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 Promo tion
Office on Smoking and Health
Suggested Citation

U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic
Minority Groups—African Americans, American Indians and Alaska Natives, Asian Americans
and Pacific Islanders, and Hispanics: A Report of the Surgeon General. 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, O.C. 2020}

 

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 ANDO HUMAN SERVICES
WASHINGTON, D.C. 2020)

 

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. C Me

 

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 1s 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 Surgeon General,
U.S. Department of Health and Human 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 Cancer Incidence and Mortality, 1973-1995: 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

ut
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 endeavors, we will succeed only if we are sensitive to our
cultural differences and similarities. | 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 toward 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

iv
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 5. 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 P. 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

Gerardo 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.

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

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 §. 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.P.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.
Surgeon General’s Report

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.PH., 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 P. 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.

vi

Robert G. 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.A., 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., M.S., 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.
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 Burhansstipanoy, 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.

vil

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

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.
Surgeon General’s Report

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, IHinois.

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., FR.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.

vit

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, Marvland.

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 Fellow, Memo-
rial Sloan-Kettering Cancer Center, Division of Psychia-
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.

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

Marissa Bernstein, Indexer, Cygnus Corporation,
Rockville, Maryland.

Nowell 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 Prevention 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.

David F. 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.
Surgeon General's Report

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 Lé, 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.LS., 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, M.S., Proofreader, Marietta, Georgia.

Eve J. Wilson, Ph.D., Project Manager, Cygnus Corpo-
ration, Rockville, Maryland.

Beatrice K. Wolman, MS., 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 19

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/Ethnicity 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 158

Coronary Heart Disease 160

Cerebrovascular Disease 164

Smoking and Pregnancy 166

Summary of Health Consequences from Active Cigarette Smoking 172
Effects of Exposure to Environmental Tobacco Smoke 172
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 213

Advertising and Promotion 2
Psychosocial Determinants 2

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 2/74

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