Tobacco Use Among U.S. Racial/Ethnic Minority Groups Pacific Oklahoma Northwest* Southwest* Other’ Total G% +CI % +Cl % +CI % +I % +CI 83.4 6.2 83.0 4.6 92.3 3.7 81.1 3.6 83.3 2.1 9.7 4.6 10.8 3.8 4.5 2.3 11.5 3.1 10.4 1.7 6.9 4.3 6.2 3.0 3.2 3.1 7A 2.2 6.4 1.3 83.3 9.1 80.2 7.1 87.3 7.3 74.7 59 79.3 3.4 8.2 6.7 12.0 5.4 7.2 4.2 14.1 5.0 11.6 2.7 8.5 6.5 7.8 5.0 5.6 6.4 11.1 4.0 91 2.3 83.5 8.4 85.3 6.2 96.4 2.7 87.5 3.9 87.1 24 10.9 6.2 9.8 5.3 2.3 2.3 8.8 3.6 9.2 2.1 5.6 5.9 4.9 3.6 1.2 1.4 3.6 1.8 3.7 1.3 84.0 10.0 83.5 7.2 98.1 2.1 83.5 5.6 85.9 2.9 9.2 71 9.2 5.5 1.8 2.1 11.9 5.2 9.3 2.5 6.8 77 7.4 5.2 0.1 0.2 4.6 2.6 4.8 1.8 74.6 11.9 81.1 7.1 84.8 8.7 74.0 6.6 76.8 3.9 16.0 10.9 12.8 6.2 7.0 4.4 13.3 5.0 13.7 3.3 9.3 6.7 6.1 4.1 8.2 8.2 12.7 5.0 9.4 2.6 90.2 8.4 86.0 11.1 87.8 11.4 87.1 6.1 87.2 4.1 49 5.5 10.9 9.9 9.9 11.2 7.6 4.6 75 3.1 4.8 6.8 3.1 5.6 2.3 2.7 5.3 4.3 5.3 2.8 86.0 12.5 69.7 14.5 80.3 10.9 75.1 8.6 78.6 4.9 9.2 10.8 22.0 13.3 16.4 10.6 11.3 6.7 11.2 3.6 4.8 7.3 8.3 8.2 3.3 4.0 13.6 6.6 10.2 3.8 82.2 7.0 84.7 5.1 92.0 5.4 80.3 4.5 82.1 2.7 10.5 5.6 9.5 4.1 3.6 2.5 12.9 4.0 11.9 2.4 73 4.7 5.8 3.3 4.5 5.0 6.7 2.7 6.0 15 495% confidence interval. SIncludes persons aged 25 years and older. Source: Centers for Disease Control, public use data tapes, 1988-1992. Patterns of Tobacco Use 53 Surgeon General's Report Table 19. Percentage of adult American Indian and Alaska Native smokers who reported they quit smoking,* overall and by region/state, gender, age, and education, Behavioral Risk Factor Surveillance System, 1988-1992 aggregate data Northern Northern Alaska California Plains? Woodlands* Characteristic % tc % +c] % +Cl % +Cl Total 37.0 6.6 44.8 11.9 31.8 8.3 44.3 6.3 Gender Men 37.1 93 44.8 16.2 32.8 11.4 49.5 9.8 Women 36.9 93 44.8 16.9 30.3 11.7 40.0 8.2 Age (years) 18-34 31.2 10.0 298 15.8 15.9 9.4 41.8 9.3 35-54 43.8 9.8 49.2 17.3 32.22 13.4 35.5 9.7 255 42.2 16.1 61.0 28.9 58.2 19.7 62.2 12.6 Education$ Less than high school 38.5 12.6 53.6 22.7 35.1 15.8 48.3 13.0 High school/any college 38.1 7.7 41.8 14.2 37.5 11.6 46.2 7.5 *The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking. *The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor Surveillance System during this period. Great Falls, 63 percent of men and 62 percent of women reported that they smoked. In both areas, rates of smoking were higher among persons aged 25 years and older than among their younger counterparts. For American Indians in Great Falls, those who had a high school education and did not go to college had lower rates of smoking than those with less than a high school education or those with some college education. Gen- der differences in smoking cessation were also ob- served. Among American Indians in Great Falls, 16 percent of men and 19 percent of women had quit smoking; among the Blackfeet American Indians, 34 percent of men and 22 percent of women had quit smoking (Goldberg et al. 1991). Ina 1990 study of members of the Oneida Indian Nation of New York, 71.6 percent of the men and 64.6 percent of the women reported having ever smoked cigarettes (CDC 1990). The prevalence of ever smok- ing cigarettes was lower among men (65.3 percent) and 54 Chapter 2 women (58.2 percent) with 12 or more years of educa- tion than among men (81.3 percent) and women (74.5 percent) with less than 12 years of education. Rates of current smoking among the Oneida Indian Nation fol- lowed similar patterns in terms of educational status: men (34.7 percent) and women (29.1 percent) with 12 or more years of education had a lower prevalence of cigarette smoking than men (59.4 percent) and women (56.9 percent) with less than 12 years of for- mal education. Overall, a greater proportion of men (44.4 percent) than women (40.0 percent) smoked. The prevalence of cessation, on the other hand, was fairly similar for men (37.9 percent) and women (38.1 percent). Similar findings were observed in a survey of people on the Warm Springs Reservation (Warm Springs Confederated Tribes 1993) and in the Western Washington Native American Behavior Risk Factor Survey of the Chehalis, Hoh, Quinault, and Shoalwater Tobacco Use Among U.S. Racial/Ethnic Minority Groups Pacific Oklahoma Northwest? Southwest* Other* Total % +Cl % +CI1 % +Cl G +CI % +CT1 40.7 10.2 46.8 8.0 51.2 10.3 39.8 7.0 41.5 4.0 33.1 15.1 44.8 11.8 51.8 15.0 35.4 9.4 39.2 5.5 47.1 13.8 48.5 11.1 50.3 13.8 46.1 10.5 44.4 5.6 - 27.8 16.1 38.7 12.3 52.7 15.9 28.5 10.0 30.6 5.4 36.9 18.0 52.7 11.7 54.1 16.7 42.2 11.9 44.0 6.6 61.0 16.7 57.4 20.6 38.0 21.2 58.7 12.2 58.2 8.3 45.0 23.5 40.4 18.1 40.9 19.5 39.7 15.3 42.6 8.3 43.5 11.7 47.8 95 53.2 13.6 41.4 8.1 42.7 4.8 195% confidence interval. ‘Includes persons aged 25 years and older. Source: Centers for Disease Control, public use data tapes, 1988-1992. Tribes (Kimball et al. 1990). In a survey of 1,318 adult American Indian and Alaska Native users of Indian clinics in northern California, 40 percent of the respon- dents reported smoking cigarettes (47 percent of the men and 37 percent of the women) (Hodge et al. 1995), Aggregated data from the BRFSS indicate that among American Indian and Alaska Native women of reproductive age, smoking rates were highest among women in Alaska (43.9 percent), the Northern Plains (39.5 percent), and the Northern Woodlands (38.8 percent) and lowest among women in the South- west (11.5 percent) and California (15.3 percent) (Table 20) (CDC, public use data tapes, 1988-1992). Smokeless Tobacco Use The use of smokeless tobacco (chewing tobacco and snuff) among American Indians and Alaska Natives also has varied by state and region. According to the BRFSS data for 1988-1992, the prevalences among men were 24.6 percent in the Northern Plains, 16.8 percent in the Northern Woodlands, 14.3 percent in Oklahoma, 11.6 percent in Alaska, 6.5 percent in the Southwest, and 1.8 percent in the Pacific Northwest (CDC, public use data tapes, 1988-1992). In the Oneida Indian Nation survey, none of the women reported using smokeless tobacco, whereas 17.3 percent of the men reported using it (CDC 1990). More recently, investigators have reported ex- tremely high rates of smokeless tobacco use among Lumbee women in North Carolina (CDC 1995). In 1991, the prevalence of smokeless tobacco use was greatest among Lumbee women 65 years of age and older (51 percent) and lowest among those 25-34 years of age (6 percent). The prevalence was also high among women with less than 12 years of education (42 percent). Oi on Patterns of Tobacco Use Surgeon General's Report Table 20. Percentage of American Indian and Alaska Native women of reproductive age who reported being current cigarette smokers,* overall and by region/state, Behavioral Risk Factor Surveillance System, 1988-1992 aggregate data Northern Northern Alaska California Plains* Woodlands* % +cCTt % +C] % +Cl % +CI 43.9 93 15.3 9.1 39.5 12.3 38.8 7.1 Total I Pacific eer Oklahoma Northwest* Southwest* Other* 24.9 3.9 % +Cl % +Cl % +ClI % +Cl 30.4 12.5 32.6 9.7 11.5 26.7 7.1 “Current cigarette smokers are 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. *The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor Surveillance System during this period. 495% confidence interval. Source: Centers for Disease Control, public use data tapes, 1988-1992. Asian Americans and Pacific Islanders Data needed to assess long-term trends in cigarette smoking among Asian Americans and Pacific Islanders have been unavailable because U.S. surveys, census data, and other national databases have not always included detailed descriptions of race/ethnicity. Although data from specific Asian American and Pacific Islander groups and state surveys have provided information about ciga- rette smoking for certain racial/ethnic subgroups, these data have been limited in quantity and quality. The NHIS first included information about Asian Americans and Pacific Islanders in the 1978 survey. However, because the proportion of Asian Americans and Pacific Islanders in the United States is small, data from several years must be aggregated to increase the precision of estimates. Be- cause of small sample sizes and aggregation of data, racial/ethnic subgroup differences in smoking behav- ior are masked. These differences are important because the category Asian American and Pacific Islander is hetero- geneous in both culture and health behaviors. For ex- ample, this category includes about 32 different national and racial/ethnic subgroups (Austin et al. 1989; Hawks 1989) and nearly 500 languages and dialects (Chen 1993), and smoking patterns among these subgroups vary. 36 Chapter 2 Prevalence of Cigarette Smoking Between 1978 and 1995, the prevalence of smok- ing declined among Asian Americans and Pacific Is- landers, according to NHIS data (Table 21) (NCHS, public use data tapes, 1978-1995). However, patterns between men and women differed. The cigarette smoking prevalence among Asian American and Pa- cific Islander men declined slightly, from 32.5 to 25.1 percent, whereas the prevalence of smoking among Asian American and Pacific Islander women declined approximately 60 percent, from 14.7 to 5.8 percent. Throughout this period, the prevalence of smoking among men remained more than twice that among women; in 1994-1995, men were 4.3 times more likely than women to report current smoking. Number of Cigarettes Smoked Daily From 1978 through 1995, the percentage of Asian American and Pacific Islander smokers who smoked fewer than 15 cigarettes per day increased significantly, according to the NHIS data (Table 22) (NCHS, public use data tapes, 1978-1995). Although large declines from 1978-1980 to 1992-1993 were observed in the prevalence Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 21. Percentage of adult Asian Americans and Pacific Islanders who reported being current cigarette smokers,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988" 1990-1991' 1992-1993 1994-1995" Characteristic % +c &% +C1 % +CI G% +CI % +CI % +CI Total 38 40 24 34 158 24 161 25 16.7 27 153 3.0 Gender Men 325 45 330 62 225 38 245 40 268 47 25.1 5.2 Women 14.7 6.6 96 3.5 92 28 6.6 2.0 6.8 2.7 5.8 2.3 Age (years) 18-34 75 58 216 46 163 35 155 32 157 42 176 53 35-54 287 85 208 48 161 36 171 46 210 47 155 43 >55 W4 47 220 86 12.7 59 15.7 5.4 83 54 92 51 Education Less than high school 231 89 238102 179 65 249 74 134 62 133 79 High school /any college 23.7 3.9 226 4.5 16.7 28 156 29 176 35 144 3.2 *Excludes Asian Americans and Pacific Islanders 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 live currently smoked every day or on some days. s and who reported at the time of survey that they *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. 495% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. of smoking 25 or more cigarettes per day, recent estimates are imprecise and should be interpreted with caution. Quitting Behavior Between 1978 and 1995, the percentage of Asian Americans and Pacific Islanders who have ever smoked 100 cigarettes and have quit smoking increased some- what, NHIS data indicate (Table 23) (NCHS, public use data tapes, 1978-1995). The prevalence of cessation among women increased from 1987-1988 to 1994-1995, but no consistent pattern was observed among men. During each survey period, the prevalence of cessation was higher among Asian Americans and Pacific Island- ers 55 years of age and older than it was among their younger counterparts (Table 23). Data from the NCI Supplement of the 1992-1993 CPS indicate that among Asian Americans and Pacific Islanders aged 18 years and older who were daily smok- ers one year before the survey, 57.8 percent reported that they were still smoking daily and that they had not tried quitting for at least one day during the previous year (Table 4). Another 32.0 percent had tried quitting for at least one day, 4.8 percent were occasional smokers (Le., smoked only on some days), 2.5 percent had not smoked for the past 1-90 days, and 2.9 percent had not smoked for the past 91-364 days. Among current smokers, Asian Americans and Pacific Islanders were slightly more likely than whites to report trying to quit for at least a day dur- ing the previous year. Women of Reproductive Age The prevalence of current smoking among Asian American and Pacific Islander women of reproductive age (18-44 years) has decreased substantially over Patterns of Tobacco Use 57 Surgeon General's Report Table 22. Percentage of adult Asian American and Pacific Islander smokers’ who reported smoking <15, 15-24, or >25 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 % +C % +CI % +CI % +CI % +Cl % x+Cl Total <15 cigarettes 43.3 11.7 53.7 81 536 7.8 604 81 618 94 706 98 15-24 cigarettes 37.0 9.7 353 85 374 74 338 76 371 94 214 8.2 >25 cigarettes 19.7 65 11.0 65 7.0 3.3 3.8 3.9 10 13 8.0 6.5 Gender Men <15 cigarettes 40.1 146 544 94 518 96 592 92 584 11.2 69.1 11.5 15-24 cigarettes 35.8 11.1 362 93 41.2 92 354 86 409 11.2 23.6 10.0 >25 cigarettes 24.1 8.2 94 6.6 70 4.2 5.5 44 0.7 14 73° 74 Women <15 cigarettes 50.4 13.7 51.1 149 644 113 65.8 168 754 11.6 77.3 13.9 15-24 cigarettes 39.6 12.8 32.0 15.2 285 98 268 165 222 11.5 11.5 11.0 >25 cigarettes 10.0 7.7 168 10.1 71 5.1 74 83 23°33 11.2 i111 Age (years) 18-34 <15 cigarettes 42.2 12.2 48.2 104 59.0 11.0 603 10.7 613 13.7 73.2 13.6 15-24 cigarettes 37.3 11.5 405 115 351 105 35.2 105 382 13.7 243 13.2 >25 cigarettes 20.5 8.2 11.3 83 5.9 4.4 45 3.8 0.6 1.1 2.5 3.9 35-54 <15 cigarettes 45.0 17.1 54.9 135 545 10.9 629 13.5 63.6 13.0 65.0 15.2 15-24 cigarettes 35.5 15.0 32.2 13.1 404 110 269 105 349 129 223 118 >25 cigarettes 19.5 90 12.9 81 5.1 4.6 10.1 9.2 16 2.3 12.8 14.0 >55 <15 cigarettes 413 185 67.9 203 41.5 23.2 55.8 185 52.7 39.1 78.0 23.9 15-24 cigarettes 40.9 13.1 26.4 18.4 39.4 25.0 43.3 18.5 47.3 39.1 4.7 93 >25 cigarettes 17.9 14.4 5.7 82 19.1 16.5 0.9 1.8 0.0 0.0 17.3 23.4 Education Less than high school <15 cigarettes 59.6 21.3 66.0 15.2 487 196 729 139 80.2 173 73.8 32.2 15-24 cigarettes 28.6 18.0 233 142 424 198 22.2 133 19.8 17.3 6.2 9.5 >25 cigarettes 11.8 13.2 10.7 98 8.9 95 48 6.0 0.0 0.0 20.0 32.8 High school/any college <15 cigarettes 40.4 124 476 96 530 84 581 98 62.2 114 648 12.0 15-24 cigarettes 394 11.8 393 10.2 394 82 34.7 93 367 114 265 10.7 >25 cigarettes 20.2 74 13.0 8.1 76 42 7.2 5.5 11 1.6 8.7 7.5 “Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers included persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers included persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495%. confidence interval. ‘Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 38 = Chapter 2 Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 23. Percentage of adult Asian American and Pacific Islander ever smokers who have quit,* overall and by gender, age, and education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980" 1983-1985' 1987-1988t 1990-1991' 1992-1993t 1994-1995 Characteristic % +c % +ClI % +Cl % +ClI G +CI % +CI Total 399 65 384 65 412 57 490 53 455 65 483 7.2 Gender Men 412 61 342 78 427 69 472 64 422 74 433 87 Women 36.9 140 496 10.2 372 96 554 101 55.0 139 62.2 128 Age (years) 18-34 345 94 258 75 313 7.7 £4341 76 30.7 96 285 10.9 35-54 357 135 455 88 463 80 553 95 441 92 555 101 >55 594 106 489 165 581149 605 110 769 13.2 70.2 14.9 Education Less than high school 37.0 18.7 46.1 17.1 30.1 15.3 37.7 133 504 181 50.3 21.9 High school/any college 452 72 392 73 467 64 548 65 482 73 53.7 8.2 *Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever smokers include current and former smokers. 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 195% confidence interval. 'Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. time, from 16.0 percent in 1978-1980 to 5.7 percent in 1994-1995, NHIS data indicate (Table 24) (NCHS, pub- lic use data tapes, 1978-1995). Overall, the greatest change occurred between 1978 and 1985, when the prevalence of current smoking declined by approxi- mately 50 percent. Since 1985, declines in smoking prevalence have slowed. Recent birth certificate data from U.S. final natality statistics indicate that 3.4 percent of Asian American and Pacific Islander mothers smoked dur- ing pregnancy (Table 6). Smoking rates for pregnant Asian American and Pacific Islander women are gen- erally low—between 0.8 and 5.2 percent for Chinese, Japanese, Filipino, and “other” Asian Americans or Pacific Islanders. Hawaiian mothers, however, havea relatively high smoking rate (15.9 percent). Ventura and colleagues (1995) reported that 3 percent of foreign-born Asian American and Pacific Islander mothers were reported as smokers, compared with 13 percent of their United States-born counterparts. Data on tobacco use among these mothers (except Hawai- ians) may be skewed because California and New York do not report this information, and together these states account for nearly half of births in each Asian Ameri- can and Pacific Islander subgroup (Ventura et al. 1996). Young People Cigarette Smoking Data from MTF surveys—one of the few studies with data on smoking prevalence among Asian Ameri- can and Pacific Islander youths—show that these youths have a lower prevalence of smoking than their counterparts in all other racial/ethnic groups except African Americans (Table 7). According to the 1990- 1994 MTF data on male high school seniors, the prevalence of smoking was 11.6 percent among Afri- can Americans, 20.6 percent among Asian Americans and Pacific Islanders, 28.5 percent among Hispanics, 33.4 percent among whites, and 41.1 percent among Patterns of Tobacco Use 59 Surgeon General's Report Table 24. Percentage of adult Asian American and Pacific Islander women of reproductive age who reported being current cigarette smokers,* overall and by education, National Health Interview Surveys, United States, 1978-1995 aggregate data 1978-1980' 1983-1985' 1987-1988' 1990-1991* 1992-1993 1994-1995" Characteristic % +cr % +Cl % x+CI % +CI % +Cl % +Cl Total 16.0 6.7 8.2 3.3 8.8 2.7 6.0 2.4 6.6 2.8 5.7 3.0 Education$ Less than high school 15.0 26.4 7.0 7.3 9.8 8.0 14.1 9.1 3.5 4.0 23 4.6 High school/any college 154 69 8.6 3.4 96 3.4 6.1 3.1 3.7 3.1 5.8 3.5 *Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. 1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. American Indians and Alaska Natives. Data on female high school seniors show that the prevalence of smoking was 8.6 percent among African Americans, 13.8 percent among Asian Americans and Pacific Is- landers, 19.2 percent among Hispanics, 33.1 percent among whites, and 39.4 percent among American In- dians and Alaska Natives. As reported by Bachman and colleagues (1991a), during 1985-1989, patterns of daily smoking were similar, with prevalence estimates being lowest among African Americans and Asian Americans and Pacific Islanders. Among Asian American and Pacific Islander high school seniors, 4.4 percent of males and 4.5 percent of females reported smoking one-half pack or more per day. In 1993, Wiecha (1996) surveyed public school students from two middle schools and two high schools in Worcester, Massachusetts. The self- administered questionnaire used items from CDC’s YRBS; every question was written in English, Vietnamese, and Spanish. Vietnamese males were as likely to report cigarette smoking (27.9 percent) as were white males (28.3 percent). The prevalence of ciga- rette smoking among Vietnamese females (3.7 percent) was lower than among African American (15.1 per- cent), Hispanic (29.7 percent), and white (30.6 percent) females. Length of time in the United States was re- 60 Chapter 2 lated to smoking prevalence for males aged 17 years and older: cigarette smoking prevalence was 7.7 per- cent among those who had been in the United States for at least six years and 45.2 percent for those who had been in the United States for less than six years. Smokeless Tobacco Use Wiecha (1996) also queried Worcester students about their use of smokeless tobacco products. The prevalence of previous-month use among males was 12.0 percent for Vietnamese, 10.3 percent for African Americans, 10.8 percent for Hispanics, and 20.5 per- cent for whites. Previous-month use among females was 3.6 percent for Vietnamese, 3.2 percent for Afri- can Americans, 1.9 percent for Hispanics, and 2.7 per- cent for whites. Small sample sizes limit the precision of some of these estimates. State and Local Smoking Estimates Among the diverse subgroups of Asian Ameri- cans and Pacific Islanders, wide variations in lifestyles, health behaviors, and health practices are evident. State and local survey data illustrate the distinct varia- tions in cigarette smoking patterns and behaviors among these ethnic subgroups (Klatsky and Armstrong 1991; CDC 1992c; Blaisdell 1993; McPhee et al. 1993; McPhee et al. 1995; Wewers et al. 1995; Jenkins et al. 1997b). Although prevalence estimates from national surveys indicate that the smoking preva- lence among Asian Americans and Pacific Islanders is lower than the prevalence of smoking in all other racial/ethnic groups and in the overall U.S. popula- tion, state and local surveys show that these estimates vary dramatically between racial/ethnic subgroups of Asian Americans and Pacific Islanders. Racial /ethnic subgroup-specific information on smoking behaviors is needed because broad groupings of these many dis- tinct racial/ethnic groups mask important differences. To characterize smoking and other risk behav- iors more fully for program planning efforts at the lo- cal level, the California State Department of Health Services and two California agencies—Asian Health Services and the University of California, San Fran- cisco, Vietnamese Health Promotion Project—adapted versions of the CDC’s Behavioral Risk Factor Surveys for use with Chinese and Vietnamese residents. The questionnaires were modified for cultural appropri- ateness and translated into Chinese or Vietnamese. The Chinese-language survey included face-to-face interviews with 296 Chinese adults in Oakland, Cali- fornia, between June 1989 and February 1990. In the Vietnamese-language survey, telephone interviews were conducted with 1,011 Vietnamese adults during February and March 1991 (CDC 1992b). Among both Chinese and Vietnamese respondents, men were more likely than women to be current smokers. The high- est smoking prevalence was among men aged 25-44 years, and the prevalence of smoking was lower among men with higher levels of education (Table 25) (CDC 1992b). The mean number of cigarettes smoked per day by smokers was 15.9 among Chinese men, 11.0 among Vietnamese women, and 10.1 among Vietnam- ese men. This number declined with older age and increasing levels of education and income. (Data on Chinese women are unavailable because the number of Chinese women who smoked was too small for analysis.) These surveys also measured acculturation by using several proxy variables, including the percent- age of lifetime spent in the United States, fluency in English, and date of immigration. Among Chinese men, the average number of cigarettes smoked per day increased as the percentage of their lifetime spent in the United States increased (Table 25). Among Viet- namese respondents, the prevalence of smoking was higher among men who immigrated in 1981 or later and who were not fluent in English. Tobacco Use Among U.S. Racial/Ethnic Minority Groups In a more recent statewide telephone survey of 32,125 California households, Burns and Pierce (1992) found that overall, the prevalence of smoking was lower among Asian Americans and Pacific Islanders than among whites, African Americans, and Hispan- ics. This trend was evident among both men and women. Because the survey was conducted only in English or Spanish, Asian Americans and Pacific Is- landers with limited English fluency were unable to participate. This exclusion of recent immigrants and those with the lowest levels of acculturation may have produced a biased estimate of the prevalence of ciga- rette smoking among California’s Asian Americans and Pacific Islanders. In assessing the smoking preva- lence for several racial/ethnic subgroups, Burns and Pierce (1992) found that Chinese reported the lowest prevalence of smoking (11.7 percent), whereas Kore- ans reported the highest prevalence (23.5 percent) (Table 26). Men in all racial/ethnic subgroups were substantially more likely than women to smoke ciga- rettes. For men, the prevalence of smoking was high- est among Koreans (35.8 percent) and lowest among Chinese (19.1 percent). The prevalence of smoking was highest among men aged 25-44 years. Smoking preva- lence declined substantially with increasing education across all racial/ethnic subgroups of men except Japa- nese men. For women, the prevalence of smoking was highest among Japanese (14.9 percent) and Koreans (13.6 percent) and lowest among Chinese (4.7 percent). Smoking prevalence declined with increasing level of education across all racial/ethnic subgroups of women except Chinese. Ina 1978-1985 survey of 13,031 persons of Asian ancestry enrolled in the Oakland, California, Kaiser Permanente Medical Care Program, the prevalence of cigarette smoking varied significantly by Asian sub- group for both men and women (Klatsky and Armstrong 1991). Among men, the prevalence of ciga- rette smoking was highest among Filipinos (32.9 per- cent) and lowest among Chinese (16.2 percent) (Table 27). Among women, the prevalence of smoking was highest among Japanese (18.6 percent) and lowest among Chinese (7.3 percent). Japanese men and women were more likely to smoke one or more packs of cigarettes per day than were their counterparts in other racial/ethnic groups. During 1989, newly arrived Southeast Asian im- migrants were surveyed by the Health Department in King County, Washington, regarding health problems and health risk behaviors (CDC 1992c). Investigators analyzed medical interview records for 274 Vietnam- ese, 147 Laotian, and 112 Cambodian immigrants and found that the smoking prevalence was substantially Patterns of Tobacco Use 61 Surgeon General's Report Table 25. Percentage of Chinese and Vietnamese men who reported they smoke* and the number of cigarettes they smoke per day, by age, education, annual household income, and level of acculturation, Behavioral Risk Factor Surveillance System, California, 1990 and 1991 aggregate data Chinese Vietnamese Characteristic % +CI* cigarettes +CI %e Mean no. +CI cigarettes +Cl Mean no. Age (years) 1-24 t t 25-44 38.5 15.3 45-64 28.1 15.6 265 24.4 12.6 Education Eighth grade or less 30.2 12.4 Some high school 45.5 20.9 High school graduate 28.6 19.4 Some college 0.0 ¢ College or more 20.0 17.5 Annual household income <$10,000 25.5 12.0 $10,000-$24,999 32.1 12.6 $25,000-$50,000 20.0 22.4 > $50,000 t t Acculturation <25% of lifetime in United States 29.8 9.8 225% of lifetime in United States 26.2 13.3 Fluent in English? 1 1 Not fluent in English® 31.8 8.8 Immigration before 1981 NA NA Immigration in 1981 or later NA NA t t 12.3 8.5 10.0 6.5 12.6 9.1 42.4 5.3 10.3 1.3 22.6 12.4 27.4 75 9.9 1.7 15.4 7.5 23.3 15.2 7.3 3.0 15.7 5.5 36.6 11.2 11.9 2.9 11.2 45 39.6 8.3 10.6 1.7 28.0 28.4 40.4 12.8 8.8 24 0.0 t 32.9 7.3 9.9 2.1 10.0 t 26.8 7.7 9.1 27 95 3.9 38.7 11.1 10.3 21 14.7 27 29.9 7.2 10.1 2.0 55.0 t 36.9 7.8 10.1 1.9 t t 29.5 10.1 8.3 3.3 13.0 3.7 NA NA NA NA 22.3 15.9 NA NA NA NA t t 29.7 7.6 10.7 2.6 13.3 3.1 36.6 4.6 10.0 1d NA NA 32.2 5.3 10.5 1.5 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. *Numbers too small for analysis. SSelf-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 1992c). 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; 62 Chapter 2 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 27), which was higher than that among Filipi- nos, Japanese, and whites (Blaisdell 1993). Tobacco Use Among U.S. Racial/Ethnic Minority 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 (%) Filipinos (%) Japanese (%) Koreans (%) —_All Asians (%) Total 11.7 15.9 17.4 23.5 15.9 Age (years) 18-24 9.7 12.2 19.7 26.9 14.6 25-44 12.4 21.0 20.3 26.1 18.1 45-64 11.4 14.4 16.8 16.2 15.3 265 11.4 6.6 9.9 23.2 8.9 Education Less than high school 17.6 19.2 23.4 38.1 21.4 High school 16.7 20.3 21.5 21.3 19.4 Some college 11.2 15.2 16.2 25.3 15.2 College 6.6 11.2 12.3 19.1 10.5 Men Total 19.1 24.0 20.1 35.8 23.5 Age (years) 18-24 13.0 19.1 17.2 34.3 19.0 25-44 20.9 29,2 24.7 44.1 27.1 45-64 19.9 25.8 22.1 22.6 24.0 265 19.8 10.6 11.1 60.6 14.0 Education Less than high school 35.4 32.1 18.4 70.6 36.9 High school 26.3 27.6 28.7 35.3 28.3 Some college 18.1 21.5 19.2 32.4 20.9 College 9.8 18.9 16.5 31.0 15.6 Women Total 4.7 8.9 14.9 13.6 8.9 Age (years) 18-24 5.8 4.0 22.9 19.9 9.5 25-44 5.5 14.6 16.3 13.9 10.4 45-64 2.5 5.] 13.4 9.9 7.4 265 2.6 3.4 8.3 NA 3.8 Education Less than high school 1.7 11.6 28.8 20.9 9.4 High school 9.8 12.7 17.5 14.4 12.6 Some college 4.8 8.7 13.4 19.4 9.5 College 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. Patterns of Tobacco Use 63 Surgeon General’s Report 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 adults Sources Location/Year Characteristics Total Men Women Klatsky and California, Current smokers Armstrong 1978-1985 Chinese NA 16.2 7.3 1991 Filipino NA 32.9 11.4 Japanese NA 22.7 18.6 Other Asians NA 30.9 12.6 Persons who smoke 21 pack/day Chinese NA 4.1 1.3 Filipino NA 7.1 1.7 Japanese NA 8.2 4.6 Other Asians NA 6.7 1.6 CDC 1992c Washington State, Southeast Asians, by 1989 age (years) 18-29 17.6 29.5 3.0 30-39 26.3 53.7 5.6 40-59 26.6 54.5 8.3 260 28.9 55.9 7.1 Total 23.1 42.5 5.7 Blaisdell 1993 Hawaii, 1975-1980 Pure Native Hawaiians NA 61.1 NA Hawaii, 1975-1980 Part Native Hawalians NA 56.3 NA Hawaii, 1985 Native Hawaiians NA 42 34 Hawaii, 1989 Native Hawaiians 28.2 NA NA McPhee et al. San Francisco and Vietnamese adults 1993 Alameda Counties, 1987 NA 56 9 California, 1989 NA 45 2 1987, 1989 McPhee et al. Santa Clara County, Vietnamese men 1995 California, 1990 NA 36 NA Wewers et al. Franklin County, Cambodians 20.6* 34.0 6.6 1995 Ohio, 1992 (30.3)" (38.8) (21.5) Laotians 27.8 45.6 4.2 (32.9) (48.2) (10.8) Vietnamese 27.6 43.3 6.0 (29.0) (43.3) (9.3) CDC 1997a Alameda County, Korean adults 21 39 6 California, 1994-1995 Jenkins et al. San Francisco and Vietnamese men NA 36.1 NA 1997b Alameda Counties, California, 1990 Jenkins et al. Houston, Texas Vietnamese men 1997b 1990, 1992 1990 NA 39.6 NA 1992 NA 40.9 NA *Figures not in parentheses are from self-report. Figures in parentheses represent cotinine-adjusted prevalences. Persons whose saliva cotinine levels were > 14 ng/mL were considered to be smokers. NA = data not available. 64 Chapter 2 Data collected from several surveys (conducted in 1987, 1989, 1990, and 1992) 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 1989 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 (13.2). 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 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 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 Patterns of Tobacco Use 65 Surgeon General's Report and a relatively low prevalence among women (Weng et al. 1987; Liet 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 schoo] 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 schoo] 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: (1) 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 66 = Chapter 2 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 1982-1984 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 1989), 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 by gender, age, and education, National Health Interview Surveys, aggregate data Tobacco Use Among U.S. Racial/Ethnic Minority Groups smokers,* overall and United States, 1978-1995 1978-1980' 1983-1985 1987-1988t 1990-1991' 1992-1993" 1994-1995' Characteristic % +CR % +Cl % +Cl % +Cl % +tCl % +C1 Total 30.1 19 256 16 236 14 215 14 205 16 189 0.7 Gender Men 376 30 316 29 296 23 278 23 25.9 26 22.9 24 Women 33 20 204 19 184 15 159 16 155 19 15.1 17 Age (years) 18-34 323 27 258 22 236 19 211 19 210 24 198 22 35-54 30.4 2.7 284 32 263 23 257 22 234 27 198 25 >55 29 28 #199 42 182 28 137 26 124 37 143 3.5 Education’ Less than high school 33.4 35 280 26 261 23 229 24 216 27 202 24 High school 52 39 281 38 278 30 276 2.7 242 33 216 34 Some college 327 65 24 40 203 32 199 31 195 42 21.0 41 College 171 66 204 61 13.9 30 161 34 13.1 38 8.7 3.1 *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. 11978, 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. 195% 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. 1990), the slightly different target populations in the HHANES and in the NHIS—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 28). This pat- tern also was observed ina 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 Patterns of Tobacco Use 67 Surgeon General's Report Table 29. Percentage of adult Hispanic smokers* who reported smoking <15, 15-24, or >25 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" 1992-1993t 1994-1995" Characteristic % +cH % +ClI % +Cl % +CT % +ClI % +CI Total <15 cigarettes 56.0 45 55.6 4.1 58.3 3.2 64.5 3.3 72.7 3.8 65.0 4.1 15-24 cigarettes 30.7. 43 31.3 3.0 30.9 3.1 29.3 3.2 21.2 3.5 27.3 3.9 >25 cigarettes 13.3. 2.4 13.2 3.0 10.9 2.1 6.2 1.4 6.2 2.0 7.7 2.0 Gender Men <15 cigarettes 52.4 5.9 52.5 5.5 54.9 4.6 62.5 44 71.8 5.2 62.4 5.1 15-24 cigarettes 32.6 5.0 33.0 4.2 32.1 4.6 29.8 4.2 20.7 45 29.9 4.7 >25 cigarettes 15.0 3.6 144 3.9 13.0 2.9 7.7 21 7.6 3.0 7.6 3.7 Women <15 cigarettes 61.4 5.2 59.8 4.9 63.0 4.2 67.6 4.7 74.1 5.3 68.8 5.6 15-24 cigarettes 27.8 5.3 28.8 5.1 29.1 4.2 28.6 4.5 22.0 5.1 23.5 5.1 >25 cigarettes 10.7 3.6 115 3.9 7.9 23 3.8 1.5 3.9 2.0 7.7 3.1 Age (years) 18-34 <15 cigarettes 61.7 6.2 61.4 53 61.6 4.8 69.8 43 78.1 4.7 70.2 6.3 15-24 cigarettes 28.5 5.5 29.2 45 29.3 48 27.8 4.1 173 42 25.1 6.1 >25 cigarettes 99 2.6 94 3.7 91 2.7 2.4 1.1 46 24 4.7 2.5 35-54 <15 cigarettes 49.0 63 445 6.5 56.0 5.0 59.7 49 66.5 6.7 60.4 6.2 15-24 cigarettes 33.4 6.7 35.1 5.0 31.7 4.7 29.6 4.6 25.2 6.1 28.6 5.9 >25 cigarettes 17.7 4.5 20.4 49 12.3 3.5 10.6 2.9 8.2 3.9 11.0 3.8 >55 <15 cigarettes 496 8.6 61.2 9.7 50.8 7.7 55.2 9.7 69.8 13.5 56.2 11.5 15-24 cigarettes 33.3 83 29.2 8.7 34.8 7.5 36.0 10.2 24.6 13.1 32.9 10.5 >25 cigarettes 17.1 7.6 96 58 144 59 8.5 5.5 5.6 45 10.9 7.0 *For 1978-1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. +1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 495% confidence interval. age-adjusted (to the 1980 U.S. population) cigarette smoking prevalence; 19 percent of Mexican-oriented women and 28 percent of U.S.-oriented women were current cigarette smokers (Haynes et al. 1990). The unadjusted prevalence of cigarette smoking among US. women aged 18 years and older in 1983 was 29.5 per- cent (CDC 1994c). No clear relationship was observed among Mexican American men (Haynes et al. 1990). 68 Chapter 2 Navarro (1996) used data from the 1990 Califor- nia Tobacco Survey to study level of acculturation in Hispanics (most of whom were of Mexican origin). Level of acculturation was defined based on the lan- guage spoken in the home: persons from English- speaking homes were classified as having a high level of acculturation, and persons from Spanish-speaking homes were classified as having a low level of Table 29. Continued Tobacco Use Among US. Racial/Ethnic Minority Groups 1978-1980* 1983-1985' 1987-1988t 1990-1991 1992-1993" 1994-1995" Characteristic % +CH % ++Cl % +Cl % +C1 % ++4Cl % +CI Education$ Less than high school <15 cigarettes 554 5.0 541 53 59.2 5.1 66.2 5.2 71.1 66 635 7.2 15-24 cigarettes 299 56. 33.7 59 303 47 276 5.1 23.1 61 30.0 7.2 >25 cigarettes 147 43 123 47 105 33 6.2 23 5.8 - 3.6 6.5 3.4 High school <15 cigarettes 534 99 339 75 539 66 609 60 705 72 61.3 7.3 15-24 cigarettes 34.7 94 33.2 71 325 66 326 57 254 7.0 28.7 6.6 >25 cigarettes 11.9 5.9 129 44 136 45 6.5 2.6 42 3.0 10.1 44 Some college <15 cigarettes 50.6 10.3 505 11.8 541 92 S551 86 708 97 555 99 15-24 cigarettes 37.3 10.8 241 96 319 82 351 84 21.0 89 36.1 10.1 >25 cigarettes 12.2 75 255 99 140 64 98 5.3 8.2 5.1 8.4 5.1 College <15 cigarettes 55.6 22.1 50.0 17.1 55.3 11.7 644 11.3 75.8 11.7 71.6 15.7 15-24 cigarettes 17.8 15.2 364 135 296 106 27.1 103 167 10.3 17.9 128 >25 cigarettes 26.7 21.7 13.6 10.1 15.0 9.3 8.5 59 7.5 63 105 10.7 SIncludes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. acculturation. The data were analyzed by gender and for three levels of educational attainment (<12, 12, and >12 years). Among men, smoking prevalence varied for those with <12 and 12 years of education; smoking prevalence was highest among whites, intermediate among Hispanics of high acculturation, and lowest among Hispanics of low acculturation. This pattern also existed for women, but in all three of the educa- tion categories. Additionally, in a multivariate analy- sis that controlled for age, gender, educational attainment, and Mexican origin, Hispanics witha 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 1996), 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, 1978-1995). 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 Surgeon General’s Report 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 NCI 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 1-90 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 1978-1980' 1983-1985' 1987-1988 1990-1991* 1992-1993t 1994-1995" Characteristic % +c % +Cl % +C1 % +C1 % +Cl % +CI Total 35.0 28 393 28 428 24 441 26 442 3.1 462 3.2 Gender Men 355 34 405 41 4430 33 430 36 458 41 482 43 Women 342 43 376 43 425 34 456 35 416 45 43.1 45 Age (years) 18-34 279 42 326 32 337 36 343 35 314 43 325 49 35-54 372 39 392 52 449 3.7 453 36 464 47 496 4.9 >55 510 55 372 76 604 50 671 56 703 69 681 64 Education$§ Less than high school 30.5 36 37.7 40 433 36 455 44 428 50 476 5.1 High school 457 71 400 60 412 46 419 44 442 60 445 62 Some college 385 98 47.8 69 55.0 63 526 6.1 52.8 88 49.1 7.6 College 594 142 522103 592 72 566 73 640 89 711 91 *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. 11978, 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. 495% confidence interval. ‘Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. 70 Chapter 2 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 varies 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 women of reproductive age were less likely than their white counterparts to smoke cigarettes at each of the repro- ductive stages (interconception, pregnancy, lactation, and postpartum). Tobacco Use Among US. Racial/Ethnic Minority Groups The National Survey of Family Growth collected data in 1982 and 1988 on the smoking behavior of females 15-44 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 (Pamuk and Mosher 1992; Chandra 1995). More recent data from US. 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 1987-1988t 1990-1991 1992-1993' 1994-1995" Characteristic % +CH % +CI % +CI % +CI % +CI % +CI 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 Education$§ Less than high school 29.2 43 24.4 4.4 23.5 4.0 17.6 3.7 17.0 44 17.0 3.7 High school 21.3 5.6 27.6 5.3 24.1 3.7 214 3.6 25.1 5.3 21.4 4.7 Some college 12.9 7.5 21.5 6.7 15.9 46 19.5 4.2 17.0 6.1 16.5 5.23 College 17.3. 12.0 16.7 8.3 12.7 4.7 15.2 5.0 12.9 58 5.1 4.1 *For 1978-1991, current cigarette smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992-1995, current smokers include women aged 18-44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked every day or on some days. +1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined; 1990 and 199] data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined. 95% confidence interval. “Includes persons aged 25 years and older. Source: National Center for Health Statistics, public use data tapes, 1978-1995. Patterns of Tobacco Use 71 Surgeon General's Report 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 18—44 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 72 Chapter 2 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. 1988) although limited (Mont- gomery and Carter-Pokras 1993) 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) (USDHHS, 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 Latino 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. 1991b). In addition, 11.6 percent of Mexican Ameri- can males, 13.3 percent of Puerto Rican and Latino 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. 1991b). 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 Latino males over the entire survey period (Bachman et al. 1991b). 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. Ina 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. 1994). Also, acculturation may influence smoking behavior. In a study of sixth and seventh graders in Dade County, Florida, Vega and col- leagues (1993) found that cigarette smoking was 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- Tobacco Use Among U.S. Racial/Ethnic Minority Groups 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). Asimilar 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- year 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, ethnicity, gender, paren- tal educational level, region of the country, and other risk behaviors. Patterns of Tobacco Use 73 Surgeon General's Report 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 NCI (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 rt Chapter 2 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 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 (1958-1967) showing the highest peak (Figure 8). Tobacco Use Among U.S. Racial/Ethnic Minority Groups 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 1950s, 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* 80> High school 70,4 education 60- Vv - é 5054 5 40-4 zo & 30-4 207 10-4 0 1910 1920 1930 1940 1950 1960 1970 1980 Year Birth cohorts: mms 1908-1917 ----- 1918-1927 1928-1937 805 Less than a high 79- school education,. 60-4 504 40- 30- 204 10- 0 To 1910 1920 1930 1940 1950 1960 1970 1980 Year Percentage ecee 1938-1947 mmm 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. Patterns of Tobacco Use 75 Surgeon General'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* 804 High school 70 education 60 50-4 40 30 20-4 10- “ Percentage 0 T —T 1910 1920 1930 1940 1950 1960 1970 1980 Year Birth cohorts: mmm 1918-1917 ~---- 1918-1927 1928-1937 80> Less than a high 70+ school education 60- 50- 404 30-4 20- 10- 0 ’ ‘1 T t— | 1910 1920 1930 1940 1950 1960 1970 1980 Year Percentage 1938-1947 meme 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 Chapter 2 Tobacco Use Among U.S. Racial/Ethnic 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> High school 80> Less than a poets 70 education 704 high school wf 60-1 ee ges 60- education uv uv ge 504 B® 50- 5 40- 5 40-4 2 30 £ 30- 20- 20- 10 10-— 0 T 0 T 7 T I T 1910 1920 1930 1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 Year Year Birth cohorts: ws 1908-1917 ---++ =1918-1927 1928-1937 sere 1938-1947 mem 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* 80> High school 807 Less than a high 704 education 704 school education 60 4 60- ov v ep 50-4 % 50 & & 5 40+ & 40+ = g 2 30- 2 30 20-4 20- 10- 10- 0 T 0 T ri pat T T 1910 1920 1930 1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 Year Year Birth cohorts: mee 1918-1917 ----- 1918-1927 1928-1937 e=e== 1938-1947 mmm 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. Patterns of Tobacco Use 77