Surgeon General's Report ¢ They may be unable to afford the high cost of some group interventions. ¢ They may perceive such efforts to be inconvenient (e.g., requiring transportation and child care) and time consuming. ¢ They may prefer to deal with personal problems alone or in the family rather than to seek profes- sional or other help outside of the home. ¢ They may lack access to linguistically appropriate services. ¢ They may distrust researchers and health care pro- viders who are not members of their racial/ethnic groups or who are unaware of their culture and behavioral expectations and traditions. * Ifthey have physically demanding jobs or heavy caregiving responsibilities, they may be too ex- hausted to attend program meetings. The difficulty in obtaining enough individuals to participate in smoking cessation groups or even to continue their participation after a few initial sessions has been a problem for many ethnic smoking cessa- tion programs, including those targeting Hispanics in San Francisco, California (Pérez-Stable et al. 1993) and Queens, New York (Nevid and Javier 1992), African Americans in Atlanta, Georgia (Ahluwalia and McNagny 1993), and Chinese restaurant workers in Boston, Massachusetts (Betty Lee Hawks, personal communication, 1993). As a result, many programs have stopped using cessation groups as a possible in- tervention strategy and as a way to deliver informa- tion personally. As an alternative to group approaches, interve- nors in San Francisco began offering personal consulta- tion over the telephone and face-to-face (Pérez-Stable et al. 1993). Trained individuals provide information and support to smokers who want more information than is provided in a self-help manual. This approach (labeled consultas, or personal consultations), although demanding in terms of time and personnel, is consid- ered culturally appropriate among Hispanics, who tra- ditionally value personal attention. This alternative also allows telephone advisors to tailor the information to each person’s needs. Another alternative program, which provides individual counseling to Southeast Asian smokers in their homes rather than in clinics, has been well received in Long Beach, California (Mary Anne Foo, personal communication, 1994). 278 Chapter 5 Community Approaches Most community smoking cessation programs targeting members of racial/ethnic groups have been conducted in fairly large urban communities and have used self-help materials together with mass media and outreach workers. Ina recent overview of community- wide programs targeting cardiovascular disease, Winkleby (1994) noted the need to conduct focused studies with populations that have not been reached successfully in the past with large-scale projects, as is the case with members of the four racial/ethnic minority groups considered in this report. Because so many racial/ethnic groups place a high value on the family and on the authority of older relatives (Sabogal et al. 1987), some community pro- grams have employed family-centered interventions, working under the assumption that a smoker’s chil- dren and other relatives can effectively intervene and that parents can be a child’s best source of informa- tion regarding smoking-prevention programs. In Boston, the South Cove Community Health Center involved more than 350 Chinese elementary school children in a poster contest to depict the hazards of tobacco. Many of these posters depicted the father smoking at home and motivated children to discuss cigarette smoking in their homes (Esther Lee, personal communication, 1993). In a Vietnamese Saturday lan- guage school program in Sacramento, California, youths have been mobilized to carry antismoking messages to their families and to encourage them to avoid using tobacco (Debra Oto-Kent, personal com- munication, 1993). In another project, Asian American and Pacific Islander children were asked to compete in a “letter to my parents” writing contest, asking them not to smoke (Irene Linayao-Putman, personal commu- nication, 1993). Anecdotal information about this and similar programs indicates that the children enjoy these activities and that their parents are seldom discomforted by the letters, particularly when they perceive the pro- grams to be sanctioned by the school system. Never- theless, the usefulness of such an approach may be limited in families that maintain strict patriarchal or ma- triarchal structures in which children’s interventions may be perceived as a lack of respect toward adults or as a challenge to the parents’ authority. As mentioned previously, large-scale community projects generally have used multiple strategies and channels to disseminate smoking cessation informa- tion and to motivate smokers to quit. Asample of pro- grams targeting members of the four racial/ethnic groups is presented below. This listing represents the variety of community approaches developed to help racial/ethnic smokers quit but should not necessarily be perceived as a list of model programs. Stanford Five-City Multifactor Risk Reduction Project Researchers at Stanford University developed the Stanford Five-City Multifactor Risk Reduction Project to examine cardiovascular disease and related risk fac- tors over a nine-year period in five small communi- ties in northern California. The project was based on behavior-change models and social-learning theory (Farquhar et al. 1985, 1990) and used television, mass- distributed print media, direct mailings, contests, cor- respondence courses, and school-based programs for youths. In the communities with very high concen- trations of Hispanics, Spanish-language radio and newspaper columns were chosen as the primary meth- ods of disseminating information. The decline of smoking rates was 13 percent greater in the treatment cities than in the control cities (Farquhar et al. 1990). Although researchers observed no differences in the proportion of experimental or control respondents who reported ever receiving advice from physicians on quitting smoking, whites (51.1 percent) were much more likely to report having received this advice than Hispanics (32.6 percent) (Frank et al. 1991). Researchers found that the project was fairly suc- cessful in promoting the use of self-help smoking ces- sation materials among whites. A greater proportion of smokers in the experimental communities (22.1 per- cent) than in the control communities (15.0 percent) reported using smoking cessation materials in the 12 months before the interview (Jackson et al. 1991). In the experimental communities, Hispanics and whites did not differ in their reported use of materials to re- duce cardiovascular risk. When asked about their use of tobacco control materials, 31.0 percent of Hispanic women and no Hispanic men reported using smok- ing cessation print materials during the previous 12 months, compared with 21.3 percent of white women and 13.7 percent of white men. The project was less effective in promoting smok- ing cessation programs; no Hispanic smokers reported using such programs, compared with 6.3 percent of white smokers. More recent analyses of and comment onrisk-reduction data from this and other community- based interventions suggest that such interventions can achieve more positive results by being coupled with policy initiatives, developing more focused studies, and broadening evaluation concepts (Winkleby et al. 1992; Fortmann et al. 1993; Winkleby 1994). Tobacco Use Among U.S. Racial/Ethnic Minority Groups Programa Latino Para Dejar de Fumar (Hispanic Program to Quit Smoking) The Programa Latino Para Dejar de Fumar was a community-based, culturally appropriate intervention designed specifically for Hispanic smokers in San Fran- cisco (Pérez-Stable et al. 1993; Marin and Pérez-Stable 1995). Funded by the NCI for 1985-1995, the program was operated jointly by the University of California, San Francisco, and the University of San Francisco. To motivate Hispanic smokers to quit and to inform them of strategies to stop smoking, the program used mass media (primarily radio and television public service announcements), outreach efforts, and distribution of the Guia. Program planners developed the various versions of the Guia, implemented the consultas ap- proach to deal with individual needs for counseling, and used a periodic raffle to reward individuals who quit smoking within a given period of time (Pérez- Stable et al. 1993). Intervention messages were based on research that identified the attitudes, norms, expect- ancies, and values of Hispanic smokers (Marin et al. 1990a,b). The strategies incorporate significant cultural values such as familialism (the normative and behav- ioral influence of relatives) (Sabogal et al. 1987) and simpatia (a social mandate for positive social relation- ships) (Triandis et al. 1984). For example, a key mes- sage of the program was that smokers should quit to protect the health of their children and to avoid set- ting a bad example for children. To incorporate simpatia into the program, planners developed inter- vention materials that emphasized the positive aspects of quitting and avoid confrontational approaches. This latter approach was similar to that used in materials developed for American Indians (American Indian Cancer Control Project 1991). The Programa Latino Para Dejar de Fumar has been evaluated through a number of cross-sectional and longitudinal surveys as well as through smaller scale studies that have examined the effectiveness of specific strategies (Marin et al. 1990c, 1994; Pérez-Stable et al. 1993; Marin and Pérez-Stable 1995). The program has significantly increased Hispanics’ knowledge about the dangers of smoking, awareness of the pro- gram, and participation in the program. Most impor- tant, the program has decreased the prevalence of smoking among Hispanics in San Francisco (Marin and Pérez-Stable 1995). These changes have been observed primarily among the less acculturated Hispanic smok- ers who make up the targeted group. For example, during the first year of the program, 24.9 percent of the less acculturated Hispanics in San Francisco re- ported awareness of the program; two years later, that Tobacco Control and Education Efforts 279 Surgeon General's Report proportion had increased to 48.5 percent (Marin et al. 1990b; Marin and Pérez-Stable 1995). During the first year in which the Guia was available, 23 percent of the less acculturated Hispanic women and 12 percent of the less acculturated Hispanic men in San Francisco reported having a copy. One year later, the propor- tion of the less acculturated Hispanics who reported having a copy of the Guia had increased to 37.7 per- cent of the women and 34.1 percent of the men. Si Puedo (Yes, I Can) Si Puedo was an eight-week smoking cessation program designed specifically for Hispanic smokers in a largely Hispanic area of Queens, New York. The program used the Guia and other print materials, weekly bilingual group meetings, regular telephone calls to offer support to participants, and videotaped vignettes in which Hispanic actors conveyed smok- ing cessation messages. Persons were recruited through mass media advertising, direct mailings to Hispanic physicians and clergy, and fliers posted throughout the community. Most participants were from South America (57 percent); the rest were from the Caribbean (25.4 percent) or Central America (9 percent). Some people participated in all aspects of the program, whereas others used only the self-help materials. Preliminary figures show that 55.6 percent of the participants who took part in all components of the Si Puedo smoking cessation program stopped smoking by the end of the program (Nevid and Javier 1992). In comparison, 21.7 percent of those who used only the self-help materials abstained from smoking. Pathways to Freedom Community Demonstration Project The American Cancer Society (ACS) used the Pathways to Freedom manual and videotape as part of a demonstration project to lower the prevalence of ciga- rette smoking among African Americans (Robinson et al. 1992; Robinson and Sutton, in press). During the first phase (1992-1993), the ACS provided funds to eight of its local units in Long Beach and central Los Angeles, California; Philadelphia, Pennsylvania; Dela- ware; the District of Columbia; Georgia; Kansas; and Texas. The ACS units developed programs to recruit African American smokers to quit smoking using the Pathways to Freedom materials and to expand the ACS’s outreach into African American communities. Many of them planned their projects to coincide with the Great American Smokeout (GAS). In the second phase of the project (1993-1994), the ACS provided funding to seven more local units 280 Chapter 5 in Contra Costa and San Diego Counties, California; Maryland; Nebraska; Chattanooga and Memphis, Ten- nessee; and Utah. Cessation activities expanded to include efforts to mobilize African American commu- nities and to identify more individuals and groups willing to become tobacco control advocates. The process evaluation of the first phase showed that the program was easier to implement in commu- nities with a previous history of community-based outreach efforts (Robert G. Robinson et al., unpub- lished data). Dissemination of the self-help manual was most difficult in multiethnic communities and areas of a city. Most ACS agencies used a variety of distribution channels, including churches, health care organizations, and recreation centers. The program helped the ACS to approach African Americans and to gain support from African American volunteers. Even though the project emphasized self-help approaches, several ACS units incorporated Pathways to Freedom materials into smoking cessation groups conducted in African American communities. The outcome evaluation of the first phase con- sisted of telephone interviews with 763 smokers who returned a screening postcard that was attached to each Pathways to Freedom manual. Respondents reported a favorable impression of the manual and a 10 percent quit rate at 30 days. In addition, smokers who viewed the Pathways to Freedom videotape were significantly more likely than others to accept and use the self-help materials as well as to move from precontemplation to contemplation in the process of changes involved in smoking cessation. Quit Today! A two-part study funded by the NCI will evalu- ate the effectiveness of the Pathways to Freedom manual and videotape when incorporated into a community- based campaign targeting adult African American smokers. In the first phase of the project, the Pathways to Freedom videotape will be distributed communitywide, and paid radio announcements will be aired, encouraging smokers to call the CIS for help. In the second phase of the project, callers to the CIS will be randomly selected to receive either the Path- ways to Freedom manual and smoking cessation coun- seling related to the manual or an NCI manual and standard CIS smoking cessation counseling. Results of this study should produce important information about the effectiveness of targeted self-help smoking cessation materials for African Americans combined with established services such as the CIS. Chicago Lung Association’s Multifaceted Smoking Cessation Intervention In 1985, Warnecke and colleagues (1991) launched a multifaceted smoking cessation interven- tion on behalf of the Chicago Lung Association. Like a number of programs, this intervention used materi- als originally produced for whites to target members of other racial/ethnic minority groups. The program used televised messages on techniques for quitting smoking and avoiding relapse as well as the ALA self- help manual and smoking cessation groups. More than 325,000 smokers in the targeted population viewed televised messages featuring role models who encour- aged them to obtain a self-help manual, Freedom from Smoking in 20 Days, by mail or at one of three loca- tions—a local hardware store, an HMO, or the Chi- cago Lung Association. A total of 9,182 smokers (23 percent of whom were African American) registered to participate in the study and were followed for 24 months. The results showed that African American and white smokers responded differently to various smoking cessation strategies. For example, African Americans were more likely than whites to report see- ing the televised messages on a daily basis and were more likely to recall the messages. However, African Americans were less likely than whites to attend smok- ing cessation groups. As an adjunct to the Chicago Lung Association’s program, Jason and colleagues (1988) studied the ef- fects of a television program in the West Garfield Park neighborhood of Chicago, where 86 percent of the resi- dents were African American. Before the television program aired, individuals who reported smoking were randomly assigned to a control group (91 per- cent were African American) or to an experimental group (96 percent were African American). Members of the control group viewed the program or read the self-help manual at their leisure, whereas members of the experimental group received motivational calls prompting them to view the television program and inviting them to attend smoking cessation meetings at a community health center three times during the 20-day program. Eight percent of the smokers in the experimental group reported quitting at the end of the program, compared with 1 percent of those in the con- trol group. After four months, 20 percent of the smok- ers in the experimental group had quit, compared with 9 percent of those in the control group. Chicago Community-Based Interventions for Low-Income African Americans In conjunction with the smoking cessation television program sponsored by the Chicago Lung Tobacco Use Among U.S. Racial/Ethnic Minority Groups Association, Lacey and colleagues (1991) designed community-based interventions for low-income African Americans living in four subsidized housing projects in Chicago. Residents were trained as lay health advisors to deliver smoking cessation messages to their neighbors. They made weekly home visits during the 20 days in which the television program was aired, and they used reminder cards to support the positive behaviors outlined in the program. A subsample of women in the housing projects watched the televised program and participated in six smok- ing cessation classes, which used a curriculum similar to the one presented in the television program. Health educators gave the women supplemental materials ap- propriate for them and tips on sources of social sup- port for smoking cessation. Classes were held in the housing projects. Of the 235 residents who preregis- tered for the smoking cessation intervention, 141 at- tended at least one class or accepted at least one home visit. Of the 56 women who attended at least one class session, 11 percent quit smoking. About one-half of the 174 residents who registered for the home visita- tion accepted such a visit, but none quit smoking. Focus groups conducted in conjunction with the in- tervention indicated that residents of the housing projects perceived that they were not vulnerable to the negative health consequences of smoking, that smok- ing helped them to cope with stress, and that they had few environmental supports for quitting smoking. Freedom from Smoking® for You and Your Family on TV/Por Su Salud y Su Familia Like the Chicago Lung Association's interven- tion, the Freedom from Smoking® for You and Your Family Project in California featured role models in televised pieces and distributed self-help materials. In 1991, project planners produced special editions of the ALA Freedom from Smoking® for You and Your Family self-help manual and the Guia and placed them ina newspaper insert that was distributed throughout seven English-language television markets—Eureka, Fresno, Los Angeles, Sacramento, Santa Barbara, San Diego, and the San Francisco Bay area—and four Spanish-language television markets—Fresno, Los Angeles, Sacramento, and the San Francisco Bay area. In addition, locally produced television pieces in both English and Spanish were shown for seven days as part of the daily news. These news pieces included interviews with Hispanic and white experts on tobacco-use control and with four local residents who had volunteered to use the self-help materials to quit smoking. The program reached nearly 1.2 million Tobacco Control and Education Efforts 281 Surgeon General's Report smokers (C. Anderson Johnson et al., unpublished data). The newspaper insert was most frequently read by white (22 percent), Asian American and Pacific Is- lander (18 percent), and African American (16 percent) smokers; smaller proportions of English-speaking His- panics (14 percent) and Spanish-speaking Hispanics (10 percent) read the insert. The television pieces were viewed most frequently by Spanish-speaking Hispanics (25 percent), followed by African Americans (14 per- cent), Asian Americans and Pacific Islanders (9 per- cent), whites (9 percent), and English-speaking Hispanics (9 percent). A year after the intervention, 3.1 percent of the people who had read the English- language newspaper insert and had viewed the tele- vision piece were former smokers; this was true among all racial/ethnic minority groups except Spanish- speaking Hispanics. In comparison, 1.5 percent of the people who did not participate in the program were former smokers. By itself, neither the English-language television piece nor the newspaper insert was effec- tive in promoting smoking cessation. Viewers of the Spanish-language television program, which used cul- turally appropriate materials, were more successful; 9 percent of viewers were former smokers at 12 months, compared with 2 percent of smokers who did not view the program. A Su Salud (To Your Health) A Su Salud was a mass media health promotion program conducted from 1985 through 1990 to reduce smoking among Mexican Americans residing along the U.S.-Mexico border in Eagle Pass and Del Rio, Texas (Ramirez and McAlister 1988; Amezcua et al. 1990). This mass media campaign used role models, an ex- tensive media campaign, community volunteers, and behavioral modeling techniques grounded in the prin- ciples of Bandura’s (1977) Social Learning Theory. It was modeled after a similar program implemented in North Karelia, Finland (McAlister et al. 1982; Puska et al. 1987). ASu Salud recruited individuals who wanted to quit smoking, organized focus groups to determine their needs and levels of awareness about tobacco use, and then featured community role models in a series of informational programs that were televised on local Spanish-language stations. The media messages were reinforced through a network of community vol- unteers who personally contacted the targeted popu- lation individually or in small groups. The volunteers delivered calendars with community events and sto- ries about the role models. The program also produced fotonovelas—pictorial stories, presented in a comic-book format, which depicted smoking cessation behaviors. 282 Chapter 5 The program resulted in a modest but notable increase in smoking cessation rates among community mem- bers. Out of the 17 percent of smokers who reported that they had quit smoking, 8 percent were verified (McAlister et al. 1992). University of North Carolina/North Carolina Mutual Quit for Life Guide The Quit for Life program used lay leaders to pro- mote smoking cessation messages. The Quit for Life Guide was based on the ALA’s Freedom from Smok- ing® for You and Your Family Project and targeted poli- cyholders of the predominantly African American North Carolina Mutual Life Insurance Company (Schoenbach et al. 1988). The program was novel in that it was delivered by the company’s life insurance sales agents, who discussed the health consequences of smoking with their customers and provided social sup- port for quitting and avoiding relapse (Orleans et al. 1989). The Quit for Life program was moderately ef- fective in promoting smoking cessation among the targeted low- to middle-income smokers. Over a two-year period, 2,042 smokers enrolled in the program. About 14.9 percent of the participants who received self-help materials, telephone counseling, and agent support quit smoking at 12 months, compared with 14.1 percent of the participants who received just self-help materials and agent support, and 12.3 percent of the control subjects, who received agent support only. Veri- fying these self-reported quit rates was impossible, how- ever, because few respondents agreed to provide saliva samples for a cotinine test, which would have provided biochemical verification (Schoenbach et al. 1988). In an eight-week follow-up study, the Quit for Life program targeted the insurance company’s cor- porate employees in a large urban center. Preliminary results regarding policyholders in one sales district and lasting eight weeks showed that 8 of the 126 African American smokers enrolled in the program (6 percent) were nonsmokers six months after enrollment (Sandra W. Headen et al., unpublished data). Legends Beginning in 1993, the NMA and CDC began co- sponsoring the Legends campaign. Legends is the only national-level, mass media motivational campaign di- rected at African Americans who want to quit smok- ing. The campaign consists primarily of public service television and radio announcements that use famous African American leaders and historic figures, such as Martin Luther King, Jr., and Malcolm X, to motivate smokers to quit. Individuals interested in quitting can request the Pathways to Freedom cessation guide by call- ing a toll-free telephone number; the Legends campaign generated more than 7,500 calls for the Pathways to Free- dom guide within the first 18 months. The NMA has supported the campaign at the local level by promot- ing media and community outreach activities, includ- ing billboard advertisements, in 14 NMA-sponsored “Healthy People 2000” cities across the country. Great American Smokeout GAS is an annual ACS-sponsored event that en- courages smokers to quit. The results of a 1991 Gallup poll indicated that smokers of various racial/ ethnic minority groups may respond favorably to the GAS (CDC 1992). Fewer African Americans and His- panics than whites reported being aware of the Smokeout. However, 25 percent of African Americans and Hispanics who were aware of the GAS reported participating in the project, and 14 percent of those who participated reported that they were not smok- ing cigarettes one to three days after the GAS (CDC 1992). The same poll estimated that during the 1991 GAS, approximately one-third of smokers in the United States participated, either by not smoking or by reduc- ing the number of cigarettes they smoked (CDC 1992). Lieberman Research Inc. (1993) found that 26 percent of smokers from racial/ethnic communities (i.e., African Americans, Asian Americans, Hispanics, and others) participated in the 1993 GAS, compared with only 19 percent of white smokers. In interviews conducted 1 to 10 days after the GAS, however, similar proportions of racial/ethnic group members (18 per- cent) and whites (17 percent) reported that they had quit or that they were smoking less than before the GAS. Suc Khoe La Vang! (Health is Gold!) From 1990 to 1992, Suc Khoe La Vang! (Health is Gold!), the Vietnamese Community Health Promotion Project, conducted media-led smoking reduction cam- paigns targeting Vietnamese men in San Francisco and Alameda Counties and in Santa Clara County, Cali- fornia (McPhee et al. 1993, 1995; Jenkins et al. 1997). Both interventions used materials that were produced in Vietnamese. The programs included antitobacco counteradvertising campaigns that used billboard, print, and television advertisements; published articles in Vietnamese-language newspapers; a videotape that aired on Vietnamese-language television stations; health education materials such as brochures, a quit kit, posters, bumper stickers, and a calendar; a Tobacco Use Among U.S. Racial/Ethnic Minority Groups continuing medical education course on smoking cessation counseling methods for Vietnamese physi- cians; and the distribution of printed “no smoking” signs and ordinances. Unlike the Santa Clara inter- vention, the San Francisco campaign was preceded by a 15-month pilot antitobacco media program and in- cluded a component for students and their families. The evaluation of the programs showed that the Santa Clara intervention did not influence cigarette smoking prevalence or recent quitting status (quitting during the prior two years) (McPhee et al. 1995). How- ever, a program effect was observed in the San Fran- cisco trial, such that the odds of being a smoker were significantly lower and the odds of quitting recently were significantly higher in San Francisco than in a comparison community (Jenkins et al. 1997). The au- thors explained the difference in two ways, the longer duration of exposure to the antitobacco campaign in San Francisco (39 months) than in Santa Clara (24 months) and the added school- and family-based component of the San Francisco campaign. Involvement of Health Care Providers A number of successful smoking cessation ap- proaches use health care providers, primarily physi- cians and dentists, to inform patients about the urgency of quitting smoking and to suggest quitting strategies (Health and Public Policy Committee 1986; Flay et al. 1992; Reid et al. 1992; NCI 1994; Fiore et al. 1996). Al- though this approach may be effective with members of the four racial/ethnic minority groups studied in this report—particularly those groups that exhibit high power distance (i.e., the respect for and deference to authority figures such as physicians, teachers, and older people) (Hofstede 1980)—a number of structural characteristics limit the usefulness of this approach. The most important limitation is that a large propor- tion of members of these racial/ethnic minority groups lack access to primary care providers. This problem has been widely documented among adult members of racial/ethnic groups (Aday et al. 1993) and adoles- cents (Lieu et al. 1993), such as among African Ameri- cans (Hopkins 1993) and Hispanics (Trevijio et al. 1991; GAO 1992; Pierce et al. 1994b). Data from the 1990 California Tobacco Survey showed that 46.9 percent of Hispanic smokers had not visited a physician in the 12 months before the survey, compared with 42.0 percent of Asian Ameri- cans and Pacific Islanders, 26.7 percent of African Americans, and 33.4 percent of whites (Burns and Pierce 1992). According to the 1992 NHIS data on Tobacco Control and Education Efforts 283 Surgeon General’s Report cigarette smokers, 37.6 percent of Hispanics, 26.1 per- cent of African Americans, and 29.2 percent of whites had not visited a physician during the year preceding the survey (Tomar et al. 1996). Data from the 1989 NHIS on the number of annual visits per person to the dentist showed that African American men (1.0 visits) and women (1.4 visits) made fewer visits than Hispanic men (1.5 visits) and women (1.7 visits) and white men (2.1 visits) and women (2.4 visits) (Bloom et al. 1992). Among smokers, national data collected in 1992 showed that 42.6 percent of African Americans, 39.3 percent of Hispanics, and 54.4 percent of whites had visited a dentist during the preceding year (Tomar et al. 1996). In addition, because many health care providers lack linguistic skills and training in cultural sensitivity, they tend to be ineffective advocates of smoking cessation among members of ethnic groups. Equally problematic is the fact that few physicians have the necessary training, feel qualified and supported, or express interest in recom- mending quitting to smokers (Kottke et al. 1994). Available data indicate that a large proportion of health care providers, primarily physicians, do not take advantage of office visits to encourage smokers to quit. In general, members of racial/ethnic groups are less likely than whites to receive advice on quit- ting smoking from their physicians, and they are even less likely to receive such advice from their dentists (e.g., Kogan et al. 1994; Winkleby et al. 1995; Hymowitz et al. 1996). According to data from the 1992-1993 CPS, about 42.4 percent of Hispanics and 45.4 percent of African Americans who had visited a physician dur- ing the previous year reported that within that year they had received a physician’s advice on quitting smoking, compared with 50.4 percent of whites (Table 5) (U.S. Bureau of the Census, NCI Tobacco Use Supple- ment, public use data tapes, 1992-1993). In general, women reported receiving a physician’s advice in greater proportions than men. When asked if they had ever received a physician’s advice on quitting smok- ing, only 39.8 percent of Hispanics said they had, com- pared with 47.2 percent of African Americans, 45.7 percent of Asian Americans and Pacific Islanders, 54.5 percent of American Indians and Alaska Natives, and 58.1 percent of whites. Results of the 1991 NHIS show that whereas 38.2 percent of whites reported receiv- ing advice to quit from a physician or other health care professional at any visit during the preceding 12 months (CDC 1993a), a percentage significantly higher than for Hispanics (30.6 percent), such advice was re- ceived by 34.4 percent of African Americans, 41.4 per- cent of American Indians and Alaska Natives, and 34.4 percent of Asian Americans and Pacific Islanders. According to the 1992 NHIS data on cigarette smok- 284 Chapter 5 ers who had visited a physician during the previous year, 55.5 percent of whites, 50.2 percent of African Americans, and 35.1 percent of Hispanics reported that a physician had advised them to quit smoking during the preceding year; among smokers who had visited a dentist during the previous year, 23.4 percent of whites, 26.3 percent of African Americans, and 27.2 percent of Hispanics reported that a dentist had advised them to quit during the preceding year (Tomar et al. 1996). Be- cause questions were worded differently about advice from health care providers on quitting smoking, esti- mates based on data from the 1991 NHIS and the 1992 NHIS are not directly comparable and cannot be in- terpreted as indicating a secular trend. Findings from other surveys show that among African Americans, pregnant women are the most likely to receive smok- ing cessation advice and services in a health care set- ting (O’Campo et al. 1992; Tiedje et al. 1992). Results from the 1992 California Tobacco Survey showed that among smokers who visited a physician in the previous year, 60.9 percent of Hispanics did not receive advice on quitting smoking, compared with 56.0 percent of African Americans and 47.8 percent of whites (Pierce et al. 1994b). These figures are comparable to those found in the Stanford Five-City Multifactor Risk Reduction Project, in which 63.4 percent of Hispanic smokers reported never being advised to quit smoking by their physician, compared with 45.9 percent of whites (Frank et al. 1991). These differences seem to be particularly notable among less educated Hispanics (Winkleby et al. 1995). Despite these limitations, the use of health care providers to promote smoking cessation can have promising results (Royce et al. 1995). The CDC has funded the design of protocols that will prescribe strat- egies health care providers can use when counseling patients in smoking cessation, using the Guia for His- panics and the Pathways to Freedom program for Afri- can Americans. In addition, the NCI has produced a number of publications reviewing this approach (NCI 1994) as well as training materials to teach health care personnel how to promote smoking cessation (Glynn and Manley 1992), and a recent publication has evalu- ated the effectiveness of various smoking cessation approaches available to primary care clinicians (Fiore et al. 1996). For You and Your Family The For You and Your Family project provides tobacco-use prevention services to racial/ethnic com- munities in health care settings. The project, sponsored by California’s Department of Health Services, was Tobacco Use Among U.S. Racial/Ethnic Minority Groups Table 5. Percentage of adult smokers who have received advice to quit smoking from either a medical doctor or a dentist, by race/ethnicity and gender, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +r % +cl % +Cl % +Cl % +CI Received advice from a medical doctor in past yeart Total 454 1.7 48.3 6.2 49.6 5.3 424 2.6 504 0.7 Men 42.5 2.6 45.2 9.0 50.1 6.8 396 3.6 488 1.0 Women 473 2.2 51.0 8.5 48.8 8.6 45.5 3.8 51.7 09 Received advice from a medical doctor ever | Total 47.2 14 54.5 5.3 45.7 41 39.8 2.0 58.1 0.6 Men 405 2.1 50.4 7.5 43.7 4.8 33.2 2.5 53.1 0.8 Women 53.1 2.0 58.6 7.4 50.4 7.9 50.0 3.3 63.1 0.8 Received advice from a dentist in past year? Total 20.6 18 - 21.1 6.3 30.5 5.0 226 2.6 19.6 0.6 Men 22.0 28 28.5 10.1 36.3 6.4 23.3 3.6 214 09 Women 19.6 23 14.2 7.5 19.3 7.3 21.7 3.7 18.0 08 Received advice from a dentist ever Total 14.7. 1.0 18.2 4.1 24.9 3.5 16.7. 16 18.6 04 Men 154 15 21.2 6.1 26.7 4.3 15.7 2.0 194 0.6 Women 141 14 15.2 54 20.8 6.1 18.2 2.6 178 0.6 *95% confidence interval. *Among persons who visited a medical doctor during the past year. +Among persons who visited a dentist during the past year. Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes, 1992-1993. developed recently by a team of California research- ers. This multicultural perinatal project seeks to re- duce cigarette smoking among pregnant women and to limit their exposure to ETS. The project includes a trainer’s guide, a health care provider’s guide, and targeted client education materials for African Americans, American Indians, Hispanics, and Asian Americans (i.e., Cambodians, Chinese, Koreans, and Laotians). Materials for clients differ in their content and format, depending on the racial/ethnic group be- ing targeted; the materials range from a brochure for African Americans entitled Hey, Girlfriend, Let's Talk About Smoking and You to a four-color magazine entitled La Mujer: La Familia y el Cigarrillo, which motivates Hispanic women to quit and provides sug- gestions and techniques for quitting and maintaining abstinence (Otero-Sabogal and Sabogal 1991). The importance of developing smoking cessation programs for pregnant women of various races/ ethnicities has been documented recently among American Indians (Bulterys et al. 1990). By using sta- tistical models with information on the health status of American Indians in the Aberdeen IHS area, Bulterys and colleagues found that by quitting smoking, Ameri- can Indian pregnant women would prevent 2.6 per- cent of all infant deaths, 3.7 percent of postneonatal deaths, and 1.2 percent of neonatal deaths. Tobacco Control and Education Efforts 285 Surgeon General’s Report American Indian Cancer Control Project The American Indian Cancer Control Project in California used self-help techniques, individual coun- seling, and cultural interventions to help American Indian smokers quit. Access to American Indians over the age of 18 years was facilitated through 18 north- ern California clinics owned and operated by Ameri- can Indians. Fourteen rural clinics located on or near reservations and four urban clinics participated in the project. The project has been testing a clinic-based, physician-initiated message enhanced by using Ameri- can Indian community health representatives who also provide outreach support. Recent data indicate that the clinic-based procedures were an acceptable and accessible means of reaching the American Indian population in northern California (Hodge et al. 1995, 1996). Evidence from this project suggests the need for culturally appropriate smoking cessation programs (Hodge et al. 1995). Involvement of Employers Employer-provided smoking cessation programs could help to lower the prevalence of smoking, yet very few individuals report having such programs avail- able to them. Data from the 1992-1993 CPS showed that 23.6 percent (95 percent confidence interval [CI] = + 0.9 percent) of African Americans reported having such services at work, compared with 22.4 per- cent (CI + 0.3 percent) of whites, 21.8 percent (CI + 1.8 percent) of Asian Americans and Pacific Islanders, 18.8 percent (CI + 3.6 percent) of American Indians and Alaska Natives, and 15.8 percent (CI + 0.9 percent) of Hispanics (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). Among smokers, 25.0 percent (CI + 1.8 percent) of Af- rican Americans, 19.7 percent (CI + 0.6 percent) of whites, 18.4 percent (CI + 4.1 percent) of Asian Ameri- cans and Pacific Islanders, 17.7 percent (CI + 5.8 per- cent) of American Indians and Alaska Natives, and 14.3 percent (CI + 1.9 percent) of Hispanics reported hav- ing access to employer-provided smoking cessation services (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). Involvement of Nontraditional Providers Community members who traditionally have not been perceived as health promoters also have become involved in tobacco control efforts. For example, Af- rican American religious leaders have been involved 286 Chapter 5 in tobacco control efforts as well as in other health promotion activities, such as the National High Blood Pressure Education Program (1992). These ministers and pastors carry great influence among African Americans and are responsible for dictating social and moral values. In addition, the church often has been central in mobilizing African American communities around issues of social justice. Examples of tobacco control efforts involving community members, includ- ing religious leaders, are presented in this section. Unfortunately, little evidence is available about the success or effectiveness of this type of intervenor. Heart, Body, and Soul is a church-based intervention in east Baltimore, Maryland, a predominantly (88 per- cent) African American community (Stillman et al. 1993; Voorhees et al. 1996). Focus groups conducted before the intervention revealed that African American smok- ers were knowledgeable of the health risks of smoking but knew few strategies beyond quitting cold turkey. The smokers perceived little support for quitting from their friends and family, with the exception of their children, who tended to be strong motivators to quit smoking. The smokers participating in the focus groups did not approve of nicotine replacement and viewed it as substituting one addiction for another. The intervention phase of the study emphasized the impor- tance of self-efficacy to promote behavior change and social actions that promote large, systemic, social changes as a strategy for affecting individual behav- ior. The project was carried out through a partnership with the local ministerial alliance. Of 130 churches in the area, 22 participated in the intervention. After introductory activities, which included a health fair, churches were randomly assigned to re- ceive either an intensive smoking cessation interven- tion or the minimal level of activity, which involved distribution of the ALA educational brochure Don’t Let Your Dreams Go Up in Smoke (ALA 1990a). Churches participating in the intervention received the same brochure but also were involved in the following ac- tivities: (1) training of smoking cessation specialists, who conducted weekly support groups with a spiri- tual overtone; (2) a kickoff service that included an inspirational sermon, distribution of One Day at a Time (a Scripture-based book of inspirational messages for smokers), and an inspirational audiocassette on quit- ting smoking; and (3) reinforcement of successful quit- ting through recognition during church services and the provision of certificates to volunteers participat- ing in the program. The program is now being extended to churches in 13 cities throughout the coun- try. As a result of this program, a number of African American clergy have formed a coalition, Black Clergy for Substance Abuse Prevention, to implement tobacco control programs and other substance abuse preven- tion efforts. The coalition is affiliated with the National Association of African Americans for Positive Imagery (NAAAPI). A recent study showed that church-based programs can be effective in moving in- dividuals along the continuum of change toward quitting smoking (Schorling et al. 1997). Innovative programs are also under way in California. In San Diego, the Union of Pan Asian Com- munities of San Diego County delivers antismoking messages through fortune cookies (Irene Linayao- Putman, personal communication, 1993). The St. Mary Medical Center and the United Cambodian Commu- nity, Inc., in Long Beach, California, developed audiocassettes that feature traditional Laotian and Cambodian music as well as antismoking messages. These audiocassettes are distributed through racial/ Tobacco Use Among ULS. Racial/Ethnic Minority Groups ethnic shops, health fairs, and other community events. Barbers and beauty parlor operators also have been trained to provide antismoking messages to their cli- ents in small community programs in California and other states. Although not all of these smoking cessation in- terventions are culturally appropriate, preliminary figures on the overall effectiveness of these massive interventions show that progress is being made in a number of areas. In California, for example, the over- all prevalence of smoking has declined, more smok- ing cessation services are available, people are more aware of the dangers of cigarette smoking, and in- creases in adolescent smoking appear to have stopped (Breslow and Johnson 1993; Pierce et al. 1994b; Elder et al. 1996). These results are true for members of racial/ethnic minority groups as well as for whites. Environmental Tobacco Smoke and Clean Indoor Air Policies A large number of individuals from racial/ ethnic groups work in the service industry (e.g., res- taurants) and in blue-collar jobs (e.g., factories and repair shops)—areas of employment where cigarette smoking usually is allowed. Thus, they are probably heavily exposed to ETS. Although the data are incomplete, a few studies indicate the extent to which nonsmokers, particularly those who are members of racial/ethnic groups, are exposed to ETS. Data from the 1993 California Tobacco Survey showed that 32.0 percent of nonsmoking His- panics were exposed to ETS at indoor workplaces, compared with 19.1 percent of African Americans and 19.0 percent of whites (Pierce et al. 1994b). Exposure to ETS at home is also a concern among members of racial/ethnic groups. Data from the 1992- 1993 CPS (Table 6) showed that a majority of Asian Americans and Pacific Islanders (60.6 percent) and His- panics (56.6 percent) did not allow cigarette smoking in their homes (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992— 1993). In comparison, smaller proportions of whites (41.3 percent), African Americans (38.9 percent), and American Indians and Alaska Natives (35.6 percent) reported that they prohibited smoking at home. Mi- nor gender differences were observed in the reporting of such restrictions. Other surveys indicate that expo- sure to tobacco smoke at home is a valid concern. An analysis of data from the Hispanic Health and Nutrition Examination Survey indicates that 31 to 62 percent of Mexican American nonsmoking women had household exposure to ETS (Pletsch 1994). In addi- tion, 22 to 59 percent of Puerto Rican women and 40 to 53 percent of Cuban American women had such ex- posure. In recent years, businesses and governments have adopted policies, laws, and ordinances that limit ciga- rette smoking in public places and in workplaces (Rigotti and Pashos 1991). The effects of these policies can be expected to benefit all U.S. residents, including members of racial/ethnic minority groups. In addi- tion, systemwide antismoking policies are being pro- mulgated. For example, no-smoking policies have been implemented in a number of federal workplaces, including IHS hospitals and clinics and Department of Defense installations. States have also been restrict- ing smoking at a fairly rapid pace by banning smok- ing on public transportation vehicles as well as in health care offices and facilities, airports, other public buildings, and elevators (O’Connor 1992). A number of states also restrict smoking in indoor cultural and recreational facilities, including libraries, museums, Tobacco Control and Education Efforts 287 Surgeon General's Report Table 6. Percentage of adults who reported that no one is allowed to smoke anywhere inside the home,” by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +CIt % +CI % +ClI % +CI % +l Overall Total 38.9 0.7 35.6 3.2 60.6 1.6 56.6 0.9 41.3 0.3 Men 37.7. 1.1 34.1 4.7 57.9 2.3 54.3 13 41.2 0.4 Women 39.6 0.9 36.8 4.3 63.2 2.2 58.5 1.2 41.4 0.4 Nonsmokers Total 499 0.9 53.4 4.2 67.3 1.6 64.5 1.0 51.7 0.3 Men 50.22 1.4 54.1 6.6 66.7 2.5 63.6 1.5 51.6 0.5 Women 498 1.1 52.9 5.5 67.8 2.2 65.2 1.2 51.8 0.4 Smokers Total 74 08 7.9 2.9 25.2 3.5 21.6 1.7 10.1 0.3 Men 9.2 12 8.7 4,2 28.5 4.4 26.7 2.4 12.4 0.5 Women 59 = =60.9 7.1 3.9 17.5 5.7 13.9 2.3 7.8 0.4 *Includes persons who reported having a rule that no one is allowed to smoke anywhere inside the home. *95% confidence interval. Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes, 1992-1993. theaters, galleries, shopping malls, sports arenas, and auditoriums. An ever-increasing number of states have restricted smoking in schools and on school grounds for students, school personnel, and other persons with access to the school; 27 states restrict smoking in child day-care centers. As of December 31, 1997, 41 states have some kind of restriction on smoking in govern- ment worksites, 21 have restrictions on smoking in pri- vate worksites, and 31 restrict smoking in restaurants (CDC, Office on Smoking and Health, State Tobacco Ac- tivities Tracking and Evaluation System, unpublished data). An increasing number of employers are also re- stricting cigarette smoking. In the 1992-1993 CPS, a substantial proportion of respondents reported that their employers had policies prohibiting cigarette smoking in work areas and in indoor public areas, such as lobbies, rest rooms, and lunch rooms. Gerlach and colleagues (1997) used data from the 1992-1993 NCI Tobacco Use Supplement to the CPS to document the prevalence and restrictiveness of workplace smoking policies reported by African Americans, Asian Ameri- cans and Pacific Islanders, Hispanics, and whites who were employed in indoor workplaces. Their data 288 Chapter 5 showed that 43.3 percent of African Americans, 51.4 percent of Asian Americans and Pacific Islanders, 45.1 percent of Hispanics, and 46.2 percent of whites worked for employers who provided smoke-free policies. In all four groups, women were more likely than men to be protected by smoke-free policies. Over- all, about one-third of employees worked in places that either had no policy on smoking or allowed smoking in private work areas. These minimal policies were reported by 33.9 percent of African Americans, 29.7 percent of Asian Americans and Pacific Islanders, 37.3 percent of Hispanics, and 35.6 percent of whites. This report did not present data on American Indians and Alaska Natives. Members of the racial/ethnic minority groups considered in this report tend to favor restrictions on tobacco smoking (see Royce et al. 1993 for data on African Americans). In the 1992-1993 CPS, Asian Americans and Pacific Islanders and Hispanics were generally more likely to support the total restriction of cigarette smoking in restaurants, hospitals, indoor workplaces, and indoor shopping malls (Table 7) (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). Smokers were more likely to agree with partial restrictions of cigarette smoking (limiting smoking to some areas within each enclosed space) than to support the total restriction of cigarette smoking in each of the public places included in the CPS. Results of an ABC News/The Washington Post poll conducted in February 1993 showed that larger proportions of African Americans (54.3 percent) and Hispanics (52.9 percent) favored banning smok- ing in public places, compared with whites (48.3 per- cent) (Roper Center for Public Opinion Research 1993). The same poll showed that fairly similar proportions of Hispanics (87.9 percent), African Americans (84.3 percent), and whites (84.1 percent) felt that ETS was a health risk. However, Hispanics (50.8 percent) and African Americans (44.2 percent) reported worrying more about ETS than whites (34.4 percent). Data from the 1992 California Tobacco Survey showed that members of racial/ethnic groups had lim- ited support for the complete ban of cigarette smok- ing in restaurants and in workplaces (Pierce et al. 1994a). For example, smoking bans in restaurants drew support from 53.5 percent of Hispanics, 41.9 percent of African Americans, 35.0 percent of Asian Americans and Pacific Islanders, and 34.7 percent of whites. The data on smoking bans in the workplace were similar. Hispanics (54.5 percent) were more likely to support banning cigarette smoking in the workplace than were Asian Americans and Pacific Islanders (43.5 percent), African Americans (40.2 percent), and whites (34.4 percent). More recently, findings from a 1993 survey indi- cate that residents of eight California cities (Fresno, Hercules, Indio, Los Angeles, Paradise, Sacramento, San Bernardino, and San Diego) significantly sup- ported strong ETS controls (Sherwood et al. 1994). In this 1993 survey, 78 percent of whites supported a com- plete ban on smoking in restaurants, compared with 91.4 percent of Asian Americans, 89.5 percent of His- panics, 82.6 percent of American Indians, and 82.5 per- cent of African Americans. In addition, 84.5 percent of whites strongly supported a complete ban on smok- ing in the workplace, compared with 93.5 percent of Asian Americans, 92.0 percent of Hispanics, 87.9 per- cent of African Americans, and 85.6 percent of Ameri- can Indians. The degree to which existing no-smoking poli- cies are enforced in racial/ethnic communities is unknown. In a recent survey of 39 American Indian tribes, Glasgow and colleagues (1995) found signifi- cant intertribal variations in the types of policies and places covered by clean indoor air policies. For Tobacco Use Among U.S. Racial/Ethnic Minority Groups example, 64 percent of the tribes reported having a no- smoking policy that designated tribal schools, council meeting areas, and private offices as nonsmoking ar- eas, but none banned smoking in bingo halls. Those tribes that received a specially developed policy work- book and direct consultation on ways to implement tobacco control policies were found to have adopted stringent policies within two years of having received the intervention materials (Lichtenstein et al. 1995). A recent observational study of American Indian facili- ties in California, Idaho, New Mexico, New York, Or- egon, and Washington found that smoking policies and practices varied considerably across settings (Hall et al. 1995). Tribal schools and Indian health care fa- cilities had the most restrictive policies. Tribal council meeting areas and private offices were less likely to be designated nonsmoking areas. No-smoking signs were observed most frequently in clinics (46 percent) and tribal offices (37 percent); no-smoking posters also were prominent in clinics (49 percent). Evidence of smok- ing (e.g., persons smoking, cigarette stubs, and ash- trays) was observed most frequently in tribal offices and cultural centers or community buildings (Hall et al. 1995). A number of programs have tried to promote clean indoor air policies and practices among mem- bers of the racial/ethnic minority groups included in this report, but little information is available on their effectiveness. For example, Asian Americans for Com- munity Involvement of Santa Clara County, based in San Jose, California, has targeted 400 Asian American restaurants and businesses to encourage them to have smoke-free areas. However, the researchers had diffi- culties assuring Asian American merchants that pro- viding smoke-free areas would be good for business (Jung 1993). Among American Indians, efforts have been made to help various tribes develop comprehensive smoke-free programs. For example, Glasgow and col- leagues (1995) worked with 39 tribes in Washington, Oregon, and Idaho to review, modify, and develop tobacco-use policies that would protect tribal mem- bers from ETS. Tobacco policy committees were es- tablished to advise tribes during the policymaking process. A tobacco policy workbook also was devel- oped to guide the tribes. Although tribal leaders expressed support for more stringent tobacco-use policies, changes in tobacco policies were not produced through the tobacco policy committees as the project had originally planned. Tobacco Contrel and Education Efforts 289 Surgeon General's Report Table 7. Percentage of adults who think that smoking should be allowed in some areas or not allowed at all in selected public locations,* by race/ethnicity and smoking status, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +CIt % +Cl % +Cl % x+CI % +cI Restaurants (allowed in some areas) Total 50.8 0.7 52.4 3.3 42.1 1.6 38.1 0.9 52.9 0.3 Nonsmokers 44.3 0.9 39.1 4.1 37.6 1.7 33.5 0.9 44.4 0.3 Smokers 69.5 1.3 73.4 4.7 66.4 3.9 58.8 2.1 78.6 0.5 Hospitals (allowed in some areas) Total 22.8 0.6 26.6 29 12.8 1.1 12.9 0.6 25.8 0.2 Nonsmokers 18.5 0.7 15.6 3.1 11.2 11 10.5 0.6 19.0 0.3 Smokers 35.0 14 44.3 5.3 21.7 3.4 234 1.8 46.3 0.6 Indoor work areas (allowed in some areas) Total 39.3 0.7 43.9 3.3 24.7 1.4 25.8 0.8 40.7 0.3 Nonsmokers 32.6 0.8 30.1 3.9 21.0 1.4 216 0.8 32.4 0.3 Smokers 58.5 14 65.8 5.0 44.3 4.1 44.1 2.1 65.5 0.5 Restaurants (not allowed) Total 45.3 0.7 42.5 3.3 54.5 1.6 58.8 0.9 43.1 0.3 Nonsmokers 53.0 0.9 58.7 4.2 59.8 1.7 64.2 1.0 52.9 0.3 Smokers 23.5 1.2 16.9 4.0 25.9 3.6 34.9 2.0 13.6 0.4 Hospitals (not allowed) Total 75.3 0.6 71.3 3.0 85.1 1.1 85.7 0.6 72.5 0.3 Nonsmokers 80.0 0.7 83.5 3.2 86.9 1.2 88.3 0.6 79.9 0.3 Smokers 62.0 1.4 51.8 5.3 75.8 3.5 74.2 18 50.6 0.6 Indoor work areas (not allowed) Total 57.0 0.7 52.2 3.3 71.8 1.4 70.9 0.8 55.7 0.3 Nonsmokers 64.6 0.8 68.3 4.0 75.8 15 75.7 0.9 65.1 0.3 Smokers 35.6 1.4 26.5 4.7 50.5 4.1 50.3 2.1 27.6 0.5 *In response to the question about each place, “Do you think that smoking should be allowed in all areas, in some areas, or not allowed at all?” *95% confidence interval. Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes, 1992-1993. 290 Chapter 5 Table 7. Continued Tobacco Use Among U.S. Racial/Ethnic Minority Groups African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +Cl % +cl % +Cl % H+CI % +Cl Bars and cocktail lounges (allowed in some areas) Total 44.2 0.7 36.6 3.2 45.7 1.6 38.8 0.9 440 03 Nonsmokers 44.2 0.9 38.5 4.1 46.4 1.8 39.0 1.0 44.9 0.3 Smokers 443 14 33.3 5.0 42.2 4.0 37.8 2.0 413 0.6 Indoor sporting events (allowed in some areas) Total 30.3 0.7 25.8 2.9 23.0 14 22.4 0.7 28.7 03 Nonsmokers 27.1 0.8 17.9 3.3 21.1 1.4 20.2 0.8 23.9 0.3 Smokers 39.2 14 38.2 5.2 32.8 3.8 31.9 19 43.3 0.6 Indoor shopping malls (allowed in some areas) Total 39.9 0.7 40.8 3.3 32.3 15 28.2 0.8 416 03 Nonsmokers 35.7 0.8 31.7 4.0 29.1 1.6 25.2 0.9 35.2 0.3 Smokers 51.7 14 54.8 5.3 49.5 4.1 4430 2.1 61.2 0.6 Bars and cocktail lounges (not allowed) Total 25.6 0.6 22.2 2.8 29.8 1.5 31.3 08 22.6 0.2 Nonsmokers 318 0.8 33.2 4.0 33.5 1.7 35.6 1.0 288 03 Smokers 8.1 0.8 5.2 2.4 9.6 2.4 12.1 14 4.0 0.2 Indoor sporting events (not allowed) Total 64.5 0.7 68.2 3.1 72.3 14 72.9 0.8 65.9 03 Nonsmokers 68.9 0.8 79.3 3.4 74.8 15 75.8 0.9 72.3 0.3 Smokers 52.5 14 50.5 5.3 59.5 4.0 60.0 2.0 46.5 0.6 Indoor shopping mails (not allowed) Total 544 0.7 52.3 3.3 62.7 1.6 67.2 0.8 52.6 0.3 Nonsmokers 59.7 08 65.2 4.0 66.5 1.7 70.8 0.9 60.6 0.3 Smokers 39.7 14 32.3 5.0 42.7 4.0 513 2.1 28.6 0.5 Tobacco Control and Education Efforts 291 Surgeon General's Report Economic Efforts to Reduce Tobacco Use Numerous efforts have been made to reduce the use of cigarettes through excise and sales taxes. Be- cause these taxes increase the price of cigarettes, higher tax rates generally curb the demand for cigarettes, and ultimately, tobacco consumption (Grossman 1989; Peterson et al. 1992; Keeler et al. 1993; Townsend et al. 1994). Peterson and colleagues (1992) evaluated the effects of state cigarette tax increases on cigarette sales in the 50 states from 1985 through 1988. The research- ers found that state cigarette tax increases were associated with an average decline in cigarette con- sumption of three cigarette packs per capita (a decline of about 2.4 percent). Likewise, larger tax increases were associated with larger declines in consumption. Ina recent study in Britain, Townsend and colleagues (1994) found that individuals of low-socioeconomic status were more responsive to changes in the price of cigarettes than those who were more affluent. As of June 30, 1996, all states, the District of Co- lumbia, and 451 localities currently impose taxes on cigarettes in addition to the federal tax (Tobacco Insti- tute 1997). As of December 31, 1997, state taxes ranged from a low of 2.5 cents in Virginia to a high of $1 in Alaska; the average state tax was 37.76 cents per pack (CDC, Office on Smoking and Health, State Tobacco Activities Tracking and Evaluation System, unpub- lished data). Members of some racial/ethnic minority groups have supported increases in taxes for tobacco prod- ucts. In a 1990 survey of California smokers, 29.1 per- cent of African American smokers and 34.5 percent of Hispanic smokers reported that they would support a cigarette tax increase (Burns and Pierce 1992). Amuch smaller proportion of whites who smoke (20.0 percent) supported such an increase. Recently, larger propor- tions of California adults have supported an increase in cigarette taxes. The 1992 California Tobacco Sur- vey among both smokers and nonsmokers found that cigarette tax increases were supported by 60.2 percent of Asian Americans and Pacific Islanders, 50.4 percent of Hispanics, 49.5 percent of African Americans, and 49.8 percent of whites (Pierce et al. 1994a). Further- more, a 1993 nationwide survey conducted for the ACS found that Hispanics (71 percent) and African Ameri- cans (63 percent) supported an increase of $2 per pack to pay for a national health insurance program (Marttila & Kiley, Inc. 1993). These proportions were fairly similar to those found among whites (66 percent). 292 Chapter 5 Although tobacco taxes are effective in discour- aging smoking, some people consider increases in excise taxes to be regressive because the poorer members of society pay a higher proportion of their income in taxes. Wasserman (1992), for example, states: With respect to excise tax increases, however, we must be mindful of the distributional conse- quences of higher taxes. More precisely, because low-income smokers do not appear to be any more responsive to higher cigarette prices than high- income smokers, higher excise taxes will result in disproportionate economic harm, and, in some cases, could lead poorer smokers to forgo food, shelter, and needed health care to fulfill the per- sistent and pernicious demands of their smoking habits. As a result, higher cigarette taxes should be accompanied by measures to compensate the poor for the larger burden that they will necessar- ily have to bear. For example, federal and state income tax structures could be modified to facili- tate such compensation (p. 20). A 1990 federal government report supported this argument by presenting data from the 1984-1985 Consumer Expenditure Survey Interview showing that families in the lowest income quintile spent 4 percent of their posttax income on tobacco products, compared with families in the highest quintile, who spent 0.5 percent of their posttax income on tobacco products (U.S. Congressional Budget Office 1990). On the other hand, some argue that the hardship of increased taxes on the poor is outweighed by the fact that smoking- related health costs and suffering decline among persons who smoke fewer cigarettes or stop smoking because of the higher taxes on tobacco. A group of economists meeting in 1995 concluded that additional research on costs is needed before an optimal cigarette excise tax from an economic perspective can be deter- mined (Warner et al. 1995). These economists agreed that the strongest argument currently for increasing cigarette taxes is the protection of children. The actual effects of excise tax initiatives on mem- bers of racial/ethnic minority groups are difficult to ascertain. Nevertheless, reductions in the consumption of tobacco products resulting from increases in excise taxes should ultimately benefit members of U.S. racial/ethnic groups by lowering their prevalence of cigarette smoking and by limiting or lowering their exposure to ETS. California’s experience after increas- ing the tax on cigarettes shows that a number of community-based projects, school-based interventions, and research activities, which directly benefit members of the racial/ethnic groups and could not have been funded from other sources of tax revenue, can be Tobacco Use Among ULS. Racial/Ethnic Minority Groups funded through the revenue generated by the increased taxes (Breslow and Johnson 1993). In addition, given the need to help community-based programs and or- ganizations rely less on tobacco industry support (Satcher and Robinson 1994), earmarked tax revenues may prove to be a viable alternative. Efforts to Control Tobacco Advertising and Promotion Tobacco products are heavily advertised in racial/ethnic publications and in racial/ethnic com- munities. Efforts to restrict the effects of advertising and promotion of tobacco products in racial/ethnic communities have been limited by various factors, including the communities’ reliance on the tobacco industry (see Chapter 4), difficulties in mobilizing com- munities that are faced with problems perceived to be in need of more immediate attention (e.g., affordable housing, unemployment, unequal education, and racial/ethnic minority discrimination), the lack of trained community leaders interested in health issues, and possibly the lack of infrastructure for tobacco pre- vention and control initiatives in racial/ethnic com- munities (Robinson et al. 1995). As a result, persons residing in racial/ethnic communities are continually exposed to the advertising and promotion of tobacco products. A recent study in Los Angeles County, for example, examined the risk of exposure to outdoor advertising of cigarettes among residents of various communities (Ewert and Alleyne 1992). The results suggest that persons residing in the city of Los Angeles were more likely to be exposed to cigarette and alcohol billboard advertisements than residents of nearby sub- urbs. Cigarettes were advertised on 59 of the 299 bill- boards (19.7 percent) surveyed on 46.2 miles of streets. The number of cigarette advertisements was 4.6 times greater in the city of Los Angeles than in its suburbs. Members of some racial /ethnic minority groups tend to be more likely than whites to support a ban on tobacco product advertisements (Table 8). Data from the 1992-1993 CPS showed that 37.5 percent of whites supported a ban on advertising tobacco products, com- pared with 44.7 percent of Hispanics, 39.5 percent of Asian Americans and Pacific Islanders, and 38.3 per- cent of African Americans (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). In each racial/ethnic group, women and nonsmokers were more supportive of a total ban on tobacco advertising than were men and smokers. The 1992 California Tobacco Survey found that adult Cali- fornians supported the banning of such advertising in newspapers and magazines as well as on billboards (Table 9) (Pierce et al. 1994a). The same survey also showed support for banning tobacco companies from sponsoring cultural events. Hispanics tend to show the greatest level of support for these measures, whereas whites support them the least. Data from the 1992-1993 CPS also showed that fairly large percent- ages of racial/ethnic group members would support a ban on the free distribution of tobacco samples (Table 10) (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992-1993). Hispanics (59.4 percent) and Asian Americans and Pacific Islanders (57.5 percent) were the most likely respondents to state that they supported such a ban. In all groups, women and nonsmokers were more likely than men and smokers to favor the ban. The 1994 RWJF Youth Access Survey (Table 4) found varying support for restricting or banning dif- ferent types of tobacco advertising. Hispanics and African Americans were more likely than whites to support such proposals (Nancy Kaufman et al., un- published data). Hispanics were more supportive of bans on billboard, newspaper, and magazine adver- tising than were African Americans and whites. Re- quiring plain packaging of tobacco products (brand name and warning label in black letters on white background) was supported substantially more by Hispanics than by African Americans or whites. In recent years, the tobacco industry has shifted expenditures for advertising to promotional market- ing, with 89 percent of 1995 expenditures devoted to nonadvertising promotions (Federal Trade Commis- sion 1997). The RWJF Youth Access Survey found that broad-based support exists for eliminating coupon Tobacco Control and Education Efforts 293 Surgeon General's Report Table 8. Percentage of adults who think that the advertising of tobacco products should be always allowed or not allowed at all,* by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 1992-1993 African American Indians/ Asian Americans/ Americans Alaska Natives Pacific Islanders Hispanics Whites Characteristic % +CIt % +c] % +cl % +ClI %