1 1.3 5.4 4.3 5.0 3.6 5.0 4.1 1.1 0.1 2.6 0.3 2.2 0.1 21.9 8.0 28.3 9.6 33.7 8.9 NA 3.7 NA 3.7 NA 1.6 1.4 0.5 2.1 1.0 3.5 0.5 3.7 1.6 1.9 1.0 2.7 1.0 82.3 44.2 25.5 18.9 118.6 67.3 95.2 42.4 27.3 16.5 17.1 11.5 Respiratory diseases Bronchitis, emphysema (491-492) Chronic airway obstruction, not elsewhere classified (496) 2.2 0.9 3.2 1.3 3.3 1.0 7.6 3.7 10.5 5.3 9.1 3.1 *Per 100,000, age-adjusted to the 1940 U.S. standard population. Death rates are not available from New Hampshire for 1992 and from Oklahoma for 1992-1994. Due to limitations in the data, the population estimates for Oklahoma and New, Hampshire were not subtracted from the denominator. Based on the 1990 Census, the number of persons of Hispanic origin from New, Hampshire and Oklahoma represented about 0.04 percent of the U.S. Hispanic population. +l~zfernnfio~~~/ Clnssificnfior~ of Disen.scs, Nirlfh R~~isicjr~, World Health Organization 1977. NA = data not available. Sources: National Center for Health Statistics, public use data tapes, 1992-1994; U.S. Bureau of the Census 1997. In 1982 and 1983, lung cancer rates among Hispanic men than among white men in New Mex- Hispanic men and women in Florida also were lower ico (Samet et al. 1980), Texas (Lee et al. 1976), Califor- than the rates among whites (Trapido et al. 1990a,b). nia (Menck et al. 1975; Bernstein and Ross 1991), More recent data (1981-1989) from Dade County, Connecticut (Polednak 19931, and Colorado (Savitz Florida, again show the incidence of lung cancer to be 1986). Mortality data indicate that Puerto Ricans lower among Hispanic men than among white men living on Long Island, New York, had slightly and lower among Hispanic women than white women lower death rates for lung cancer than Puerto Ricans (Trapido et al. 1994a,b). Similarly, Mexican and Puerto living elsewhere in the United States (except Puerto Rican immigrants in Illinois have had lower standard- Rico) (Polednak 1991). However, Puerto Rican men ized lung cancer death rates than whites (Mallin and and women residing on Long Island had lung cancer Anderson 1988). In addition, lung cancer incidence death rates that were three to four times the rates and death rates have been much lower among among Puerto Rico residents. These lower rates of lung cancer among Hispan- ics appear to reflect differences in smoking between Hispanics and whites. The results of a 1980-1982 case-control study of lung cancer cases among Hispan- ics and whites residing in New Mexico indicate that the risks (adjusted for gender and age) across catego- ries of smoking consumption among both groups were comparable (Table 5) (Humble et al. 1985). This find- ing suggests that the reduced rates of lung cancer deaths among Hispanics are attributable to their lower cigarette consumption (number of cigarettes smoked daily) and not to some other correlate of Hispanic race/ ethnicity. In a mortality study conducted in Texas be- tween 1970 and 1979 using age-standardized death rates, Holck and colleagues (1982) found that Mexi- can American women had stable lung cancer death rates (approximatelv 30 per lOO,OOO), whereas white Lvomen had increasing rates of death from lung cancer. The lower lung cancer rates for Mexican American women were consistent with their lower prevalence of smoking (18.5 percent of Mexican Ameri- can women vs. 31.6 percent of white women). The elevated rates of lung cancer death among older Hispanic women in the West and Southwest ha\re been attributed to a possible pattern of early initiation of smoking among women born in Mexico before 1900 as well as the custom of cooking indoors with an open fire (Buell et al. 1968; Lee et al. 1976). The findings of a 1980-1982 case-control study in Ne\v Mexico indicate that older Hispanic women smoked hand-rolled ciga- rettes, which may have contributed to the high lung cancer death rate among older Mexican American women (Humble et al. 1985). Table 5. Odds ratios for the risk of lung cancer, by gender, racejethnicity, and smoking status, case-control study, New Mexico,* 1980-1982 Men Smoking status Former smokers Current smokers ~20 cigarettes per day 220 cigarettes per day Hispanic White 8.0+ 7.2 (1.942.2$ (3.0-17.6) 11.6 9.2 (2.7-61.5) (3.3-25.8) 26.1 24.7 (5.6-146.6) (10.0-59.9) Women Hispanic White Former smokers Current smokers ~20 cigarettes per day ~20 cigarettes per day 6.3+ 6.5 (1.5-27.8) (2.8-15.4) 18.5 19.2 (4.9-72.4) (6.5-60.8) 36.9 16.0 (7.6-217.1) (6.7-36.3) "Mantel-Haenszel estimates of exposure odds ratios were calculated for two age strata: ~65 years of age and 265 years of age. Odds ratios are relative to persons who never smoked. +p 90 1.0 1.0 1.0 1.0 3.0 2.3 3.8 2.4 1.9 1.5 3.1 1.7 4.0 2.6 3.8 2.9 4.7 2.7 5.0 3.5 4.8 3.0 5.2 2.7 Hartge et al. 1993 SEER+ registries, population-based, 1978 Never Former 1.0 1.0 Cigarettes smoked <: 20 per day 1.6 1.3 3.6 2.0 L 20 per day 1.8 1.9 5.0 1.3 Current Cigarettes smoked c 20 per day 2.2 2.1 1.7 2.0 2 20 per day 4.5 3.0 2.1 3.1 1.0 3.9* 1.0 1.0 1.3 3.2 1.0 *Ever smokers. `National Cancer Institute's Surveillance, Epidemiology, and End Results Program. that 41 percent of African Americans and 55 percent of whites were slow acetylators. A phenotyping study also found the highest percentage of slow acetylators among whites (54 percent), compared with African Americans (34 percent) and Asians (14 percent) (Yu et al. 1994). In the 1994 study by Yu and colleagues, slow acetylators had higher levels of 3- and 4-aminobiphenyl-hemoglobin adducts, regardless of race and level of smoking (Yu et al. 1994). For African Americans, Asians, and whites, however, the levels of 3- and 4-aminobiphenyl-hemoglobin adducts in- creased proportionately more for cigarette smokers compared with nonsmokers than for slow acetylators compared to rapid acetylators. In a subsequent study by Yu and colleagues (3995), the slow acetylation phenotype combined with the null genotype of the gene lGSTMl) for a phase II detoxification enzyme (glutathione S-transferase) resulted in higher levels of 3-and 4-aminobiphenyl-hemoglobin adducts than did lower risk profiles (i.e., rapid acetylator and/or at least one functional GSTMI gene allele). The highest risk profile was seen in 27 percent of whites, 15 percent of African Americans, and 3 percent of Asians. Several studies show that the highest levels of risk are experienced by smokers, because high levels of exposure to tobacco smoke overwhelm the various phenotypic traits. The differences in risks for various detoxification and activation pathways appear to be most significant among persons who did not smoke or who smoked at very low levels (Yu et al. 1994,1995; Landi et al. 1996). Health Comeyrrerrces 157 Chronic Obstructive Pulmonary Disease In addition to causing lung cancer, tobacco smok- ing aIso causes several non-malignant diseases of the lung and increases the frequency of respiratory symptoms and illnesses (USDHHS 1989b, 1990). Chronic obstructive pulmonary disease (COPD) is a clinical term applied to persons with a permanent airflow obstruction associated with significant impair- ment (Samet 1989; USDHHS 1989b). Cigarette smok- ers with COPD have impaired breathing as a result of emphysema (air space enlargement and destruction) and damage to the airways (USDHHS 1984). These smokers also may have chronic bronchitis, which is the term used by epidemiologists and clinicians for chronic sputum production. Longitudinal studies show that the development of COPD follows sustained excessive loss of ventila- tory function of the lung caused by cigarette smoking (USDHHS 1984, 1990). The rate at which ventilatory function declines tends to increase with the amount smoked and to revert to the rate associated with aging after smoking cessation (USDHHS 1990). The fre- quency of chronic bronchitis is similarly related to smoking pattern. African Americans Data from several national surveys have been used to compare the prevalence of COPD among Afri- can Americans and whites. McWhorter and colleagues (1989) used data from the 1971-1975 National Health and Nutrition Examination Survey (NHANES I) and the 1982-1984 NHANES I Epidemiologic Follow-up Study (NHEFS) to determine the prevalence of COPD among 14,404 adults aged 25-74 years. African Ameri- can race/ethnicity was associated with a lower risk for having COPD; 6.2 percent of whites and 3.2 per- cent of African Americans had COPD. In the 1990 NHIS, the prevalence of self-reported chronic bronchitis was 55.2 per 1,000 African Ameri- cans aged 45-64 years and 42.7 per 1,000 African Americans aged 65 years and older (USDHHS 1991). The prevalence of self-reported emphysema was 3.6 per 1,000 middle-aged African Americans and 41.5 per 1,000 older African Americans. Compared with Afri- can Americans, whites in both age groups reported higher prevalences of chronic bronchitis (59.7 for those aged 45-64 years and 73.8 for those aged 65 years and older) and emphysema (13.8 for those aged 45564 years 158 Chnpter 3 and 46.1 for those aged 65 years and older). However, self-reports of chronic bronchitis and emphysema, without further validation, are probably subject to sub- stantial misclassification. African Americans are also less likely than whites to die of COPD (Evans et al. 1987; NCHS 1991). Evans and colleagues (1987) found that in 1982, the age- adjusted COPD death rate was 16.6 per 100,000 whites and 12.8 per 100,000 African Americans. Data for 1986 1988 also show lower death rates from COPD among African Americans than among whites (Desenclos and Hahn 1992). More recent data (Table 2) show that Af- rican American men have higher death rates (17.6) for chronic airway obstruction than men in the other three racial/ethnic minority groups, although their rates are lower than rates among white men (20.4). The same pattern is also evident for deaths due to bronchitis and emphysema. The rate of COPD mortality is unexpect- edly low among African Americans, given their high prevalence of smoking and related high lung cancer rates. The reasons for this discrepancy remain to be explored. However, whites are more likely than Afri- can Americans to have ever smoked and to be former smokers (see Table 37 in Chapter 2). Mannino and colleagues (1997) have observed that death rates from obstructive lung disease relate to rates of ever smok- ing. These authors suggest that the differences in the race- and gender-specific relative rankings for obstruc- tive lung disease and lung cancer may be because long-term former smokers are more likely to develop obstructive lung disease than lung cancer. American Indians and Alaska Natives Little information is available on the occurrence of COPD among American Indians and Alaska Natives. In a 1987 survey of approximately 6,500 American Indians and Alaska Natives aged 19 years and older, 2.4 percent of men and 1.4 percent of women reported having emphysema, compared with 2.7 per- cent of men and 2.3 percent of women in the general U.S. population (Johnson and Taylor 1991). Rhoades (1990) studied hospitalization and death rates for COPD in American Indians and Alaska Natives. Although the death rates for COPD were lower than from other competing causes, such as chronic liver disease, diabetes, and injuries, the hospitalization rates for COI'D exceeded those for cancer and tuberculosis. Additionally, hospitalization rates and death rates for COPD varied widely between geographic regions. The contribution of COPD to hospitalization rates ranged from 1.6 percent in the Navajo IHS area to 5.1 percent in the Bemidji area; COPD death rates per 100,000 ranged from 1.7 in the Albuquerque area to 10.3 in the Billings area (Rhoades 19901. Between 1992 and 1994, COPD death rates among American Indian men were approximately two-thirds the rates among whites (Table 2). Data from the Alaska area indicate that from 1979 through 1986, COPD death rates per 100,000 were 31.6 for Alaska Native men, compared with 40.3 for white men in Alaska and 38.3 for men in the United States as a whole (Coultas et al. 1994). The COPD death rates per 100,000 were 22.3 for Alaska Native women, compared with 31.8 for white women in Alaska and 18.6 for women in the United States as a whole. Similarly, death rates for COPD in New Mexico (Samet et al. 1988bj reflect the nationwide pattern of lower rates of death among American Indians compared with whites and are con- sistent with the lower smoking prevalence among tribes in the southwestern United States (Sugarman et al. 1992). The high rates of COPD among Alaska Natives are probably related to the fact that rates of smoking among Alaska Natives are higher than rates among American Indians elsewhere, particularly in the Southwest. Asian Americans and Pacific Islanders Information on COPD morbidity and death among Asian Americans and Pacific Islanders is sparse. National mortality data indicate that the prevalence of deaths from bronchitis and emphysema is lower in this group than among African Americans and whites (Table 2); the death rate from chronic airways obstruc- tion is lowest for Asian Americans and Pacific Island- ers. Data from California show that from 1986 through 1987, the overall prevalence of COPD deaths among "Asian and other" persons was lower than among whites but varied widely for specific Asian American and Pacific Islander subgroups (Asian American Health Forum, Inc. 1990). One of the oldest studies of Asian Americans- the Honolulu Heart Study, conducted in 196Lprovides valuable age-related information on smoking and lung function among Japanese Americans. Of the 6,346 Japanese American men aged 46-68 years who under- went spirometric testing, 48 percent were current ciga- rette smokers, 25 percent were former smokers, and 27 percent had never smoked (Marcus et al. 1988). Airflow obstruction was found in 11.7 percent of the participants. The prevalence of airflow obstruction increased with age and with the amount smoked. For most age and smoking categories, the prevalence of airflow obstruction was lower among JapaneseAmeri- can men than among white men from Connecticut participating in the same study (Beck et al. 1981). In another recent analysis of data from the Ho- nolulu Heart Program, Japanese American men who continued to smoke showed steeper rates of decline in forced expiratory volume after one second (FEV,), a measure of pulmonary function, compared with never smokers. Among continuing smokers, FEV, decline was significantly associated with duration of smok- ing. Additionally, the rate of decline in FEV, among former smokers became more like that of persons who had never smoked (Burchfiel et al. 19951, consistent with previous reports on the benefits of quitting smok- ing WSDHHS 1990). In another analysis of data from the same study, Sharp and colleagues (1994) found that a diet composed of large amounts of fish may protect the lungs against damage from cigarette smoking. However, fish consumption was not associated with pulmonary function at higher levels of cigarette smok- ing (>30 cigarettes/day). Hispanics In the 1982-1984 Hispanic Health and Nutrition Examination Survey (HHANES), Puerto Ricans (2.9 percent) had a higher prevalence of reported chronic bronchitis than Mexican Americans (1.7 percent) or Cuban Americans (1.7 percent) (Bang et al. 1990). Chronic airflow obstruction (assessed using spirom- etryj was present in less than 1 percent of Hispanic adults surveyed in a New Mexico community (Samet et al. 1988a). Similarly, investigators who surveyed Mexican Americans in Tucson, Arizona, found a rela- tively low prevalence of physician-diagnosed COPD or related diagnoses (Di Pede et al. 1991). COPD has been reported to occur less frequently among Hispanics than among whites. Surveys in New Mexico have shown, for example, that physician- diagnosed chronic bronchitis or emphysema is less common among Hispanics than among whites (Samet et al. 1982, 1988a). Death rates from chronic obstruc- tive lung diseases and allied conditions are also lower among Hispanics than among whites (Tables 2 and 4). Mortality data for New Mexico indicate that between 1958 and 1982, Hispanic men had a lower death rate from COPD than white men; however, from 1958 through 1982, the death rate from COPD rose steeply among Hispanic men--from 5.0 per 100,000 in 1958-1962 to 30.1 per 100,000 in 1978-1982 (Samet et al. 1988b). During this same time, COPD death rates in- creased among Hispanic women but remained compa- rable to rates among white women (Samet et al. 1988b). Little information is available on the risk of COPD among Hispanic smokers. In a 1979 respira- tory disease survey of Hispanic and white residents of New Mexico's Bernalillo County, Samet and colleagues (1982) found that race/ethnicity was not a significant predictor of current or previous physician- diagnosed chronic bronchitis and emphysema and that no significant interaction existed between race/ ethnicity and cigarette smoking. Hispanic ethnicity also was not a significant predictor of the symptoms of chronic cough, chronic phlegm, or persistent wheeze. Similarly, the results of a survey of Hispanics Coronary Heart Disease and whites in Tucson indicated that race/ethnicity was not a significant determinant of respiratory symptoms, after survey data were adjusted for cigarette smoking (Di Pede et al. 1991). However, a recent cross-sectional study of urban pregnant women indicated that the prevalence of either doctor-diagnosed asthma or per- sistent wheeze without asthma was lower among a het- erogenous Hispanic population than among white women of similar socioeconomic background (these data were adjusted for cigarette smoking status, fam- ily history of asthma, educational level, household exposure to pets, and level of lung function). The au- thors did not conclude that their data provided evi- dence of biological protection from wheeze syndromes. An almost fivefold excess risk of persistent wheeze was detected in the total population of urban women who are current smokers (David et al. 1996). In 1994, cardiovascular diseases, comprising a diverse group of disorders including coronary heart disease (CHD), hypertension, stroke, and rheumatic heart disease, caused approximately 940,000 deaths in the United States (NCHS 1996a). The occurrence of specific cardiovascular diseases and their risk factors varies widely among the different racial/ethnic mi- nority groups. Of the cardiovascular diseases, CHD is the single largest cause of death; it results in approxi- mately 480,000 deaths annually in the United States. This section of the report focuses on CHD, lvhich is also termed coronary artery disease or ischemic heart disease (IHD). Coronary artery disease results from atheroscle- rosis of coronary arteries. Anatomical lesions become evident in young adults and are usually clinically manifest in the fifth through seventh decades as angina pectoris, myocardial infarction, and sudden cardiac death (Enos et al. 1986; Strong 1986). In this chapter, these clinical manifestations of coronary artery disease are collectively termed CHD. Numerous non-modifiable and modifiable risk factors contribute to the devrelopment of CHD. The non-modifiable factors include aging, gender (men have greater risk), and family history of CHD. The major risk factors that are potentially modifiable include hypertension, cigarette smoking, obesity, hypercholesterolemia, diabetes mellitus, and physical inactivity (Smith and Pratt 1993). The 1983 Surgeon General's report on smoking and health concluded that "Cigarette smoking should be considered the most important of the known modifiable risk factors for coronary heart disease in the United States" (USDHHS 1983, p. iv). African Americans The first population-based epidemiological in- vestigations of cardiovascular diseases in the United States that included substantial numbers of African American and white participants began in 1960 in Evans County, Georgia, and Charleston, South Caro- lina (Saunders 1991). Since 1960, follow-up data for these cohorts and a number of other epidemiological studies have provided information on the combined effects of race/ethnicity and various risk factors for cardiovascular disease. Consistent with findings for the general population, cigarette smoking increased risk of death from CHD among African Americans (Hames et al. 1993; Keil et al. 1995). Tyroler and colleagues (1984) examined deaths from CHD among the Evans County men, who were followed from 1960 through 1980, and found that the overall rate of death from CHD was lower among Af- rican Americans than among whites, with a ratio of 0.86. For current and former smokers, the probability of dying from all causes and from CHD was higher among whites with a low-socioeconomic status (on the basis of occupation, education, and source of income of the head of household) than among their African American counterparts. However, the analysis did not control for the number of cigarettes smoked, and the data were limited because of the small number of CHD deaths (31) among African Americans. In the Charleston Heart Study of CHD death rates between 1960 and 1990, Keil and colleagues (1993) found that the age-adjusted, African American- to-white death rate ratios were 0.90 for men and 1.2 for women. After controlling for age and other car- diac risk factors, the researchers found that smoking was associated with a slightly higher risk of dying of CHD among African American men than among lvhite men. White women had a slightly higher risk of dying of CHD than did African American women. These racial/ethnic group differences were not tested for statistical significance, liokvever. Other investigations that provide information on the risks for CHD and the modification of the effects of smoking, by race/ethnicity, include the Cancer Pre- lrention Study I (CI'S-I) (Garfinkel 19811, the NHEFS (Cooper and Ford 1992), the National Mortality Followback Survey (NMFS) (DeStefano and Newman 19931, and the ongoing study of Kaiser Permanente enrollees (Friedman et al. 7997). As part of the CPS-I, death patterns in the original cohort of one million people were described for 1959-1972. The observed- to-expected death rate ratios from CHD among Afri- can Americans and whites followed the same pattern as nationwide vital statistics described previously. Overall, the African American-to-white ratios of CHD deaths were 0.78 for men and 1.07 for women. Strati- fied analyses, by gender, of any effects that the amount of cigarettes smoked might have on CHD deaths showed little difference between African Americans and whites. Participants in the NHANES I, conducted be- tween 1971 and 1975, were reexamined between 1982 and 1984 as part of the NHEFS (Cooper and Ford 1992). Of the 12,599 participants in the follow-up survey, 10,741 were white and 1,858 were African American. The study showed that cumulative incidence rates of fatal CHD were higher among African Americans (6.2 percent of men and 3.7 percent of women) than among whites (5.6 percent of men and 2.6 percent of women). In contrast, cumulative incidence rates of nonfatal CHD were higher among whites (7.0 percent of men and 4.7 percent of women) than among African Ameri- cans (5.0 percent of men and 3.9 percent of women). The risk of new CHD events associated with cigarette smoking was similar among whites and African Ameri- cans. These results, however, are limited by the small number of new CHD events among African Ameri- cans and the low proportion (approximately 50 per- cent) of respondents for whom smoking information was collected at baseline. In a case-control study of CHD deaths among African Americans and whites, DeStefano and Newman (1993) used data from the 1986 NMFS to iden- tify case subjects (n = 803) and 1988 data from the BRFSS to identify control subjects (n = 25,398). When they compared the risk of death among smokers vs. persons who have never smoked (men aged 25-44 vears and women aged 25-54 years), the investigators found that among persons without diabetes, African American smokers had a lower relative risk for CHD death than white smokers. However, the 95 percent confidence intervals associated with these odds ratios ofrerlapped each other-an indication that the differ- ence in risk was not statistically significant. In the Kaiser study, the risk of death from CHD has varied among African Americans and whites, but small num- bers limit interpretation of these findings (Friedman et al. 1997). American Indians and Alaska Natives Most of the available data on CHD among Ameri- can Indians and Alaska Natives have originated from studies of selected tribes, as reviewed by Young (1994). Investigations of heart disease in southwestern Ameri- can Indians and Alaska Natives conducted several decades ago showed a low prevalence of CHD rela- tive to the U.S. population and other racial/ethnic groups (Welty and Coulehan 1993). In a descriptive study of CHD deaths occurring from 1948 through 1952 among the Navajos, Smith (1957) found that the standardized death rate ratios for CHD among the Navajos compared with whites were 0.10 for men and 0.12 for women. Since then, numerous other regional investigations of CHD deaths and the incidence of CHD in other tribes of the United States and Canada have been reported. Overall, for studies conducted in the 1950s and 196Os, the ratios of CHD death rates among American Indians and Alaska Natives com- pared with nationwide rates have ranged from 0.1 to 0.5. An analysis of death statistics from the NCHS showed that crude CHD death rates for individuals classified as American Indians, Eskimos, or Aleuts declined from 100 per 100,000 in 1969-1971 to 67 per 100,000 for the years 1979-1981 (Gillurn 1988). A re- view of New Mexico's vital statistics for 195881982 indicates that for American Indian men, CHD death rates peaked at 101.7 per 100,000 between 1968 and 1972 and fell to 76.6 per 100,000 between 1978 and 1982 (Becker et al. 1988). For American Indian women, the CHD death rate peaked at 63.0 per 100,000 between 1963 and 1967 and declined to a low of 28.3 per 100,000 between 1978 and 1982. In a recent analysis of mortality data for 1992- 1994 (Table 21, the rate of death due to CHD was lower among American Indian and Alaska Native men (100.4) and women (45.9) than among white men (132.5) and women (62.9). The ratio of CHDdeath rates among American Indians and Alaska Natives com- pared with whites was .76 for men and .73 for women. The fact that these ratios are higher than ratios from earlier studies suggests that CHD deaths among American Indians and Alaska Natives may be increas- ing (Welty and Coulehan 1993; Young 1994). Risk factors for cardiovascular disease were in- vestigated recently in a large multi-tribal study of American Indians. The results showed that mean lev- els of total, low density lipoprotein, and high density lipoprotein cholesterol were lower in American Indi- ans than in the U.S. general population. Prevalence of hypertension, non-insulin dependent diabetes melli- tus, and obesity were very high, but varied consider- ably among tribes and geographic regions (Welty et al. 1995). A second study found that levels of serum cholesterol were lower in American Indian smokers who attended a stop smoking clinic than in African American and white smokers from population-based samples (Folsom et al. 1993). However, fibrinogen lev- els and the prevalence of abdominal obesity were higher in American Indian smokers than in African Americans and whites. The IHS is another source of nationwide and re- gional health statistics on CHD deaths. Because the mortality data in IHS reports combine all cardiovas- cular diseases under "diseases of the heart" (IHS 1994b), this information cannot be compared directly with CHD data from other sources. Between 1989 and 1991, diseases of the heart accounted for 21.9 percent of deaths in all IHS areas, with a crude death rate of 115.1 per 100,000 (IHS 199413). These data indicate cardiovascular diseases were the leading cause of death among American Indians. However, because Indian race/ethnicity was underreported on death cer- tificates in several IHS areas, including California and Oklahoma as well as Portland, Oregon, this death rate may be incorrect. Death rates from heart diseases vary widely among people in the 12 IHS areas. From 1989 through 1991, the rate of death from heart diseases per 100,000 was lowest in the Albuquerque area (88.0) and high- est in the Aberdeen area (249.0) (IHS 1994a). These wide variations in deaths from diseases of the heart parallel the wide variations in the prevalence of ciga- rette smoking among the various tribes (Sugarman et al. 1992; Coultas et al. 1994) (see also Chapter 2). For example, in a 1985-1988 survey of adult American In- dians in the southwestern United States, 18.1 percent of men and 14.7 percent of women reported current smoking, compared with 48.4 percent of men and 57.3 percent of women in the Plains states (Sugarman et al. 1992). Data to assess the influence of tobacco use on the risk of cardiovascular disease among American Indians are extremely limited. One study has shown that cigarette smoking increases the risk for CHD among American Indians, after adjustment for other risk factors (Howard et al. 19951. In fact, most studies presented in this section describe cardiovascular dis- ease morbidity and mortality without ever assessing the influence of tobacco use. Nevertheless, cardiovas- cular disease is the leading cause of death among American Indians and Alaska Natives (NCHS 1996b), and tobacco use is an important risk factor for this disease. More studies are needed to evaluate the in- dependent effect of tobacco use on the risk of cardio- vascular disease among American Indians and Alaska Natives. Asian Americans and Pacific Islanders Limited data are available on risk factors and CHD among Asian Americans and Pacific Islanders in the United States (Yu 1991). A recent study of na- tionwide mortality indicated that Asian Americans and Pacific Islanders have lower rates of death from CHD than whites (Table 2). In an analysis of 1980 death rates in Los Angeles County, Frerichs and colleagues (1984) found that the age- and gender-adjusted death rates for cardiovascu- lar diseases varied widely among Asian Americans and Pacific Islanders. Koreans had the lowest rate per 100,000 (821, and Japanese had the highest rate (162). These rates were substantially lower than the overall rate for the county population, with rate ratios of 0.26 for Koreans and 0.52 for Japanese. Specific data on CHD deaths and cigarette smoking prevalence were not available. In another study, Reed and colleagues (1983) used death records from Hawaii to describe age-adjusted, gender-specific, and racial- and ethnic-specific rates of CHD deaths occurring from 1940 through 1978. For all racial/ethnic minority groups, CHD death rates were higher among men than among women. Death 162 Cllnrter 3 Tobacco Use A~~otzg U.S. Racin//Efhnic Mixorify Groups rates and the temporal trends in deaths varied widely between the different groups, with the highest death rates among Native Hawaiians and the lowest among Japanese. Filipino men had the greatest increase in CHD death rates, surpassing the rates for whites in 1978. Although most of the other groups had declines in CHD death rates between 1960 and 1970, CHD death rates for Native Hawaiian men remained level. In 1965, three cohorts of Japanese men were as- sembled in Japan, Honolulu, and San Francisco to in- vestigate the differences in CHD deaths observed among Japanese men living in the three locales (Worth et al. 1975; Yano et al. 1988). From 1965 through 1972, Worth and colleagues (1975) found that age-specific death rates were highest among the San Francisco men, intermediate among those living in Honolulu, and low- est among those living in Japan. For example, among men 60-64 years of age, the annual CHD death rates per 1,000 were 4.9 in San Francisco, 3.9 in Honolulu, and 2.1 in Japan. Mortality data for 1965-1980 indi- cate that the age-adjusted CHD death rate ratio for men in Honolulu compared writ11 men in Japan was 1.3 (Yano et al. 1988). The age-adjusted mean levels of most CHD risk factors, including cigarette smoking (measured in cigarette-years), were also higher among Honolulu men. After adjusting for these risk factors, the rate ratio for CHD declined to 1.17, indicating that more than half of the elevated CHD death rate was due to the higher mean levels of CHD risk factors among Honolulu men. In the Honolulu Heart Program cohort, com- posed of 7,705 Japanese men 45-68 years of age living in Hawaii who had no evidence of CHD at enrollment between 1965 and 1968, numerous analyses were con- ducted to further examine predictors of CHD incidence and death (Reed et al. 1982, 1987; Yano et al. 1984; Benfante et al. 1991). A higher level of acculturation was found to be associated with CHD risk factors and incidence during the 1971-l 979 follow,-up (Reed et al. 1982). Men who were primarily Japanese in culture smoked an average of seven cigarettes per day, whereas men who were more acculturated smoked an average of 11 cigarettes per day. A similar pattern was seen for total CHD incidence, which was highest among the men who were more acculturated (62 per 1,000) and lowest among the men who were primarily Japanese in culture (35 per 1,000). Yano and coworkers (1984) conducted detailed analyses of the relationship between risk factors and the incidence of CHD during a 1 O-year period, begin- ning after the enrollment period (1965-1968). Systolic blood pressure, number of cigarettes smoked, and cho- lesterol level were all independently associated with the occurrence of all CHD events. Alcohol consump- tion was found to be a protective factor. Subsequent analyses of 20-year follow-up data from the same study showed that cigarette smoking was independently associated, in a dose-response manner, with increased risk of CHD (fatal or nonfatal) and aortic aneurysm (Goldberg et al. 1995). The risk for angina was elevated in persons who smoked more than 20 cigarettes per day. Another analysis suggested that high levels of fish intake might limit the increased risk among heavy smokers, although these findings should be consid- ered preliminary (Rodriguez et al. 1996). In addition, cigarette smoking was found to be independently associated with increased prevalence of myocardial lesions in Japanese men with minimal evidence of coro- nary atherosclerosis at autopsy (Burchfiel et al. 1996). Hispanics Because of incomplete data, the NCHS reported data from 1985 death certificates on decedents of His- panic origin for only 17 states and the District of Columbia (NCHS 1996b). By 1990, data for 47 states and the District of Columbia were reported. The NCHS estimated that the 1990 reporting area encompassed 99.6 percent of the U.S. Hispanic population (NCHS 1996b). In 1993 and 1994, only Oklahoma did not pro- \ide information on Hispanic origin (NCHS 1996a,b). Between 1992 and 1994, the overall rate of death from CHD in the United States was lower among His- panics than among whites (Table 2). Among the vari- ous Hispanic subgroups, Puerto Rican men had the highest death rates per 100,000 (118.6); similarly, CHD death rates among Puerto Rican women (67.3) were higher than among Mexican (44.2) and Hispanic (42.4) women. Nationwide death rates among Hispanics and whites have been estimated by using data collected by the U.S. Bureau of the Census as part of the Cur- rent Population Survey (CPS) (Sorlie et al. 1993). Baseline interview data were obtained between 1973 and 1985 from approximately 40,000 Hispanics and 660,000 non-Hispanics aged 25 years and older. Death rates for these two groups were ascertained up to nine years after the initial interview through the National Death Index. Age-adjusted death rate ratios for CHD were lower among Hispanics than among non- Hispanics (0.60 for men and 0.75 for women). Further details for the different Hispanic subgroups were not provided. In addition to nationwide data on the occurrence of CHD among Hispanics, regional studies have been conducted in California (Schoen and Nelson 1981; Frerichs et al. 1984), Colorado (Rewers et al. 1993), New Mexico (Buechley et al. 1979; Becker et al. 1988), and Texas (Stern and Gaskill 1978; Stern et al. 1987; Mitchell et al. 1991; Goff et al. 1993). In general, these investi- gations have consistently shown that Hispanic men have lower CHD death rates than white men, although the Colorado study found little evidence for lower CHD death rates among Hispanics without diabetes (Rewers et al. 1993). The prevalence of angina was also found to be lower among Hispanics than among whites in a re- view of data from a sample of Mexican Americans participating in the 198221984 HHANES and of whites surveyed in the 1976-1980 NHANES II (LaCroix et al. 1989). Prevalence rates based on self-reports were 2.8 percent among Mexican American men and 3.9 per- cent among white men, and they were 5.4 percent among Mexican American women and 6.3 percent among white women. As with African Americans, no significant differences were observed in the distribu- tion of cardiovascular disease risk factors among Mexi- can Americans with and without self-reported angina. The results of this survey were limited by the lack of smoking-specific analyses for Mexican Americans. Several investigators also have examined the car- diovascular disease risk factor profiles of Hispanics (Mitchell et al. 1991; Shea et al. 1991; Winkleby et al. 1993). Shea and colleagues (1991) analyzed 1989 BRFSS data on 636 Hispanics, most of whom were Puerto Ricans, Dominicans, and Cubans living in New York City. Although the overall risk factor profile was high among these Hispanic subgroups, the prevalence of current cigarette smoking varied by level of educa tion. LMitchell and colleagues (1991) obtained information Cerebrovascular Disease on cardiovascular disease risk factors from 5,148 subjects, including 3,281 Mexican Americans, who participated in the San Antonio Heart Study from 1979 through 1988. The overall risk profiles were higher among Mexican Americans. For men of all ages, the prevalence of current smoking was higher among Mexican American men (36.7 percent) than among white men (30.4 percent). For women of all ages, how- ever, the prevalence of current smoking was lower among Mexican American women (21.0 percent) than among white women (26.8 percent). For both men and women, the number of cigarettes smoked per day was consistently lower among Mexican Americans than among whites. More recently, Winkleby and col- leagues (1993) examined the cardiovascular disease risk profiles of 756 Hispanics and 756 whites partici- pating in California surveys from 1979 through 1990. Hispanics and whites were matched by age, gender, educational level, city of residence, and time of sur- vey. Whites had a higher prevalence of smoking (34.2 percent) than Hispanics (24.0 percent), and they smoked more cigarettes per day (19.7) than Hispanics (11.4). Few investigators have compared the risk of smoking-related CHD between Hispanics and mem- bers of other racial/ethnic groups. Mitchell and co- workers (1991) determined the 1979-1988 prevalence of myocardial infarction among 3,281 Mexican Ameri- cans and 1,867 whites who participated in the San Antonio Heart Study. On the basis of either electro- cardiograms or self-reports, the risk of myocardial in- farction among Mexican Americans compared with whites was 24 percent lower for men but 40 percent higher for women. Race/ethnicity did not appear to modify the risk for myocardial infarction. Cerebrovascular disease is a major cause of mortality and morbidity in the United States every year. In 1994, a total of 153,306 deaths in the United States were caused by cerebrovascular disease (NCHS 1996a). Stroke, the major form of cerebrovascular disease, results from an interruption of the arterial blood sup- ply to the central nervous system, primarily the brain. Most commonly, the interruption of the arterial blood supply results from an occlusion of an artery in the brain by a thrombus, which may have resulted from atherosclerosis or blood clots from a diseased heart. A less common mechanism for development of stroke is rupture of a blood vessel in the brain. Other diag- noses under the general rubric of cerebrovascular disease include transient cerebral ischemia and cere- bral arteriosclerosis. As for CHD, risk factors for stroke may be divided into non-modifiable and modifiable charac- teristics. The non-modifiable factors include aging, gender, and family history of stroke. The major risk factors that are potentially modifiable include hyper- tension, hypercholesterolemia, diabetes mellitus, ciga- rette smoking, and heart disease (USDHHS 1989b). African Americans The rate of death from cerebrovascular disease in the United States is higher among African Ameri- cans than other racial/ethnic groups and whites (Table 2). For 1992-1994, the rate of death (per 100,000 pop~i- lation) from cerebrovascular disease M'as twice as high among African American men (53.1) as among white men (26.3) and almost twice as high among African American women (40.6) as among white women (22.6). Similar patterns have been observed in studies of persons belonging to health plans. Klatsky and col- leagues (1991) determined the incidence of hospital- ization for cerebrovascular disease among 74,096 whites and 33,041 African Americans who were mrm- bers of a prepaid health plan in northern California from 1978 through 1984. The relatille risks for hospi- talization for hemorrhagic cerebrovascular disease, cerebral thrombosis, and nonspecific cerebrovascular disease were higher among African Americans than among whites. Because hypertension is the strongest risk factor for stroke, the high prevalence of hyperten- sion among African Americans partially explains this pattern (Braithwaite and Taylor 1992). Despite lim- ited data on the link bet\veen smoking and stroke among African Americans, the high rate of cigarette smoking among African Americans (see Chapter 2) clearly appears to have played a significant role in el- evating the risks of stroke in this population (USDHHS 1983). American Indians and Alaska Natives In recent years, age-adjusted death rates for cere- brovascular disease were slightly lower among Ameri- can Indian and Alaska Native men and women than among white men and women (Table 2). For example, from 1992-1994, the age-adjusted death rate per 100,000 population for cerebrovascular disease was 23.9 for American Indian and Alaska Native men, 26.3 for white men, 21.1 for American Indian and Alaska Native women, and 22.6 for white women. Young's (1994) recent review of the literature in- dicates that few investigations have focused on cere- brovascular disease among American Indians or Alaska Natives. Middaugh (19901 found little differ- ence between the death rate from cerebrovascular dis- ease among Alaska Natives and persons of other race/ ethnicities, with death rate ratios of 1.13 for men and 1.03 for women. In a review of 1958-1987 vital statis- tics data from New Mexico, Kattapong and Becker (1993) observed lower rates of death from cerebrovas- cular disease among American Indians than among Hispanics and whites. For American Indian men, cere- brovascular disease death rates per 100,000 peaked at 70.1 between 1968 and 1972 and fell to 31.3 between 1983 and 1987. Cerebrovascular disease death rates for American Indian women also peaked at 55.7 between 1968 and 1972 and declined to a low of 19.3 between 1983 and 1987. Asian Americans and Pacific Islanders From 1992 through 1994, the age-adjusted death rate per 100,000 population for cerebrovascular dis- ease was 29.3 for Asian American and Pacific Islander men, 26.3 for white men, 22.4 for Asian American and Pacific Islander women, and 22.6 for white women (Table 2). In a study of stroke deaths occurring between 1965 and 1972 among Japanese men living in Japan, Honolulu, and San Francisco, age-specific stroke death rates were highest among men living in Japan (Worth et al. 1975). Among men 60-64 years of age, annual death rates per 1,000 men were 5.4 in Japan, compared with 2.5 in San Francisco and 1.1 in Honolulu. For CHD, however, the death rates in Japan were lower than rates in Honolulu and San Francisco. Data from the Honolulu Heart Program suggest that other risk or protective factors associated with a Japanese diet, such as high alcohol intake and low, intake of food from animal sources, may play important roles in the de- velopment of stroke and CHD in Honolulu and Japan, along with smoking, older age, high systolic blood pressure, and high serum cholesterol and glucose lev- els (Reed 1990). In a study of 1980 death rates among Asian Americans in Los Angeles, Frerichs and colleagues (1984) found that Koreans had the lowest age- and gender-adjusted death rate for cerebrovascular disease (48 per 100,000) and that Japanese had the highest rate (80 per 100,000). When the investigators compared the average age- and gender-adjusted death rates for these Asian Americans with rates for the entire county, the mortality ratio was 1.07 for Japanese and 0.65 for Koreans. Cigarette smoking was found to be an indepen- dent risk factor for stroke among men of Japanese ancestry who participated in the Honolulu Heart Program (Abbott et al. 1986). For all types of stroke, the estimated relative risk of smoking, adjusted for age and other major risk factors, was 2.5. This risk de- creased to 1.5 among men who quit smoking during the six-year follow-up period and increased to 3.5 among men who continued to smoke, indicating that cigarette smoking is a cause of stroke in Japanese men. A subsequent analysis of plrtlcipants in the Honolulu Heart Program iniicated that cigarette smoking sig- nificantlv increased the risk for thromboembolic stroke (Goldbe;g et al. 1995). Hispanics Studies about stroke among Hispanics have fo- cused on the magnitude of this outcome in relation to other racial/ethnic groups. Between 1986 and 1988, the overall rate of death from cerebrovascular disease was lower among Hispanics than among whites in the United States (Desenclos and Hahn 1992). When cere- brovascular disease death rates for Hispanics and whites were compared, the mortality ratio for Hispanic men was 0.89, and the ratio for Hispanic women was 0.84. Of the different Hispanic subgroups, Mexican Americans had the highest death rates from cere- brovascular disease. Sorlie and colleagues (1993) had similar observations when they estimated death rates using census data collected between 1973 and 1985. Age-adjusted death rate ratios for cercbrovascular dis- ease were lower among Hispanics than among whites (0.60 for men and 0.76 for women). No details were provided for the different Hispanic subgroups. In more recent years, age-adjusted death rates for cere- brovascular disease were slightly lorcer among His- panic men and women than among \\rhite men and women. For example, from 1992-1994, the age- adjusted death rate per 100,000 population for cere- brovascular disease was 22.7 for Hispanic men, 26.3 for white men, 16.7 for Hispanic M'ornen, and 22.6 for white women (Table 2). Regional studies in California (Frerichs et al. 1984), New Mexico (Kattnpong and Becker 199X), and Texas (Stern and Gaskill 1978) provide further evidence that Hispanics have a lower risk of death from cerebrovascular disease than do \\`hites and African Smoking and Pregnancy Smoking has long been known to be associated with poor outcomes for the infants of mothers who smoke. Mean infant birth weight and low birth weight (LBW) (~2,500 grams or ~5.5 pounds) are often stud- ied as measures of fetal morbidity because birth weight is easy to measure. LBW can result either from preterm delivery (~37 weeks' gestation) or from intrauterine Americans. Frerichs and colleagues (1984) compared 1980 death rates among the different racial/ethnic groups in Los Angeles County. The age- and gender- adjusted cerebrovascular disease death rates per 100,000 were 64 for Hispanics compared with 76 for whites (death rate ratio, 0.84) and 94 for African Americans (death rate ratio, 0.68). After reviewing New Mexico vital statistics data for 1958-l 987, Ka ttapong and Becker (1993) described time trends in deaths from cerebrovascular disease among Hispanics, whites, and American Indians. Ex- cept for the period 1983-1987, Hispanic men had lower death rates than white men. From 1983 to 1987, the ratio of death rates among Hispanic men (45.8 per 100,000) compared with the rate among white men (36.1 per 100,000) was 1.27. For women, the pattern of death rates was less consistent. From 1958 through 1972, Hispanic women had higher death rates than white women; between 1973 and 1982, they had lower rates; and from 1983 through 1987, Hispanic women had slightly higher death rates (43.1 per 100,000) than white women (39.3 per 100,000). Stern and Gaskill (1978) examined temporal trends in stroke deaths from 1970 through 1976 among Hispanics and whites living in Bexar County, Texas, which includes San Antonio. Stroke deaths were gen- erally lower among Hispanic women, but no signifi- cant difference was observed between the rates among men of either racial/ethnic group. Furthermore, no temporal trends in stroke deaths were evident for either gender or racial/ethnic group. Cigarette smoking probably explains some of the risk of stroke among Hispanics. However, data to as- sess the strength of this relationship are not available. Because the data presented here suggest that stroke is a leading cause of morbidity and death among His- panics (NCHS 19931, future studies should examine the specific role that cigarette smoking plays. growth retardation, but the distinction may be diffi- cult to make. Smoking has been associated with an average decrease in birth weight of about 200 grams as well as LBW, preterm birth, perinatal mortality, and infant mortality (USDHHS 1980, 1989b; Malloy et al. 1988; English and Eskenazi 1992). Tobacco Use Anmg U.S. Racial/Ethm'c Minority Groups Evidence that the relationship between smoking and poor infant outcomes is causal has been strength- ened by recent studies that used biomarkers of tobacco exposure, such as saliva and serum cotinine (Bardy et al. 1993; Li et al. 1993; English et al. 1994). Bardy and colleagues (1993) demonstrated a dose-response rela- tionship between serum cotinine and decreased ges- tational age, decreased birth weight, and decreased crown-heel length. The exact mechanisms whereby smoke exposure affects the fetus are poorly understood. Carbon mon- oxide, which impairs oxygen delivery to the fetus, and nicotine, which impairs placental blood flow, have been implicated as the causative substances in tobacco smoke (USDHHS 19801. The infant outcomes most often studied have been LBW and infant mortality. Sudden infant death syndrome (SIDS) is an important component of infant mortality because it is the most common cause of death among infants older than one month of age. Available data show that LBW, infant mortality, and SIDS occur differentially in different racial/ethnic groups in the United States (Table 10) (Kleinman 1990; NCHS 1994). In general, whites have lower rates of these conditions and other racial/ethnic groups tend to have higher rates, but considerable variation exists. Several studies have reported different effects of smoking on LBW, infant mortality, and SIDS across racial/ethnic minority groups. This section focuses only on those studies that have investigated potential racial/ethnic group differences in the rela- tionship between smoking and infant outcomes. Studies of Low Birth Weight Nearly 25 years ago, the possibility was raised that smoking might have a differential effect on repro- ductive outcomes in different racial/ethnic groups (Lubs 1973). In a study of all singleton live births at Yale-New Haven Hospital in 1972, Lubs reported a dif- ference in the effect of maternal smoking on LBW among 783 African American and 3,415 white women. A strong dose-response relationship was observed be- tween the number of cigarettes smoked during preg- nancy and infant LBW (defined as 52,500 grams for whites and 12,350 grams for African Americans). Among African American women, smoking 20 or more cigarettes per day was associated with a threefold in- crease in LBW, compared with only a twofold increase among white women. These racial/ethnic group dif- ferences were not explained by differences in age, prepregnancy weight, education, or marital status. Several more recent studies also provide evidence for the possibility of a differential effect of smoking on LBW among white and African American women. English and colleagues (1994) used interview data from the Child Health and Development Studies, conducted from 1959 through 1966 in California. Stored serum samples were analyzed for cotinine, and the levels were compared with self-reported cigarette consump- tion and infant birth weight for 374 African American and 829 white pregnant smokers separately. African American pregnant smokers were found to have higher serum cotinine levels than white pregnant smokers after the data were controlled for smoking dose and demographic confounders. No racial/ ethnic minority group difference was found in the rate of decrease in mean birth weight per given amount of cotinine in the serum of women who smoked. These data suggest that cigarette smoking may have a greater effect on birth weight among African Americans than among whites because higher cotinine levels are present in African American women than in white women who smoke the same amount; the higher cotinine levels may result from a greater intake of to- bacco smoke per cigarette by African American women than by white women. Li and colleagues (1993) found a differential ef- fect of smoking reduction during pregnancy on infant birth weights among African American and white women. Study subjects were 803 participants in an experimental trial of smoking cessation for pregnant women in Alabama; self-reported smoking was vali- dated with saliva cotinine. Reduction was defined as a minimum drop in saliva cotinine values between the baseline (early pregnancy) visit and the late pregnancy visit. Smoking reduction increased the birth weight of infants of both African American and white women, but racial/ethnic group differences were present. Among white women, a reduction in smoking in- creased infant birth weight regardless of the baseline cotinine value. However, among African American women with high baseline cotinine values, a reduc- tion in smoking had no effect on infant birth weights. The authors suggested that high levels of cigarette smoking (as detected by high cotinine levels) early in pregnancy may have irreversible effects on African American infants. Another recent study reported a differential ef- fect of smoking on LBW (~2,500 grams) among multi- parous African American and white women, but in the opposite direction (Neggers et al. 1994). Among Afri- can American women, the investigators found no sig- nificant difference in birth weight between smokers Health Comxquences 267 Table 10. Rates of selected infant outcomes, by mother's race/ethnicity,* United States African American Indian and Asian American and Pacific Islander Reference Outcome/years American Alaska Native Total Chinese Japanese Filipino Other NCHS, public Low-birth-weight use data tapes, (~2,500 grams) 1992s rate per 100 live births, 1992 13.4 NCHS 19945 Infant mortality rate per 1,000 live births, 1987 17.8 6.2 6.6 5.2 7.5 7.4 6.9 13.0 7.3 6.2 6.6 6.6 7.9 Kleinman 1990 Sudden infant death syndrome rate per 1,000 live births, 1983-1984 2.41 3.44 0.95 NA NA NA NA *The categories African American and white include persons of Hispanic and non-Hispanic origin. Conversely persons of Hispanic origin may be included in other categories as well. `Reported for selected states only; reporting areas for Hispanic origin vary by year. and nonsmokers, whereas among white women, the infants of smokers weighed significantly less than those of nonsmokers. However, no information was available on the number or type of cigarettes smoked or the biomarker of exposure; these results were ad- justed only for the mother's parity, age, height, and alcohol consumption as well as the infant's gender and gestational age at birth. In addition, the study was not designed to study the relationship between smok- ing and LBW but to determine whether the relation- ship between maternal triceps skinfold thickness and infant birth weight was modified by smoking and race/ethnicity. Two studies have reported that smoking is re- lated to an elevated risk of LBW among both African American and white women, but neither study found significant racial/ethnic group differences. In a popu- lation-based, case-control study of African American and white women delivering singleton infants with- out congenital anomalies in a large urban county of California, the Alameda County Low Birth Weight Study Group (1990) found that the risk of LBW associ- ated with regular smoking throughout pregnancy was 3.0 (95 percent confidence interval ICI], 1.7-5.3) for white women and 3.6 (95 percent CI, 2.4-5.6) for African American women (adjusted for age, parity, prepregnancy weight, socioeconomic status, alcohol use, prior LBW birth, and prenatal care). Unfortu- nately, the authors were unable to adjust the data for the number of cigarettes smoked. Castro and colleagues (1993) reported a study of maternal smoking and substance abuse during preg- nancy and found similar associations between smok- ing during pregnancy and small size for gestational age (birth weight of less than the 10th percentile for gestational age) for African American and white women (odds ratio [OR] for African American women, 2.0 [95 percent CI, 1.3-3.11; OR for white women, 2.4 [95 percent CI, 1.7-3.01). These results were adjusted for maternal age, parity, marital status, in- surance status, alcohol use, marijuana use, and other drug use; however, no information was available on the number of cigarettes smoked or the biomarker of exposure. Few studies have examined the relationship be- tween smoking and LBW among Hispanic popula- tions. Cohen and colleagues (1993) analyzed birth weight data on 19,571 Hispanic infants and 206,973 white infants (those whose mothers did not indicate they were of Hispanic origin) born in Massachusetts Total Mexican American Hispanic+ Puerto Rican Cuban Central and South American OtherJ White 6.4 6.0 8.8 6.0 5.6 7.5 5.9 8.2 8.0 9.9 7.1 7.8 8.7 8.2 IiA 0.x-l 1.38 %~~ludes persons of unknown Hispanic origin. `Data calculated to one significant digit. NA = data not available. between 1987 and 1989 and found that the incidence of LBW ranged from a high of 73 per 1,000 Puerto Rican infants to a low of 32.2 per 1,000 Cuban infants. The crude percentage of LBW was higher for smokers than for nonsmokers in each racial/ethnic group; however, multivariate adjusted risks were not presented for racial/ethnic groups separately. Several studies have demonstrated associations between smoking and LBW in specific racial/ethnic minority groups, including Puerto Ricans (Becerra and Smith 19881, Mexican Americans (Wolff et al. 19931, North American Indians (Godel et al. 19921, and Afri- can Americans (Jacobson et al. 1994; Johnson et al. 1994). In each instance, smoking was shown to be re- lated to lower birth weight; however, these studies did not provide data on other racial/ethnic groups, which might have allowed comparisons. The percentage of LBW (~2,500 grams) in the United States in 1993 was higher overall for smok- ers (11.8 percent) than for nonsmokers (6.6 percent) (NCHS 1996b). Although a higher percentage of white mothers (16.8) smoked during pregnancy than did African American mothers (12.7), African American women had a higher percentage (13.3) of LBW live births than white women (6.0) did in 1993. Age- and 0.83 0.53 1.52 1.21 racial/ethnic-specific analyses of population data may be more revealing. Land and Stockbauer (1993), for example, found that the teenage-specific LBW rate for African Americans in Missouri dropped by 13.6 percent from 1978-1990, concomitant with a drop in cigarette smoking prevalence among young African American mothers. Analyses of individual data sta- tistically controlled for confounding factors such as preterm deliveries and maternal parity, weight, and access to health care (USDHHS 1989a) would be pref- erable. The studies of individuals that are reported in this section provide more useful data than do popula- tion-based ecological comparisons on the relationship between cigarette smoking and the increased occur- rence of LBW in various racial/ethnic groups. Studies of Infant Mortality and Sudden Infant Death Syndrome Only one study has examined the risks of smok- ing associated with overall fetal and infant mortality in specific racial/ethnic groups (Kleinman et al. 1988). The authors used data from Missouri live birth, fetal death, and infant death certificates for births during Table 11. Risk of sudden infant death syndrome associated with smoking, by race/ethnicity, selected studies, United States Reference Exposure/years Li and Daling Active smoking 1991$ 1984-1989 African American OR" c1+ 3.1 1.7-5.9 American Indian and Alaska Native OR CI 1.4 0.9-2.4 Asian American and Pacific Islander OR CI 2.7 1.1-6.6 Schoendorf and Kiely 1992$ Passive exposure 1988 Combined exposure 1988 1.8 1 .o-3.0 NA NA NA NA 3.1 2.3-4.2 NA NA NA NA Klonoff-Cohen Passive exposure et al.A 1995 1989-1992 .~~~ *OR = odds ratio. `CI = 95% confidence interval. 5.0 1 .l-22.8 NA NA NA NA SLi and Daling assessed the risk, by mother's ethnicity, associated with active maternal smoking during pregnancy; ORs are adjusted for maternal age, marital status, prenatal care, parity, and birth weight. "Schoendorf and Kiely assessed the risk, by mother's ethnicity, associated with (1) passive smoking (maternal smoking after birth but not during pregnancy) and (21 combined exposure (maternal smoking during pregnancy and after birth); ORs are adjusted for maternal age, education, and marital status. `Klonoff-Cohen et al. assessed the risk, by infant's ethnicity, associated with total passive smoke exposure from all adults (mother, father, live-in adults, and day-care providers); ORs are adjusted for birth weight, routine sleep position, medical conditions at birth, breast-feeding, prenatal care, and maternal smoking during pregnancy. NA = data not available. 1979-1983 to examine the risk of mortality associated with smoking during pregnancy. They found no sig- nificant variation in the effects of smoking on African American and white women, with adjusted ORs rang- ing from 1.3 to 1.6, depending on parity and the amount smoked. Three studies have examined the effects of smok- ing on SIDS in specific racial/ethnic minority groups (Table 11) (Li and Daling 1991; Schoendorf and Kiely 1992; Klonoff-Cohen et al. 1995). Li and Daling (1991) used data from Washington State birth records from 1984 through 1989, linked with infant death records. After adjusting the data for maternal age, marital sta- tus, prenatal care, parity, and birth weight, they found a statistically significant increased risk of SIDS associ- ated with maternal smoking during pregnancy in all racial/ethnic groups except American Indians (Table 11). The ORs were not significantly different between groups, except between African Americans and Ameri- can Indians. No information was available on the num- ber of cigarettes smoked or the biomarker of exposure. Schoendorf and Kiely (1992) used data from the 1988 National Maternal and Infant Health Survey to study the association between SIDS and maternal smoking (either passive [only after birth] or combined [during pregnancy and after birth]) among infants of normal birth weight. They found similar increased risks of SIDS among African American and white in- fants exposed to maternal smoking (Table 111, after adjusting the data for maternal age, education, and marital status. Although white mothers reported heavier smoking than African American mothers, the authors did not adjust their findings for the number of cigarettes smoked. Implications Hispanic White OR CI OR CI 5.5 1.4-22.0 2.2 1.8-2.6 NA NA 3.1 234.2 NA NA 1.8 1 .o-3.1) 2.6 0.9-7.3 3.4 1.6-7.2 Klonoff-Cohen and colleagues (1995) conducted a 1989-1992 case-control study of passive smoking and SIDS in five counties in southern California. The OR for SIDS associated with all types of passive smoke exposure combined was 3.50 (95 percent CI, 1.81-6.75), after adjustment for birth weight, routine sleep posi- tion, medical conditions at birth, breast-feeding, pre- natal care, and maternal smoking during pregnancy. The evidence suggested a dose-response relationship, with an increased risk of SIDS associated with in- creased passive exposure to smoke. The authors also stratified the data by racial/ethnic group and found similar effects across groups (Table ll), although the results were not adjusted for the number of cigarettes smoked. Health Problems Affecting Pregnant Women Smoking is related to a variety of health prob- lems affecting pregnant women, ranging from ectopic pregnancy to abruptio placentae (LJSDHHS 1980; Rosenberg 1987), but race- and ethnic-specific data are not generally available. In addition to exploring smoking's effects on fetuses and infants, future re- search should focus on the race- and ethnic-specific effects of smoking on the pregnant woman herself. The question of whether race- and ethnic-specific differences exist in the relationship between smoking and infant outcomes has not been satisfactorily resolved. Many intriguing questions have been raised, but investigators have not yet determined the exact nature of such differences or what factors mediate them. Comparative studies have been hampered by inconsistent and inadequate measurement of exposure. For example, fe\v investigators have fully explored is- sues of dose of smoking such as the number of ciga- rettes smoked or the levels of biomarkers, although the amount of smoking during pregnancy does differ among racial/ethnic minority groups (see Chapter 2). Moreover, even though the timing of smoking during pregnancv may plav a critical role in the development of LBW (Lieberman et al. 1994), few studies of LBW ha\re separately assessed the effects of smoking dur- ing each trimester of pregnancy. Patterns of quitting and reducing smoking during pregnancy may in fact differ by race/ethnicity. Racial/ethnic group differences in nicotine me- tdbolisni may also be important (Wagenknecht et al. 1990; English et al. 1994). African American pregnant smokers appear to have higher serum cotinine levels than white pregnant smokers when the data are con- trolled for nicotine dose (English et al. 1994). Thus, fetal exposure may be higher among African Ameri- cans than among whites for a given number of ciga- rettes smoked. Racial/ethnic group differences in oxygen- carrying capacity may also play a role in mediating the effects of smoking. In 1973, Lubs suggested that the increased effects of smoking on birth weight among Af- rican American women might in part be explained by higher rates of sickle cell trait or glucose-6-phosphate dehydrogenase (G6PD) deficiency, which impair oxy- gen-carrying capacity (Lubs 1973). No published re- ports have examined Lubs's hypothesis. In addition, anemia, which is more prevalent among African Ameri- can women, may be a risk factor for preterm delivery (Hague and Yip 1989). Future studies of smoking and pregnancy outcomes should consider racial/ethnic group differ- ences in the timing of smoking during pregnancy, nicotine metabolism, and factors that affect oxygen- carrying capacity, such as sickle cell trait, G6PD defi- ciency, and anemia. Summary of Health Consequences from Active Cigarette Smoking Attempts to predict racial- and ethnic-specific rates of disease incidence and mortality from racial- and ethnic-specific cigarette smoking prevalences are of limited value, because other factors can also influence disease rates. When studies of individuals are con- ducted, the data lead to the conclusion that cigarette smoking is a major cause of disease and death in each of the four U.S. racial/ethnic minority groups studied in this report. These studies reveal few major differ- ences in the risk ratios for various diseases. Limited epidemiological and biological data suggest that Afri- can Americans may be at an especially high level of risk for lung cancer. Although further research could clarify the nature of the interrelationships between cigarette smoking, other risk factors, potential modi- fying factors, racial/ethnic group membership, and various disease outcomes, it is clear that reducing to- bacco use in each of the nation's racial/ethnic groups will reduce the incidence and mortality from several of the nation's leading causes of death and is a major public health goal to pursue. Effects of Exposure to Environmental Tobacco Smoke Environmental tobacco smoke (ETS) is the mix- ture of sidestream smoke and exhaled mainstream smoke that is produced by acti\re smokers and then involuntarily inhaled by nonsmokers. Over the past decade, the ad\rerse effects of ETS have been reported in the literature. The 1986 Surgeon General's report on smoking and health (USDHHS 1986a) concluded that the inhalation of ETS (labeled "in\~oIuntarv smok- ing" in that report) is a cause of diseases, including lung cancer, in healthy nonsmokers and that the chil- dren of parents who smoke are more likely than the children of nonsmoking parents to ha\,e respirators infections, respiratory symptoms, and abnormal matu- ration of lung function. Similar conclusions Lvere also reached in 1986 by a committee of the National Re- search Council (1986). More recently, the U.S. Eniri- ronmental Protection Agency (1992) assessed the risks associated with ETS, and the results reaffirmed that ETS is carcinogenic and that it exacerbates and may even cause childhood asthma. To date, racial/ethnic group differences in the adverse effects of ETS ha\re not been investigated, although a number of studies have investigated racial/ethnic group differences in the level of exposure to ETS and in people's reactions to ETS. O\rerpeck and Moss (1991) examined patterns of exposure to ETS among children five years of age and younger included in the 1988 NHIS and found that exposure varied by race/ethnicit)l and socioeconomic status (Table 12). African American children M'ere the most likely to be exposed to ETS, tvhereas Hispanic children were the least likely to be exposed to ETS. Moreover, in the CARDIA (Coronary Artery Risk De- velopment in [Young] Adults) study, the prevalence of exposure to ETS was significantly higher among African Americans (32 percent) than among whites (24 percent) (Wagenknecht et al. 1993). OveraIl, 28 per- cent of individuals 18-30 years of age were exposed to ETS, as detected by a serum cotinine level of 2-13 ng/mL. Adult sur\re\i data from the 1992 California Tobacco Survey sho\iT that Hispanics (21.3 percent) i\rere most likelv to report working around a cigarette smoker within the two Lveeks before the survey (Pierce et al. 1993). Asian Americans (13.2 percent) and Afri- can Americans (12.8 percent) reported being exposed to ETS at M'ork in lolver proportions than whites (17.9 percent). Data from the 1988 NHIS (CDC 1992) sho\~ that 40.3 percent of employed adults reported that cigarette smoking was allowed in their place of employment. The percentages of persons who reported experiencing discomfort caused by ETS ex- posure at work did not differ significantly by racial/ ethnic group. In a 1992-1993 study of U.S. adults who worked indoors, Asian Americans and Pacific Island- ers (51.4 percent) were the most likely and African Americans (43.3 percent) were the least likely to work under a completely smoke-free ETS policy (Gerlach et al. 1997). Since most studies suggest that differences exist in the ETS exposure of various racial/ethnic groups, studies to monitor the health effects of this exposure are needed. 7hbm-c) Usr Amug U.S. Racid/Efhnic Minority Groups Table 12. Exposure to household smoke among children 5 years of age and younger and percentage distribution, by level of exposure since birth and selected characteristics, United States, 1988 Characteristic Percentage distribution* Exposed since birth Number of Current Former children smoker in smoker in (in thousands)+ Total Not exposed since birth Totali household household All children+ 19,019 Ethnicity African American White Hispanic origin Non-Hispanic Hispanic Mexican American Annual household income 12 years Place of residence Metropolitan statistical area Central city Not central city Not metropolitan statistical area 2,759 15,575 16,923 2,096 1,006 2,685 5,436 4,871 4,149 3,376 14,582 3,279 8,014 7,505 14,550 5,994 8,556 4,469 100.0 51.1 (0.9) 48.9 (0.9) 42.4 (0.9) 6.1 (0.4) 100.0 41.5 (2.4) 58.5 (2.4) 51.3 (2.4) 6.7 (1.2) 100.0 51.9 (1.0) 48.1 (1.0) 41.6 (1.0) 6.1 (0.4) 100.0 50.4 (1.0) 49.6 (1.0) 43.2 (1.0) 6.0 (0.4) 100.0 56.4 (2.6) 43.6 (2.6) 35.8 (2.5) 6.9 (1.2) 100.0 60.7 (4.1) 39.3 (4.1) 31.8 (3.8) 6.5 (1.5) 100.0 33.4 (2.1) 66.6 (2.1) 57.7 (2.3) 8.7 (1.1) 100.0 44.3 (1.5) 55.7 (1.5) 48.8 (1.6) 6.3 (0.7) 100.0 55.9 (1.7) 44.1 (1.7) 38.3 (1.6) 5.4 (0.7) 100.0 63.7 (1.8) 34.3 (1.8) 29.5 (1.5) 4.6 (0.9) 100.0 36.4 (2.1) 63.6 (2.1) 55.7 (2.3) 7.6 (1.0) 100.0 54.8 (1.0) 45.2 (1.0) 39.2 (1.0) 5.6 (0.4) 100.0 33.3 (2.2) 66.7 (2.2) 61.2 (2.1) 5.1 (0.8) 100.0 44.5 (1.4) 55.5 (1.4) 47.9 (1.4) 7.3 (0.6) 100.0 66.3 (1.2) 33.7 (1.2) 27.6 (1.1) 5.4 (0.6) 100.0 51.5 (1.0) 48.5 (1.0) 42.2 (1.1) 5.9 (0.4) 100.0 49.4 (1.4) 50.6 (1.4) 43.6 (1.5) 6.3 (0.6) 100.0 52.9 (1.4) 47.1 (1.4) 41.1 (1.4) 5.6 (0.6) 100.0 49.7 (1.9) 50.3 (1.9) 43.1 (1.7) 6.8 (0.8) *Figures in parentheses are standard errors of estimates. `Excludes children whose exposure status is unknown. *Includes children exposed since birth whose period of exposure is unknown. `Includes all other ethnicities, unknown household income, unknown poverty status, unknown education of mother, and unknown assessed health status. Poverty status determined in the National Health Interview Survey by family size, number of children, and household income by using 1987 poverty levels defined by the U.S. Bureau of the Census. Source: Adapted from Overpeck and Moss 1991. Effects of Smokeless Tobacco Use Smokeless tobacco refers to moist oral snuff, dry oral and nasal snuff, and chewing tobacco. Smokeless tobacco is commonly used by youths, particularly those in rural areas, and it is highly addictive (USDHHS 1986b; Boyd and Glover 1989). Among the adverse health effects of smokeless tobacco use are oral cancer, oral leukoplakia (white mouth lesions that may be precancerous), gingival recession, periodontal dis- eases, elevated blood pressure, and increased risk for cardiovascular disease (NC1 1992; USDHHS 1994; Bolinder et al. 1994). Few studies have examined the adverse health effects of smokeless tobacco use in racial/ethnic minority populations, and the research that has been conducted has been limited in several ways: (1) popu- lation-based, case-control studies rarely have sufficient numbers of racial/ethnic group members to allow group-specific analyses for groups other than African Americans (Blot et al. 1988; Day et al. 1993); (2) be- cause the use of smokeless tobacco and associated health effects are relatively rare in most racial/ethnic groups, the feasibility of conducting prospective in- vestigations is limited; and (3) smokeless tobacco us- ers often report current or past use of other substances, such as cigarettes and alcohol, that are risk factors for health effects also associated with smokeless tobacco use, such as oral cancer (Blot et al. 1988; Mattson and Winn 1989). These multiple risk factors complicate or preclude analysis of the independent effects of smoke- less tobacco use. The valid data that are available, however, indi- cate that for men, the prevalence of smokeless tobacco use is highest among American Indians, Alaska Natives, and whites; for women, the prevalence is highest among American Indians, Alaska Natives, and African Americans (CDC 1993~). Data for 1989-1991 show that rates of death from cancers of the lip, oral cavity, and pharynx have been higher among African American men (7.8 per 100,000) than among Puerto Rican men (3.9 per lOO,OOO), Asian American and Pa- cific Islander men (3.4 per lOO,OOO), and white men (3.2 per 100,000) (Table 2) (NCHS, public use data tapes, 1989-1991; U.S. Bureau of the Census 1993). In a case-control study, Winn and colleagues (1981) examined the estimated relative risk of oral and pharyngeal cancer associated with snuff-dipping among African American and white women in the southern United States. Although the relative risk was higher among white women (4.2) than among African American women (1.51, white women had dipped snuff for significantly longer periods and had con- sumed more snuff per week than African American women had. The relative risk for cancers of the gum and buccal mucosa increased with longer duration of snuff use, but this analysis was not conducted sepa- rately for African Americans and for whites. A few studies of the health effects associated with smokeless tobacco use have been conducted among American Indian and Alaska Native populations. In a study of Navajo youths aged 14-19 years in New Mexico (Wolfe and Carlos 1987), 64 percent of the teen- agers used smokeless tobacco products. Oral leuko- plakia was found in 26 percent of smokeless tobacco users, representing a ninefold increase in risk when these youths were compared with those who did not use smokeless tobacco. The estimated relative risk of leukoplakia increased with duration and frequency of smokeless tobacco use. The investigators observed no apparent differences between users and nonusers of smokeless tobacco regarding gingival bleeding, calcu- lus accumulation, or the extent or severity of gingival recession or loss of periodontal attachment. In a survey of students in grades 7-12 attending schools on the Rosebud Sioux Reservation in South Dakota, more than one-third of the students reported regularly using smokeless tobacco (CDC 1988). Of these regular users, 37 percent had oral lesions (i.e., any white or red wrinkled area in the mouth or buccal mucosa). The students with oral lesions had used smokeless tobacco for a mean of 3.4 years, 6.6 times per day, and they had held each dip or chew for an average of 40 minutes. Students who used smokeless tobacco but did not have lesions had used the product for a mean of 2.3 years, 2.9 times per day, and they had held each dip or chew for an average of 30 min- utes. This suggests a possible relationship between duration and intensity of smokeless tobacco use and the occurrence of oral lesions. The prevalence of oral lesions among nonusers of smokeless tobacco was not reported. The 1986-1987 National Survey of Oral Health in U.S. School Children conducted oral clinical exami- nations on 17,027 children aged 12-17 years who provided information on their use of various tobacco products (Tomar et al. 1997). Smokeless tobacco lesions (defined by the authors as slight to heavy wrinkling of the oral mucosa) were more common chewing tobacco use. Lesions were more common among white (2.0 percent) than among African Ameri- with increasing duration and frequency of smokeless can (0.2 percent) or Hispanic (0.8 percent) school chil- tobacco use. Because of small sample sizes, analyses dren. In white males, the strongest correlates of le- were not conducted on data for other racial/ethnic sions were, in order, current snuff use and current groups. Nicotine Addiction and Racial/Ethnic Differences Most smokers have difficulty quitting because they are addicted to nicotine (USDHHS 1988). An un- derstanding of the role of nicotine addiction in deter- mining smoking behavior could help clarify racial/ ethnic differences in tobacco use and facilitate smok- ing cessation treatment. Nicotine addiction was _ reviewed extensivelv in the 1988 Surgeon General's report on smoking and health (USDHHS 1988). Con- cepts of addiction also ha\,e been relriewed in subse- quent Surgeon General's reports (USDHHS 1989b, 1994). However, relati\rely little research has been con- ducted on racial/ethnic minority differences in nico- tine addiction. This section provides a brief revie\\r of nicotine addiction and discusses the limited data on racial/ethnic differences and nicotine addiction. Nature of Addiction In the broadest sense, addiction (often used in- terchangeably with dependence) indicates a loss of control over drug-taking behavior. The World Health Organization describes drug dependence as "a behav- ioral pattern in which the use of a given psychoactive drug is given a sharply higher priority over other be- haviors which once had a significantly higher value" (Edwards et al. 1982). In other words, drug use con- trols one's behavior to an extent considered detrimen- tal to the individual or to society. The criteria for drug dependence, described in the 1988 Surgeon General's report on smoking and health (Table 13) (USDHHS 19881, include highly con- trolled or compulsive use of a drug, the use of a drug that produces psychoactive effects, and evidence that drug-taking behavior is reinforced by the effects of the drug. Other criteria for drug dependence have been developed by the American Psychiatric Association [APA] (1994) for the fourth edition of the Diagr~ostic and Sfafistical Mnnunl r$Melztal Disonfers lDSM-Wr"J (Table 14). These criteria are quite specific and useful in diagnosing drug dependence in individual patients. Pharmacologic Factors in Nicotine Addiction Nicotine addiction, like all drug addictions, is a complex process involving the interplay of pharma- cology, learned or conditioned factors, personality, social setting, and genetics (USDHHS 1988, 1994; Benowitz 1992a). The pharmacologic reasons for drug use include an enhancement of one's mood or func- tioning. Drugs produce such effects either directly or by relieving withdrawal symptoms. The pharmaco- logic factors involved in nicotine addiction work in selFera ways. For example, positive effects reported after smoking tobacco include pleasure, arousal, and relaxation as well as improved attention, reaction time, and performance of certain tasks. In addition, ciga- rette smoking has been cited as effective in relieving aversive emotional states, including reducing anxiety or stress, relieving hunger and preventing weight gain, and relieving nicotine withdrawal symptoms (Table 15) (Benowitz 1992a). The pharmacology of nicotine addiction can be discussed in relation to several processes: (1) absorp- tion, distribution, and elimination of nicotine in the body (pharmacokinetics); (2) pharmacologic effects of nicotine on target organs (pharmacodynamics); and (3) translation of pharmacologic effects into behavior. These processes are reviewed in the following sections, and racial/ethnic differences are discussed when information is available. Absorption, Distribution, and Elimination of Nicotine in the Body Nicotine from tobacco smoke is absorbed rapidly across the lungs' alveolar membranes and into the sys- temic circulation (Benowitz 1990). Following absorp- tion from the lung, concentrations of nicotine in the blood rise quickly and peak at the completion of smoking. Concentrations of nicotine in arterial blood leaving the lungs and heart are several times higher than those measured in venous blood (Henningfield Table 13. Criteria for drug dependence Primary criteria Highly controlled or compulsive use Psychoactive effects Drug-reinforced behavior Additional criteria Addictive behavior often involves- stereotypic patterns of use use despite harmful effects relapse following abstinence recurrent drug cravings Dependence-producing drugs often produce- tolerance physical dependence pleasant (euphoric) effects Source: Adapted from U.S. Department of Health and Human Services 1988. et al. 1993). Within 10 to 19 seconds after the start of a puff, nicotine is delivered to the brain. Rapid delivery of high concentrations of nicotine to the brain provides the possibility for rapid behavioral reinforcement from smoking and allows the smoker to control the concen- tration of nicotine in the brain and, hence, to modu- late the pharmacologic effects of nicotine. In contrast, the absorption of nicotine from smokeless tobacco is gradual, with blood levels peak- ing at the end of chewing tobacco or using snuff (Benowitz et al. 1988). Buccal-oral absorption results in a gradual increase in concentrations of nicotine in the brain, with relatively little arterial-\renous disequi- librium, This pattern of absorption may provide a less intense pharmacologic reinforcement than that pro- duced by smoke inhalation but is sufficient to produce addiction. The level of nicotine in the body is determined by the balance of nicotine intake from tobacco and the rate of nicotine elimination from the body. Nicotine is eliminated primarilv by hepatic metabolism, with a small amount (5-14 percent) excreted unchanged in the urine. The primary metabolite of nicotine is cotinine, which has been used as a measure of nicotine exposure (Benowitz 1996). Keenan and colleagues (1994, 1995) recently published preliminary data consistent with the hypothesis that cotinine has some psychoactive properties. These effects do not appear to be mediated by nicotine receptor agonism, but could play some role in nicotine addiction, The rate of me- tabolizing nicotine varies considerably from person to person (Benowitz et al. 1982). A person who metabo- lizes nicotine slowly would not need to take in as much nicotine to achieve a particular level of nicotine in the body as a person who metabolizes nicotine more rap- idly. The level of nicotine in the body appears to be positively correlated with the degree of nicotine de- pendence and negatively correlated with the likelihood of successful cessation therapy (USDHHS 1988; Pomerleau et al. 1990; Sutherland et al. 1992). Theoretically, racial/ethnic differences in the ab- sorption, distribution, or elimination of nicotine could influence the likelihood of developing nicotine depen- dence (see Racial/Ethnic Differences in Nicotine Me- tabolites later in this chapter for further discussion of this topic). Pharmacodynamics of Nicotine Nicotine acts on nicotinic cholinergic receptors in the brain and other organs of the body, enhancing the release of neurotransmitters such as acetylcholine, norepinephrine, dopamine, beta-endorphin, and sero- tonin (USDHHS 1988). The physiologic consequences of nicotine intake include behavioral arousal and sym- pathetic neural activation (Table 15) (Benowitz 1992a). The release of specific neurotransmitters has been speculatively linked to the various reinforcing effects of nicotine (Pomerleau and Pomerleau 1984). For ex- ample, the enhanced release of dopamine and norepi- nephrine may be associated with pleasure as well as appetite suppression, the latter of which may contrib- ute to lolver body weight. The release of acetylcho- line may be associated with improved performance of beha\rioral tasks and improved memory, whereas the release of beta-endorphin may be associated with re- duced anxiety and tension. Although smokers give different explanations for smoking, most agree that smoking produces arousal, particularly with the first few cigarettes of the day, and paradoxically, smoking can also be calming or relax- ing, especially in stressful situations (Pomerleau and Pomerleau 1984; Benowitz 1992a). Consistent with reports of arousal, the smoking of cigarettes or the administration of nicotine is followed by electroencephalographic desvnchronization, with an upward shift in the brain's dominant alpha frequency and decreased total alpha and theta power (Pickworth et al. 1989). Table 14. American Psychiatric Association diagnostic criteria for substance dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following consequences, occurring at any time in the same 12-month period: Tolerance, as defined by either- need for markedly increased amounts of the substance to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount of the substance. Withdrawal, as manifested by either- the characteristic withdralval syndrome* for the substance or the same (or a closely related) substance being taken to relieve or avoid writhdrawal symptoms. Consumption of the substance in larger amounts or over a longer period than was intended. Having a persistent desire to cut down or control substance use or unsuccessfully trying to do so. Spending a great deal of time in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects. Giving up or reducing important social, occupational, or recreational activrities because of substance use. Continuing to use the substance, despite the knowledge that one has a persistent or recurrent physical or psychological problem likely caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was worsened by alcohol consumption). *The characteristic withdra\yal syndrome for nicotine refers to the daily use of nicotine for at least several weeks and abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by four or more of the following signs: dysphoric or depressed mood; insomnia; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; increased appetite or weight gain. Source: Adapted from American Psychiatric Association 1994. Several researchers have studied the effects of cigarette smoking and nicotine administration on the behavior of smokers who have abstained from tobacco use (abstinent smokers) (USDHHS 1988; Hughes et al. 1990; Warburton 1990; Le Houezec and Benowitz 1991; Heishman et al. 1994). Many of these studies have shown that nicotine restores tobacco-abstinence- related deficits in attention and short-term memory and decreases reaction time (Peeke and Peeke 1984; USDHHS 1988; Snyder et al. 1989; Snyder and Henningfield 1989; Warburton 1990; Levin 1992; Pritchard et al. 1992). Nicotine also may increase a person's vigilance in performing repetitive tasks and increase selective attention in abstinent smokers. The effects of nicotine on the cognitive functioning of non- smokers have not been clearly identified (USDHHS 1988; Heishman et al. 1994). Smokers commonly re- port pleasure, mental stimulation, and reduction of stress after smoking a cigarette (McKennell 1970; Russell et al. 1974). Cigarette smoking and nicotine also have sym- pathomimetic action, producing brief increases in blood pressure, heart rate, and cardiac output with cutaneous vasoconstriction (Benowitz 1988). Nicotine causes muscle relaxation by stimulating discharge of the Renshaw cells and pulmonary afferent nerves, which inhibit motor neuron activity and relax certain muscles. However, not all muscles are relaxed; increased electromyographic activity and tonicity of the large upper-back muscles (trapezius) have been observed after smoking (Fagerstrom and Gotestam 1977). Table 15. Human pharmacology of nicotine Primary effects* Withdrawal symptoms Pleasure Arousal, enhanced vigilance Improved task performance Relief of anxiety Reduced hunger Body weight reduction Electroencephalogram desynchronization Increased circulating levels of catecholamines, vasopressin, growth hormone, adreno- corticotropic hormone (ACTH), cortisol, prolactin, beta-endorphin Increased metabolic rate Lipolysis, increased free fatty acids Heart rate acceleration Cutaneous and coronary vasoconstriction Increased cardiac output Increased blood pressure Irritability, restlessness Drowsiness Difficulty concentrating, impaired task performance Anxiety Hunger Weight gain Sleep disturbance Cravings or strong urges for nicotine Decreased catecholamine excretion+ Heart rate slowing' Skeletal muscle relaxation *Some of these effects are related in part to relief of withdrawal symptoms. `May represent a return to baseline rather than true withdrawal. Source: Benowitz 1992a. Genetic differences in the number of nicotinic receptors and pharmacologic responses to nicotine have been well demonstrated in animals (Marks et al. 1991). Genetic differences in pharmacologic responses to nicotine could underlie different susceptibilities to nicotine addiction, as appears to be the case for cer- tain types of alcohol addiction (Hughes 1986; Cloninger 1987; Carmelli et al. 1992). Genetic suscep- tibility may vary by ancestry of origin (for example, sickle cell disease and African American ancestry). Genetic differences in nicotine responsiveness associ- ated with ancestry of origin remain to be explored. Tolerance, Withdrawal, and Addictive Tobacco Use With prolonged or repeated exposure to nicotine, neurologic changes (neuroadaptation) occur. In ani- mals, chronic nicotine exposure results in an increased number of nicotinic receptors in the brain (Marks et al. 1985). During the course of these changes, the smoker develops more brain nicotinic receptors and an increased tolerance to the various effects of nico- tine. For example, previous studies have shown that at autopsy, the number of nicotinic receptors was greater in the brains of cigarette smokers than in those of nonsmokers (Benwell et al. 1988). Smokers develop substantial tolerance to the behavioral arousal and cardiovascular effects of nicotine in the course of a single day (Benowitz et al. 1989b). They can regain sensitivity to the effects of nicotine, at least in part, after overnight abstinence from smoking. As a consequence of these neurologic changes, nicotine withdrawal symptoms appear when nicotine use is abruptly stopped (Table 16) (Hughes and Hatsukami 1992). Withdrawal symptoms include rest- lessness, irritability, anxiety, drowsiness, impatience, confusion, impaired concentration, and depression (Hughes et al. 1990). Some abstaining smokers gain weight, and others have impaired performance measures, such as reaction time. Many abstaining 178 Chapter 3 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 16. Incidence* of nicotine withdrawal symptoms, United States Symptom Clinic Self- attendees quitters (%) (%) Anxiety 87 49 Irritability 80 38 Difficulty concentrating 73 43 Restlessness 71 46 Hunger 67 53 Craving 62 37 Nocturnal awakenings 24 39 Depression NA 31 *Percentage of subjects with postcessation ratings greater than precessation ratings 2 days after they quit smoking. NA = data not available. Sources: Hughes 1992; Hughes and Hatsukami 1992. Adapted from Hughes and Hatsukami 1992. smokers have a strong craving to smoke a cigarette. Most of the withdrawal symptoms reach maximal in- tensity 24 to 48 hours after cessation and gradually diminish in intensity within three to four weeks (Gross and Stitzer 1989; Hughes et al. 1990), although some individuals experience longer lasting symptoms (USDHHS 1988). These symptoms, which also appear after quitting the use of smokeless tobacco (CDC 1994) or nicotine gum, are relieved following the adminis- tration of nicotine-a strong indication that the with- drawal symptoms are related to the effects of nicotine. The degree of nicotine dependence is determined in part by the level of nicotine that accumulates in smokers. In general, the level of accumulated nicotine is proportional to the number of cigarettes smoked per day. Consistent with the concept of a daily tolerance- withdrawal cycle, a short duration of time between awakening and smoking the first cigarette is associ- ated with a high degree of nicotine dependence (Heatherton et al. 1989). This presumably reflects an effort to reIieve nicotine withdrawal symptoms. These two factors-the number of cigarettes smoked per day and the amount of time from awakening to smoking the first cigarette-are commonly used to assess the severity of nicotine dependence (FagerstrGm and Schneider 1989). Level of Addiction Assessments of the level of nicotine addiction help predict responses to nicotine and serve as a potential guideline for therapeutic approaches to smoking cessation. The professionals who design strat- egies to prevent tobacco use and treat persons with nicotine addiction need to understand the high level of addiction among cigarette smokers and to appreci- ate the group-specific cultural characteristics of the be- havior and smokers' individual reasons for initiating, continuing, and quitting tobacco use (Krasnegor 1979; Grunberg and Acri 1991). The most widely used in- dexes of addiction levels are the number of cigarettes smoked per day, the serum nicotine or cotinine level, the Fagerstrijm dependence questionnaire (Fagerstriim and Schneider 1989), and the diagnostic criteria of the DSM-IV>' (APA 1994). The FagerstrGm dependence questionnaire incorporates questions about the num- ber of cigarettes smoked per day, the time between awakening and smoking the first cigarette of the day, as well as episodes in which the smoker lost control of smoking behavior (such as smoking at inappropriate times or in inappropriate places). The prevalence of smoking cessation-and conversely, the number of unsuccessful quit attempts-also reflects the level of addiction, at least in part. The brand of cigarette smoked might be expected to correlate with a person's level of dependence because high-yield cigarettes nominally deliver more nicotine per cigarette. How- ever, in large surveys of smokers, only a modest rela- tionship was found between yield (measured by a smoking machine) and levels of nicotine or cotinine in the body (Benowitz et al. 1986; Coultas et al. 1993). This is because people smoke differently than ma- chines that are set to a standardized testing protocol- that is, they are able to take more frequent or deeper puffs, to smoke each cigarette more completely, to smoke more cigarettes per day, and to block ventila- tion holes in the cigarettes (Henningfield et al. 1994; NC1 1996a). Racial/Ethnic Differences in Nicotine Metabolites Evidence suggests that African Americans have higher cotinine levels per reported number of ciga- rettes smoked per day than whites (Wagenknecht et al. 1990; English et al. 1994; Clark et al. 1996a) (Figure 5). In Figure 5, the racial/ethnic minority group com- parisons among those who smoked 25 or more ciga- rettes per day may be somewhat biased, because the average daily consumption for whites was substantially higher than that for African Americans and Mexican Health Consequences 179 Surgeon General's Report Figure 5. Serum cotinine levels by number of cigarettes smoked daily for African Americans, Mexican Americans, and whites, National Health and Nutrition Examination Survey, United States, 1988-1991 350 1 . African 300 American 250 - =i 6 -& 200- 6 2 :s 150- 3 loo- &l Mexican American O White 15-~25 Average number of cigarettes smoked per day (past 5 days) Note: N = 2,136. Source: National Center for Health Statistics, public use data tape, 1997. Americans. Clark and colleagues (1996b) found no evidence that underreporting of daily cigarette con- sumption occurred more often in African American than in white smokers. One possible explanation for the higher cotinine level among African Americans is that African Ameri- cans may absorb more nicotine from their cigarettes than whites (Benowitz et al. 1995). Greater absorp- tion could result from several factors, including group- specific patterns of smoking behavior (i.e., more and deeper puffs per cigarette or longer retention of tobacco smoke in the lungs) (Benowitz et al. 1995). Addition- ally, menthol in cigarettes may facilitate absorption of cigarette smoke constituents (Jarvik et al. 1994; McCarthy et al. 1995; Clark et al. 1996a). However, the fact that African Americans smoke menthol ciga- rettes more commonly than whites do explains only a small percentage of their higher levels of cigarette 25+ smoke constituents (Wagenknecht et al. 1992; Ahijevych et al. 1996; Clark et al. 1996a). Racial/ethnic differences in nicotine metabolism could influence the development of nicotine addiction. Several researchers have suggested that African Ameri- cans might metabolize cotinine differently than whites (Pattishall et al. 1985; Wagenknecht et al. 1990; English et al. 1994; Benowitz et al. 1995). Results of studies of nonsmokers support this hypothesis (Pattishall et al. 1985; Wagenknecht et al. 1993; Crawford et al. 1994; Knight et al. 1996; Pirkle et al. 1996). Most of these investigations (Pattishall et al. 1985; Crawford et al. 1994; Knight et al. 1996; Pirkle et al. 1996) reported that African Americans had higher cotinine levels than whites, even after ETS exposure and other factors were taken into account. These findings may be limited by the fact that no measures of tobacco smoke or nicotine concentrations in the air were obtained. 180 Chapter 3 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Based on a preliminary report of data for 40 Af- rican Americans and 39 white controls matched for age, gender, and cigarette consumption, Benowitz and col- leagues (1995) reported that the disposition kinetics of nicotine were similar for both groups. For example, the percentage conversion of nicotine to cotinine was similar across groups. However, the clearance of cotinine was significantly lower for African Americans than for whites. Additionally, the average estimated intake of nicotine per cigarette smoked was 1.41 mg in African Americans and 1.09 mg in whites. This differ- ence is of borderline statistical significance (p = 0.07) (Benowitz et al. 1995). African Americans took in 28 percent more nicotine per cigarette than would have been expected based on FTC yields; whites took in 9 percent more nicotine per cigarette than would have been expected based on FTC yields (Pkrez-Stable et al., unpublished data). Investigators have also found cotinine levels in African Americans that were higher than expected for the number of cigarettes smoked. Ahijevych and Wewers (1993) found an average salivary cotinine level of 402 ng/mL in African American women who smoked an average of 15 cigarettes per day. This level is much higher than the expected level found in other persons who smoked the same number of cigarettes. Clark and colleagues (1996b) reported that African American smokers smoked longer cigarettes and more of each cigarette than white smokers. However, be- cause they smoked fewer cigarettes each day, African Americans smoked fewer total daily millimeters of cigarettes. Among young adults in the CARDIA study, African Americans (48 percent) were more likely than whites (36 percent) to report that a substantial amount of their cigarette burned without their smoking it (Wagenknecht et al. 1992). Also, in a study of 33 Afri- can American and white women, Ahijevych and colleagues (1996) did not find a racial/ethnic differ- ence in total puff volume (per cigarette). PQez-Stable and colleagues (1990) reported that among Mexican Americans who were part of the 1982-l 984 HHANES, cotinine levels were unexpect- edly high in smokers reporting low levels of cigarette consumption. Higher-than-expected cotinine levels may reflect underreporting of smoking by Hispanics, but the possibility also exists that Hispanics absorb or metabolize nicotine differently than whites (Henningfield et al. 1990). However, recent data from NHANES III (Figure 5) indicate that, among persons who smoked at least one cigarette daily, Mexican American smokers had lower serum cotinine levels in each consumption category than African American and white smokers. Racial/Ethnic Differences in Self-Reported Nicotine Dependence The use of questionnaires to systematically in- vestigate racial/ethnic differences in nicotine depen- dence has been limited. Data from the 1987 NHIS (Table 17) show that African Americans were more likely than whites and Hispanics to report smoking their first cigarette of the day within 10 minutes of awakening, although these differences tended to dis- appear among those who reported smoking 25 or more cigarettes per day (NCHS, public use data tapes, 1987). Telephone survey data on smoking, collected as part of the Community Intervention Trial (COMMIT) for Smoking Cessation, also indicate that African Ameri- cans were more likely than whites to smoke within 10 minutes of awakening (an indicator of nicotine depen- dence [USDHHS 19881), even after the researchers con- trolled for the number of cigarettes smoked per day (Royce et al. 1993). Conversely, Andreski and Breslau (1993) conducted a study that used the dependence criteria of the DSM-IIITM and found that, compared with African Americans, greater proportions of whites had symptoms of nicotine dependence. The research- ers randomly selected 1,200 adults aged 21-30 years from the members of a health maintenance organiza- tion in southeast Michigan. Overall, 22.6 percent of the whites who smoked met the criteria for nicotine dependence, compared with 9.3 percent of the Afri- can Americans who smoked. Nicotine dependence was found to have a significant association with psychological distress, as measured by the Brief Symp- tom Inventory for smokers in both groups. Poor physical health was also associated with nicotine de- pendence, and this relationship was stronger among African Americans than among whites. Kandel and colleagues (1997) used questions from the 1991, 1992, and 1993 (combined) National Household Surveys on Drug Abuse (NHSDAs) to de- velop a proxy measure of DSM-IVTM (APA 1994) de- pendence on various substances (including nicotine). Respondents were asked, for example, if they felt un- able to reduce their use when they tried to cut down, experienced withdrawal symptoms (described in this survey as feeling sick because they stopped or cut down), felt that they needed or were dependent on the substance, and felt the need for larger amounts to obtain the same effect. This study used responses from 87,915 persons aged 12 years and older. Among per- sons who smoked during the previous year, whites were more likely than African Americans, Hispanics, and other racial/ethnic minority group members to be rated as dependent on nicotine. The authors Health Consequences 181 Surgeon General's Report Table 17. Percentage of adult smokers* who reported that they smoked their first cigarette within 10 minutes and within 30 minutes of awakening, by race/ethnicity and number of cigarettes smoked per day, National Health Interview Survey, United States, 1987 Characteristic 1-14 cigarettes 510 minutes 130 minutes African Americans Hispanics % KI+ % WI 21.9 4.9 11.3 5.3 39.2 5.5 26.2 7.3 Whites % WI 11.1 2.1 27.1 3.0 15-24 cigarettes 110 minutes 51.7 8.4 32.7 10.3 36.9 2.4 530 minutes 77.6 5.9 61.3 10.3 68.4 2.5 2 25 cigarettes 110 minutes 69.0 18.0 63.3 17.2 61.9 3.0 130 minutes 95.6 3.6 93.4 8.2 88.8 1.8 *Persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. `95% confidence interval. Source: National Center for Health Statistics, public use data tapes, 1987. acknowledged that their study was limited somewhat because the NHSDA indicators of dependence were not based on diagnostic interviews designed specifi- cally to assess DSM-IVTM criteria. Nevertheless, the finding that whites were more likely to exhibit indica- tors of dependence than African Americans was con- sistent with that of Andreski and Breslau (1993). Fur- ther research is needed to resolve the apparent dis- crepancy for African Americans between studies that are based on the number of minutes to the first ciga- rette of the day and those that are based on DSM-IIP or DSM-IVTM criteria for dependence. Navarro (1996) used population-based data from the 1990 California Tobacco Survey on white (n = 70,997) and Hispanic (n = 28,000) adults. Her analy- ses indicated that whites were significantly more likely than Hispanics to smoke on a daily basis and to smoke at least 15 cigarettes each day. Furthermore, among the daily smokers, whites were more likely than Hispanics to smoke a cigarette within 30 minutes of awakening. Among Hispanics, those who were less acculturated (i.e., who came from households where the language spoken in the household was not English) were significantly less likely than those who were more acculturated (i.e., who came from households where English was the language spoken) to be daily smokers and to smoke at least 15 cigarettes each day. Among Hispanics who were daily smokers, the percentage who smoked within 30 minutes of awakening did not differ significantly by level of acculturation. Smoking to maintain a lower body weight is be- lieved to contribute to tobacco dependence. In a sur- vey of high school students in Memphis, Tennessee, Camp and colleagues (1993) found that more whites than African Americans believed that cigarette smok- ing could help them control their body weight. Among the high school students who smoked, 39 percent of white females and 12 percent of white males reported smoking to control their body weight, compared with none of the African American students. A few studies have analyzed the perceptions that members of racial/ethnic groups have regarding the addictive nature of tobacco. In a San Francisco area study of 2,835 primary care patients who smoked, Vander Martin and colleagues (1990) found that whites smoked more cigarettes per day and were more likely to consider themselves addicted to cigarettes than Af- rican American, Asian American, and Hispanic smok- ers. Smoking within 15 minutes of awakening was least likely among Hispanic smokers but equally com- mon among smokers in the other groups. In addition, African Americans and Hispanics were less likely than the others to believe that quitting smoking would lead to weight gain. 182 Chapter 3 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Most Americans of all races and ethnicities real- ize that cigarette smoking is addictive. In a survey of 2,092 adults in St. Louis and Kansas City, Missouri, Brownson and colleagues (1992) found that a similar number of whites (90.3 percent) and African Ameri- cans (88.5 percent) believed cigarette smoking was addictive. Results from the 1992-1993 CPS (see Chap- ter 5, Research and Development Limitations) showed that most members of the four racial/ethnic groups as well as whites agreed with the statements that ciga- rette smoking was an addiction or both a habit and an addiction (Table 18) (U.S. Bureau of the Census, NC1 Tobacco Use Supplement, public use data tapes, 1992- 1993). Minor differences across gender were observed, although smokers were somewhat less likely to agree with the statements. Approximately 5 percent of the Asian American and Hispanic smokers indicated that cigarette smoking was neither a habit nor an addic- tion, compared with 1.9 percent of white smokers. Racial/Ethnic Differences in Quitting Smoking Because nicotine is addictive, highly addicted smokers have great difficulty in quitting. Differences in quitting can be used as another measure of the level of dependence. Some studies have found that although a similar percentage of whites and African Americans have ever been smokers, the percentage of former smokers has been greater among whites (26.4 percent) than among African Americans (17.2 percent) (Novotny et al. 1988) (see also Chapter 2). Data for 1989 from the BRFSS indicate that the standardized prevalence of smoking cessation was 47 percent among whites vs. 39.1 percent among African Americans (prevalence of cessation was defined as the percent- age of ever smokers who were former smokers) (CDC 1990). Similar findings were reported by Kabat and Wynder (19871, Hahn and colleagues (19901, and Geronimus and colleagues (1993). The 1991 NHIS Health Promotion and Disease Prevention supplement collected data on smokers who had quit for at least one day at the time of survey and for at least one month in the previous year (CDC 1993b). Hispanics (52.1 percent) and African Americans (48.7 percent) were more likely than whites (40.3 percent) to have quit smoking for one day. However, data on abstinence from smoking in the previous year showed that His- panics (16.3 percent) and whites (14.0 percent) were more likely than African Americans (7.9 percent) to have quit smoking for one month or longer. Thus, African Americans were less likely than whites to maintain abstinence. This effect remained after the findings were controlled for socioeconomic status. In an unadjusted analysis of data from the Current Popu- lation Survey NC1 Supplement, a similar pattern was observed, although the differences between Afri- can Americans and whites were slight (see Table 2 and African Americans, Quitting Behavior in Chapter 2). The lower smoking cessation rates among Afri- can Americans do not appear to result from a lack of desire to quit (Royce et al. 1993). In the COMMIT tele- phone survey, 46.0 percent of African American women and 44.4 percent of African American men stated that they wanted to quit smoking "a lot," com- pared with 35.0 percent of white women and 33.3 per- cent of white men. Thus, the lower prevalence of cessation among African Americans may be related to factors other than the desire to quit, such as the absence of culturally appropriate smoking cessation interventions, difficulties in accessing community resources for quitting smoking, and possibly a higher level of nicotine dependence as indicated by compara- tively higher levels of cotinine when the data are con- trolled for the number of cigarettes smoked. Addiction to Smokeless Tobacco Considerable nicotine is absorbed from smoke- less tobacco. An average systemic dose of nicotine is 3.6 mg for snuff, 4.6 mg for chewing tobacco, and 1.8 mg for cigarettes (Benowitz et al. 1988). Blood nic- otine concentrations throughout the day are similar among smokers and those who use smokeless tobacco (Benowitz et al. 1989a). Plasma cotinine levels in regu- lar smokeless tobacco users are often similar to the lev- els in cigarette smokers (Holm et al. 1992). Abstinence from smokeless tobacco use results in signs and symp- toms of nicotine deprivation that are similar to those seen in smokers after they stop smoking (Hatsukami et al. 1987; CDC 1994). These symptoms are reversed by the use of tobacco or administration of nicotine gum. In a study of Swedish oral snuff users, many of the participants considered themselves addicted to snuff, and they reported having as much difficulty giv- ing up smokeless tobacco use as was reported by ciga- rette smokers trying to quit smoking (Helm et al. 1992). Evidence also suggests that when regular snuff users are deprived of snuff, they will smoke cigarettes to satisfy their need for nicotine (Benowitz 1992b). How- ever, no data are available on racial or ethnic differ- ences in the level of addiction to smokeless tobacco. Health Consequences 183 Surgeon General's Report Table 18. Percentage of men and women who considered smoking a habit or addiction,* overall and by smoking status, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic %+ %I* % XI % XI % KI % 4cI Overall Habit Addiction Both Men Habit Addiction Both Women Habit Addiction Both Nonsmokers Habit Addiction Both Men Habit Addiction Both Women Habit Addiction Both Smokers Habit Addiction Both Men Habit Addiction Both Women Habit Addiction Both 31.7 0.7 19.6 2.6 23.9 1.4 25.1 0.8 17.8 0.2 19.8 0.6 19.6 2.6 17.8 1.2 26.3 0.8 21.9 0.2 41.3 0.7 54.6 3.3 46.4 1.6 38.4 0.9 57.0 0.3 32.3 1.1 19.5 3.9 25.5 2.0 26.4 1.2 19.3 0.3 20.4 0.9 21.4 4.0 18.4 1.8 26.7 1.2 22.0 0.3 39.5 1.1 52.6 4.9 45.8 2.3 36.7 1.3 55.2 0.4 31.3 0.9 19.6 3.5 22.5 1.9 24.0 1.0 16.5 0.3 19.5 0.8 18.1 3.4 17.2 1.7 25.9 1.1 21.9 0.3 42.5 0.9 56.2 4.4 46.9 2.2 39.8 1.2 58.6 0.4 29.8 0.8 18.3 3.3 21.7 1.4 23.5 0.8 16.4 0.2 20.4 0.7 21 .l 3.5 18.9 1.4 27.1 0.9 23.0 0.3 42.9 0.8 54.6 4.2 47.5 1.8 39.4 1.0 57.7 0.3 30.3 20.5 41.6 1.3 1.1 1.4 1.0 0.9 1.1 1.4 1.1 1.4 2.0 1.7 2.0 1.9 1.5 1.9 19.8 5.3 22.2 2.2 24.6 1.3 18.0 0.4 22.4 5.5 20.2 2.1 27.9 1.4 22.8 0.4 51.4 6.6 48.1 2.6 38.0 1.5 56.1 0.5 29.6 20.3 43.7 17.3 4.2 21.3 1.9 22.7 1.1 15.0 0.3 20.2 4.5 17.8 1.8 26.5 1.1 23.1 0.4 56.8 5.5 47.0 2.4 40.4 1.3 59.0 0.4 36.6 18.6 37.2 21.5 4.4 36.0 3.9 32.7 2.0 22.1 0.5 17.5 4.0 12.3 2.7 22.6 1.7 18.9 0.4 54.4 5.3 40.9 4.0 34.1 2.0 55.2 0.6 36.4 20.2 35.1 19.4 5.9 36.6 4.7 32.3 2.5 22.9 0.7 20.5 6.1 12.6 3.2 23.3 2.3 19.7 0.6 53.6 7.5 38.3 4.7 32.8 2.5 53.0 0.8 36.7 17.2 39.0 23.7 6.4 34.6 7.1 33.2 3.1 21.2 0.7 14.4 5.3 11.5 4.8 21.4 2.7 18.1 0.6 55.2 7.5 47.0 7.5 36.1 3.2 57.3 0.8 *In response to the question, "Do you think smoking is a habit, an addiction, neither, or both?" `Percentages in this table do not include all categories of responses and thus may not equal 100%. *95% confidence interval. Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes, 1992-1993. I84 Chapter 3 Tobncco Use Among U.S. Racial/Ethnic Minority Groups Conclusions 1. Cigarette smoking is a major cause of disease and death in each of the four racial/ethnic groups stud- ied in this report. African Americans currently bear the greatest health burden. Differences in the magnitude of disease risk are directly related to differences in patterns of smoking. 2. Although lung cancer incidence and death rates vary widely among the nation's racial/ethnic groups, lung cancer is the leading cause of cancer death for each of the racial/ethnic groups studied in this report. Before 1990, death rates from malig- nant neoplasms of the respiratory system increased among African American, Hispanic, and American Indian and Alaska Native men and women. From 1990 through 1995 death rates from respiratory can- cers decreased substantially among African Ameri- can men, leveled off among African American women, decreased slightly among Hispanic men and women, and increased among American Indian and Alaska Native men and women. 3. Rates of tobacco-related cancers (other than lung cancer) vary widely among members of racial/ ethnic groups, and they are particularly high among African American men. 4. The effect of cigarette smoking (as reflected by biomarkers of tobacco exposure) on infant birth weight appears to be the same in African American and white women. As reported in previous Sur- geon General's reports, cigarette smoking increases the risk of delivering a low-birth-weight infant. Appendix. Methodological Issues 5. 6. 7. 8. No significant racial/ethnic group differences have been consistently demonstrated in the relationship between smoking and infant mortality or sudden infant death syndrome (SIDS); cigarette smoking has been associated with increased risk of SIDS and remains a probable cause of infant mortality. Future research is needed and should focus on how tobacco use affects coronary heart disease, stroke, cancer, chronic obstructive pulmonary disease, and other respiratory diseases among members of racial/ethnic groups. Studies also are needed to determine how the health effects of smokeless to- bacco use and exposure to environmental tobacco smoke vary across racial/ethnic minority groups. Persons of all racial/ethnic backgrounds are vul- nerable to becoming addicted to nicotine, and no consistent differences exist in the overall severity of addiction or symptoms of addiction across racial/ethnic groups. Levels of serum cotinine (a biomarker of tobacco exposure) are higher in African American smok- ers than in white smokers for similar levels of daily cigarette consumption. Further research is needed to clarify the relationship between smoking prac- tices and serum cotinine levels in U.S. racial/ ethnic groups. Variables such as group-specific patterns of smoking behavior (e.g., number of puffs per cigarette, retention time of tobacco smoke in the lungs), rates of nicotine metabolism, and brand mentholation could be explored. It is important to review some methodological issues involved in collecting the data discussed in this chapter. These methodological problems affect the quality of the data and the type of conclusions that can be reached from studies conducted to date. Also, because cigarette smoking tends to be associated with other lifestyle risk factors that impact on health (e.g., Wingard et al. 1982; Vickers et al. 1990; Perez- Stable et al. 19941, there is a need to control their co-occurrence in order to better understand the health effects of tobacco use. Classification of Smoking Status In investigating the health effects of smoking cigarettes and using other tobacco products, research- ers typically obtain information from the subjects or surrogate respondents on the use of such products. Questionnaires usually cover cigarette smoking sta- tus (i.e., never, former, and current smoker), number of years of smoking and age at initiation of smoking, number of cigarettes smoked per day, and use of other tobacco products (e.g., pipes, cigars, and smokeless Health Consequences 185 Surgeon Gerzeral `s Report tobacco). However, this information may not be fully valid, resulting in misclassification of exposure to ciga- rette smoking. A previous report of the Surgeon Gen- eral reviewed the classification of cigarette smoking status and the consequences of misclassification (USDHHS 1990). Misclassification of smoking information merits consideration in investigating tobacco use among racial/ethnic populations, because of the potential for bias in comparing the effects of smoking across racial/ ethnic groups. To date, such bias has not been identi- fied, although several studies show that Hispanics may underreport cigarette smoking. In a population-based survey in New Mexico, Coultas and colleagues (1988) compared self-reports of smoking against salivary cotinine level (a product of nicotine that has been used as a measure of exposure to nicotine) and end-tidal car- bon monoxide concentration. Based on the question- naire results, the age-standardized prevalence rates of current smoking were 30.9 and 27.1 percent for His- panic men and women, respectively After adjusting for cotinine and carbon monoxide levels, these percent- ages were 39.1 and 33.2. The rate of misclassification was greater in self-reported former smokers than in never smokers, but self-reported never smokers also had levels of cotinine and carbon monoxide indicative of active smoking. Using information from the Hispanic Health and Nutrition Examination Survey (HHANES), Perez- Stable and colleagues (1992) documented the misclassification of smoking status through compari- sons of self-reports with serum cotinine levels. Among 65 Mexican American former smokers participating in the HHANES in 1982 through 1983, 7 (10.8 percent) had a cotinine level indicative of active smoking; among 124 reported never smokers, 5 (4 percent) were probably active smokers based on their cotinine lev- els. In a number of surveys, Hispanics, particularly Latin0 groups in the southwestern and western United States, have been found to smoke about one-half pack of cigarettes per day, compared with non-Hispanic whites who typically report smoking one pack per day (Coultas et al. 1994). Perez-Stable and colleagues (1992) used data from 547 Mexican American participants in the HHANES to examine underreporting of cigarette consumption using the ratio of serum cotinine to self-reports of the number of cigarettes smoked per day as the "gold standard." This study found that among Mexican Americans, 20.4 percent of men and 24.7 percent of women who were self-reported smokers underreported smoking between one and nine cigarettes per day. Self-reported Mexican Ameri- can smokers who reported smoking greater numbers of cigarettes per day underreported less frequently. An analysis of the data from the Coronary Artery Risk Development in (Young) Adults Study (CARDIA) showed that there were higher rates of misclassification in terms of self-reported nonsmok- ers who had serum cotinine levels of at least 14 ng/ mL among African Americans (5.7 percent) than among non-Hispanic whites (2.8 percent) (Wagen- knecht et al. 1992). Alternative explanations for underreporting, such as more efficient smoking and differences in cotinine metabolism, could not be excluded. Two additional studies examined the relation- ship between ancestry of origin and levels of biochemi- cal markers in smokers. In a study of participants in CARDIA, African American smokers demonstrated higher cotinine levels than non-Hispanic white smok- ers after controlling for several dimensions of cigarette- smoking behavior (Wagenknecht et al. 1990). Lactose intolerance, which elevates breath hydrogen concen- tration, may increase the apparent level of expired air carbon monoxide, a readily measured marker of ac- tive smoking (McNeil1 et al. 1990). Lactose intolerance is common in a number of racial/ethnic groups, in- cluding Asian Americans and African Americans. Classification of Race/Ethnicity The data included in this chapter are derived from diverse sources, including vital statistics, cancer registries, and epidemiological studies on smoking. Race/ethnicity has been classified in these studies us- ing various techniques, including designation on death certificate, classification according to cancer registry protocols, self-reports, birthplace, language use, and surname. The validity of each of these approaches is undoubtedly imperfect; moreover, validity varies across regions and over time. However, comprehen- sive assessments of the validity of racial/ethnic mi- nority classification in various types of health data have not been reported. The limited information available indicates some potential for misclassification. For example, Frost and colleagues (1992) compared the classification of "Native American," as recorded by the Seattle-Puget Sound registry of the Surveillance, Epidemiology, and End Results (SEER) Program against an Indian Health Service (IHS) registry of patients eligible for services. A substantial portion of patients with invasive cancer in the IHS registry were not similarly classified by the Seattle-Puget Sound cancer registry. Similarly, an injury registry for the state of Oregon under- counted those with injuries (Sugarman et al. 1993). Using data from the National Longitudinal Mortality Study Sorlie and colleagues (1992) compared demographic characteristics reported on the CI'S of the 186 Chapter 3 Tobacco Use Among U.S. Racial/Ethnic Minority Groups U.S. Bureau of the Census with those characteristics reported on the death certificates for persons who died (during a seven-year follow-up period). Among 216 persons identified as American Indians or Alaska Natives by the CPS, only 159 (73.6 percent) were so classified on the death certificate. Similarly, the con- cordance rate for 272 persons classified by the CPS as Asian Americans or Pacific Islanders was 82.4 percent. Such disagreement suggests that current estimates of mortality rates for selected racial/ethnic groups are underestimated. However, in New Mexico, the classi- fication of "American Indian" by the New Mexico Tu- mor Registry, also a participant in the SEER Program, closely corresponded with the classification by the state's Bureau of Vital Statistics (Eidson et al. 1994). Another study in New Mexico also showed a high concordance between self-reported Hispanic race/ethnicity and the designation by the Bureau of Vital Statistics (Samet et al. 1988bl. In the report by Sorlie and colleagues (1993), 10.3 percent (n = 62) of persons identified as Hispanics by the CPS were not classified as Hispanics on the death certificate. Sur- names also have been used to classify Hispanic ethnicity, using either surname lists developed by the U.S. Bureau of the Census or name recognition algo- rithms (Howard et al. 1983; Wiggins and Samet 1993). Although studies in parts of the southwestern United States have shown a generally high validity for sur- name-based approaches for identifying Hispanic ethnicity, the sensitivity and specificity of the various Census Bureau lists have varied over time, and data from the Southwest cannot be readily generalized to other locales. In addition, surname lists tend to ex- clude women who marry non-Hispanic whites and who take their husband's last name and to exclude as well their children when given the father's non- Hispanic last name (Marin and Marin 1991). These studies suggest that the validity of classi- fication of race/ethnicity is likely to vary across loca- tions and possibly by type of data. In interpreting health data for racial/ethnic populations, consideration should be given to the potential for misclassification of race/ethnicity and the consequences of any result- ing bias. Classification of Health Outcomes Comparisons of disease occurrence among racial/ethnic groups also may be biased by differen- tial patterns of disease diagnosis and labeling by race and ethnicity. Such differences may have multiple causes that reflect the complex sequence that begins with the development of symptoms and signs and ex- tends to the labeling of an illness by a clinician or the statement of cause-of-death on a death certificate. Health beliefs and knowledge, ability to access and pay for medical care, the quality of care available, and differential patterns of care by race/ethnicity may all affect diagnoses of illnesses. A full review of these top- ics is beyond the scope of this report, but several ex- amples are offered to illustrate the potential for differ- ential patterns of classification of health outcomes by race/ethnicity. Becker and colleagues (19901 examined the assign- ment of underlying cause of death to the category "symptoms, signs, and ill-defined conditions" in the Mnnual of the International Classification of Diseases, Inju- ries and Causes of Death (ICD). In the nation, the crude death rate for this non-specific category has paralleled the mortality rate in this category for African Ameri- cans. Becker and colleagues (1990) analyzed vital statis- tics data for New Mexico for 1958 through 1982 and calculated mortality rates for "symptoms, signs, and ill-defined conditions" by racial/ethnic group. The state mortality rates for Hispanics, non-Hispanic whites, and American Indians for this category ex- ceeded the nationwide rates. Among the racial/ethnic minority groups in New Mexico, American Indians had particularly high mortality rates; for men, 8.4 percent of American Indian deaths were in this category ver- sus 5.9 percent of Hispanic deaths and 5.0 percent of non-Hispanic white deaths. Similarly, mortality rates for cancers of ill-defined and unknown primary sites tend to be much higher in American Indians in several areas of the country than for all racial/ethnic groups combined (Valway 1992). Recent comparisons of the evaluation and man- agement of chest pain and coronary artery disease in African Americans and non-Hispanic whites further illustrate the potential for bias by race/ethnicity in di- agnostic classification. In a study of patients present- ing to an emergency room with chest pain, African Americans were less likely to be admitted and less likely to be sent to a coronary care unit once they were admitted (Johnson et al. 1993). The study also found that African Americans were as likely as non-Hispanic whites to have cardiac catheterization. In contrast, other studies, using Department of Veterans' Affairs, Medicare, and other large data bases, have shown that African Americans are less likely than non-Hispanic whites to have cardiac catheterization and invasive interventions for coronary artery disease (Wenneker and Epstein 1989; Udvarhelyi et al. 1992; Ayanian et al. 1993; Franks et al. 1993; Whittle et al. 1993; Peterson et al. 1994). These differential patterns of evaluation by race/ethnicity could introduce bias in investigations of tobacco smoking and coronary artery disease among African Americans and non-Hispanic whites by underestimating the effects of cigarette smoking on coronary artery disease. Health Consequences 187 Surgeon General's Report References Abbott RD, Yin Y, Reed DM, Yano K. Rise of stroke in male cigarette smokers. New England Journal of Medi- cine 1986;31502):717-20. Ahijevych K, Wewers ME. Factors associated with nic- otine dependence among African American women cigarette smokers. 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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