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Interagency Committee on Smoking and Health

Meeting Summary: March 9, 2004

Tobacco-Related Disparities Among Racial/Ethnic Populations


A Quantitative View of Tobacco-Related Disparities of Racial and Ethnic Populations

Ralph Caraballo, PhD, Epidemiology, Research Team Lead, Office on Smoking and Health, CDC

Dr. Caraballo began his remarks by emphasizing how important both quantitative and qualitative data are to better understanding racial and ethnic disparities in tobacco use. The topics to be covered in Dr. Caraballo's talk would focus on the prevalence of cigarette smoking, secondhand smoke exposure among non-smokers, and tobacco-related morbidity and mortality among specific population groups. He added that CDC's Office on Smoking and Health is in the process of developing community competent adult tobacco surveys to gather data accounting for the unique historical, cultural, and social experiences of specific population groups.

The five racial/ethnic groups that represent 25% of the United States population are African Americans; American Indians and Alaska Natives; Asian Americans; Hispanics/Latinos; and more recently; Native Hawaiians and other Pacific Islanders. Data collection on this community began in the late 1990s. To achieve significant success in curbing nationwide tobacco use, it is clear that we must effectively address this issue within each of these groups and their subgroups. Because disparities also exist within subgroups, it is also important that we collect and evaluate data for each of these groups as well.

Poverty-related risk factors and disparities in health insurance coverage among these racial and ethnic groups also contribute to high rates of tobacco use and disease burden that result in reduced access to medical care, cessation medications, advice to quit, and less information about the dangers of secondhand smoke. African Americans and Latinos/Hispanics are at particular risk compared to other communities.

Although there is a lack of good data illustrating tobacco use trends among adolescents in the various racial and ethnic populations and their subgroups, we do know that American Indians and Alaska Natives have a younger age of tobacco use initiation then other groups. The 2001 Youth Risk Behavior Survey (YRBS) indicates that American Indian youth on 26 reservations have a prevalence rate of 56.5% far exceeding all other major racial/ethnic groups.

There is some good news, however. We have made significant progress with African American youth who have already reached the Healthy People 2010 goal of 16% prevalence or less. Between 1983 and 2002, adult prevalence fell in all racial and ethnic groups except for American Indians and Alaska Natives. Significant progress has been made in reducing the gap in smoking prevalence between African Americans and Whites. However, the rates among most groups are still much higher than the Healthy People goal of 16% prevalence.

To illustrate the variability of smoking within subgroups, Dr. Caraballo presented data from the National Survey of Drug Use and Health that indicates a 16% smoking prevalence rate for Asians. However, when the data are disaggregated, certain subgroups—such as Koreans and Vietnamese—have prevalence rates that are much higher than 16%. The same is true with Hispanics/Latinos, with Puerto Ricans having higher prevalence rates compared to other sub-groups.

In terms of secondhand smoke exposure, more African American nonsmokers are exposed to secondhand smoke then whites and Mexican Americans, and they are also exposed to higher concentration levels of smoke. Importantly, findings cannot be reported for other race/ethnic populations because of the absence of data indicating cotinine levels in the blood.

Focusing on tobacco-related morbidity and mortality, about 87% of lung cancer deaths can be attributed to cigarette smoking. African Americans are more likely to die of lung cancer than people of any other racial or ethnic group. In addition, African Americans along with American Indians and Alaska Natives experience a disproportionate percentage of premature heart disease deaths and although not all heart disease is due to smoking, tobacco has been identified as a leading risk factor. Finally, asthma death rates are also much higher for African Americans than for whites.

In closing, Dr. Caraballo reiterated that no single factor determines smoking or its consequences among the populations discussed or their subgroups. Instead, cigarette smoking is a result of complex interactions of multiple factors, including socioeconomic status, advertising, community disapproval and many other factors.

A Qualitative View of Tobacco-Related Disparities

Dr. Robert Robinson, DrPH, Associate Director for Program Development, Office on Smoking and Health, CDC

Dr. Robinson began by reiterating Dr. Caraballo's comment that both quantitative and qualitative data are important to understanding disparities and how communities are differentially affected.

For example, racial and ethnic communities are targeted by the tobacco industry in their advertising and promotional campaigns in ways that are designed to exploit their unique vulnerabilities. This kind of advertising is evident in magazines intended for specific populations, as well as the prevalence of tobacco imagery in predominately poor and blighted urban areas of the country.

The tobacco industry is also a large financial supporter of community-based and cultural organizations, educational institutions, support and service groups and political leaders. For many of these organizations and individuals, this may be the largest source of support and therefore hard to pass by when no other source of funding is available. Therefore, contradictory messages abound—tobacco is harmful, but many organizations rely on industry support for their livelihood. However, there are some encouraging indications that some racial and ethnic organizations are trying to free themselves from the tobacco yoke by repudiating sponsorship and support from the tobacco industry and seeking other avenues to underwrite their survival. But many more are still floundering outside of the safety net and they need our help and support.

In addition to the challenges created by the strong tobacco industry influence in many racial and ethnic communities, there is also inadequate capacity and infrastructure in these communities to build solid, comprehensive tobacco control programs. This capacity and infrastructure will evolve as research data specific to race and ethnic communities become available and as programs develop which are tailored specifically to these communities. When educational materials are community competent and responsive to specific values and attitudes of racial and ethnic communities, there is more likelihood that they will be adopted and disseminated. Capacity and infrastructure are also likely to develop when national leaders are engaged in tobacco prevention and control and when community/organizations in racial/ethnic minority communities are engaged to help sustain these efforts over time. Networks focused on tobacco prevention and control must also be present and have been limited in racial and ethnic communities up to this point.

Understanding a community through its history, culture, environmental context and geography—elements of community competence—is critical to developing appropriate strategies and materials to help people address tobacco addiction or to engage in seeking change in their communities. In the development of community competent materials and programs, literacy levels must be factored in and even subtle idiomatic differences in language must be addressed. Other components impacting community competence are language, positive and salient imagery, multigenerational, and diversity.

In closing, Dr. Robinson summarized the importance of looking at the full complexity of a community in efforts to develop effective programs and materials to reach racial and ethnic populations. Using qualitative and quantitative factors provides a more comprehensive picture of disparities, helps to avoid the error of relying on only one indicator, and is more likely to make an impact on addressing tobacco-related disparities.

Following his remarks, Dr. Robinson introduced each of the subsequent five speakers and provided a short biographical sketch of each individual.

The discussions focused on reviewing and understanding the magnitude of the tobacco use burden in the following five population groups: African Americans, Hispanics and Latinos, American Indians and Alaska Natives and Asian Americans, Native Hawaiians and other Pacific Islanders. There was also a presentation on how the state of Wisconsin brought together the five population groups and other diverse communities to address tobacco-related disparities.

Tobacco-Related Health Disparities Among Hispanics/Latinos

Elva Yañez, MS, Deputy Director, The Praxis Project

Ms. Yañez began her remarks by sharing a case study of the El Paso, Texas, clean indoor air initiative that she used to illustrate the potential for success as well as possible barriers to the implementation of comprehensive tobacco control strategies in Latino communities.

In January 2000, after receiving foundation support to address secondhand smoke in workplaces, the El Paso Board of Health announced its intention to introduce a clean indoor air ordinance to the City Council. The El Paso tobacco control coalition supported this effort by developing a strategic plan and engaging the community through grassroots organizing, public education and a media campaign. These efforts resulted in El Paso becoming the first community in the State to implement a 100% smokefree workplace ordinance including bars and restaurants.

Although public opinion was strongly in favor of the ordinance and adult smoking rates continued to decline in El Paso, the foundation chose to end its funding soon after the ordinance had been enacted. Ms. Yañez believes that this situation is one example of the difficulty faced by communities of color in obtaining and sustaining funding for tobacco control efforts.

The Latino population in the United States can be characterized by its diversity, youthfulness, high rates of poverty and low educational levels. A large segment of the population is comprised of immigrants who only speak Spanish. There are significant differences in tobacco use among the various Latino subgroups, with Puerto Rican men having the second highest rate of smoking among all racial/ethnic groups. Smoking rates for adult female Latinos are relatively low, with the one exception being Puerto Rican women who have very high rates of smoking. Latinos experience the second highest rate of exposure to secondhand smoke in the workplace due to a disproportionately high representation in service occupations where there are few protections.

Ms. Yañez provided several examples of ways that the tobacco industry aggressively targets Latinos in their advertising. The "Find Your Voice" and "Busca Tu Verdad" ("Search For Your Truth") are just two examples of campaigns that are targeted toward Latina women, as well as women of other racial/ethnic groups. These ads clearly illustrate the need for tobacco control strategies that help the Latino community better understand these and other tobacco industry practices intended to recruit and retain users of their products.

To better understand tobacco-related health disparities among racial/ethnic groups, it is important to consider some of the biases that exist in the institutions that are intended to address tobacco control among these populations. For example, health disparities research is most often conducted in clinical settings, and therefore this research is unlikely to capture the interventions that are being conducted on a community level.

A second example of institutional bias can be found in funding for tobacco control efforts in minority populations. The funding requirements and structuring of large scale government and privately funded tobacco initiatives often make it very difficult for racial/ethnic communities to receive adequate funding for building capacity and infrastructure. As a result, the communities with the greatest need often receive the fewest resources.

Ms. Yañez summarized the strengths and assets of Latinos as follows:

Some of the ways that these assets are evident include: smoking during pregnancy among Latinas born outside of the United States is uncommon; protections against smoking in the home are high in Latino households; Latino voters are more aware of secondhand smoke dangers in the workplace than are white voters and are also more supportive of clean indoor air ordinances; and Latino voters are more likely than whites to support tobacco tax increases that designate funding for community-based health programs.

Ms. Yañez concluded her remarks by offering several recommendations developed for the CDC by a group of Latino tobacco control experts in August 2002.



Data, Surveillance and Evaluation:

Ms. Yañez reiterated that there is no "quick fix" and for this reason it is crucial that funding must be adequate and sustained over time in order for real change to occur.

Tobacco-Related Disparities Among American Indians and Alaska Natives

Gerry RainingBird, MEd, National Tobacco Coordinator, National Tribal Tobacco Prevention Network, Northwest Portland Area Indian Health Board

Mr. RainingBird began his talk by reviewing the goals of the National Tribal Tobacco Prevention Network (NTTPN) including the continuing development of a national network of tribal organizations to facilitate the reduction of commercial tobacco use in American Indian/Alaska Native communities. The NTTPN works with many partner organizations that Mr. RainingBird shared with the Committee.

Several of the unique issues facing American Indians (AI) and Alaska Natives (AN) in tobacco control include their special cultural and historical relationship to tobacco as a sacred plant as well as the fact that there are more than 560 tribes which are each sovereign nations entitled to certain services. The Indian Health Service (ISH) is charged with fulfilling the U.S. trust obligation to provide healthcare, yet it is inadequately funded to provide even minimum services. Furthermore, tribes must rely on funding from the states for tobacco control activities but often the states and tribes have a complex and challenging relationship, which prevents the development of effective partnerships.

Challenges faced by the AI and AN communities include the high rate of youth experimentation with tobacco use coupled with access to cheaper tobacco products on tribal lands and the lack of financial resources to address these problems.

Furthermore, other issues often take priority over addressing tobacco use such as poverty, lack of housing, alcoholism and diabetes. To address these challenges, tribal support centers have focused on activities such as the development and implementation of an Adult Tobacco Survey, implementation of a cessation curriculum training, and hosting an annual National Native Conference on Tobacco Use. Furthermore, tribal programs are engaging young people in efforts to strengthen tobacco policies, conduct local secondhand smoke campaigns and use tribal media outlets to create community awareness of the issue.

Mr. RainingBird offered several recommendations including—

Mr. RainingBird concluded by sharing a list of community strengths called "Native Principles of Proper Living."

Tobacco Disparities, Asian Americans and Pacific Islanders, and the Need for Social Justice

Rod Lew, MPH, Director, Asian Pacific Partners for Empowerment and Leadership (APPEAL)

Mr. Lew began his remarks by sharing a story of a Cambodian American family that he had met while filming a documentary video on the impact of tobacco on communities of color. The male head of the family was a two-pack a day smoker, became ill but did not tell his family, and then finally—after experiencing challenges accessing the medical care system—went to a doctor and was diagnosed with lung disease. This story illustrates a common experience among minority communities not only tobacco use, but also difficulties in accessing health care, economics, cultural challenges, and community competence.

For the purposes of this presentation, Mr. Lew used the term "AAPI" to refer to Asian Americans, Native Hawaiians and Other Pacific Islanders, which has been one of the fastest growing racial groups in the United States over the past several decades. This is a very diverse group and includes more than 50 distinct ethnic and language groups. Unfortunately, there are some misperceptions about health risks and behaviors among AAPIs, who are often viewed as a model community given high socioeconomic status and education levels among some subgroups—but not all. This misperception is aggravated by national data which often lumps together all of the subgroups and therefore misrepresents the problem of tobacco use in specific AAPI subgroups.

When data are gathered from specific subgroups, they indicate high rates of smoking among Cambodian and Laotian American males. Smoking rates are relatively low for Asian American women, particularly for immigrant women who have not yet become acculturated. Guam, comprised primarily of Pacific Islanders, has the second highest smoking prevalence among all U.S. states and territories. Native Hawaiian men and women also have very high smoking rates. Smoking is a growing problem among AAPI youth with a large jump in both Asian American girls and boys between grades 7 and 12.

Targeted tobacco industry advertising to AAPIs is believed to contribute to the high rates of tobacco use among this population. For example, a strategy known as "Push, Pull and Corporate Goodwill" was developed to reach out to AAPI retail business owners with promotional products, recruit new users of their products, and sponsorship of community events and publications to increase their legitimacy. The "Find Your Voice" campaign for Virginia Slims cigarettes also targets AAPIs, and as the tobacco industry documents have indicated, these efforts in the United States have helped the industry better learn how to market their products overseas.

As with other ethnic/racial populations, AAPIs have not historically had the resources, infrastructure development and focused leadership that are necessary for effective tobacco control programs. Part of this is due to competing priorities such as economic development, discrimination, other health issues taking priority, civil rights, sovereignty issues, and the historic lack of inclusivity in the tobacco control movement. One example of this may be evidenced in Florida, where Asian American youth were the only group not to experience a significant decline in smoking as a result of the Florida Tobacco Pilot Program. For these and other reasons, Mr. Lew considers tobacco use a social justice issue.

Mr. Lew outlined a four-pronged advocacy strategy he believes is necessary to effectively address tobacco-related disparities. This includes advocacy within the AAPI community to raise the priority of addressing tobacco use, advocacy within the tobacco control community to make AAPI tobacco use a higher priority, advocacy among policy and decision makers to make tobacco control itself a higher priority, and finally advocacy against the tobacco industry where AAPIs are already a high priority.

On a positive note, the AAPI community has many strengths including the ability to develop leadership and creative programs to address tobacco use. Ten years ago, the Asian Pacific Partners for Empowerment and Leadership (APPEAL) organization was created as a social justice network focused on capacity building, advocacy, and leadership development in tobacco control efforts.

Mr. Lew described the community change paradigm that he believes is useful when considering health and tobacco disparities. He calls this paradigm the 4Rs: readiness, relevance, resources and responsibility. Readiness is understanding the level where the community is and understanding its capacity; relevance is developing community appropriate approaches to tobacco control; resources are need to sustain tobacco control efforts; and responsibility must be shared between individuals, communities, tobacco control organizations, the public health community and policy makers.

The APPEAL organization (described above) has developed two models based on community readiness (APPEAL Stages of Readiness Model) and leadership (APPEAL Leadership Model) that have been used to respond to the many challenges of addressing tobacco disparities among the AAPI community.

Based on a policy framework developed by APPEAL in 2000, Mr. Lew highlighted a few of the key recommendations to most effectively reduce tobacco use and disparities in the AAPI community:

To conclude his remarks, Mr. Lew reiterated that capacity building, infrastructure and leadership development must all be supported in racial/ethnic communities and that because this takes time, there must be a sustained commitment of resources.

In the Context of Health, Tobacco, and Culture

Sherri Watson Hyde, Executive Director, National African American Tobacco Prevention Network

Ms. Watson Hyde began by summarizing the four major areas of focus for her remarks:

While the African American community has made significant positive strides in reducing tobacco disparities, including reducing the percentage of Black youth who smoke to 16% or less and reducing adult prevalence to a rate equal to that of non-Hispanic Whites, there is still much work to be done. Specifically, more work needs to be done to better understand why positive changes are not happening among all ethnic groups and subgroups in a consistent fashion.

The African American community's relationship to tobacco and the tobacco industry has a long history, dating back to the 16th century. Pre-slavery, it was our cash crop. During slavery, we picked and harvested it. Post-slavery, it was our ticket to economic freedom, beginning with tobacco farming and later when it afforded African Americans their first high paying jobs in management. Tobacco industry advertising in the mid-20th century depicted tobacco use among African American as a sign of upward mobility, and most likely enticed many to begin to smoke. To this day, the tobacco industry continues to target much of their advertising—particularly of menthol cigarettes—to African Americans through point-of-purchase promotional displays found in neighborhood convenience stores. This multi-million dollar advertising campaign has paid off as evidenced by brand preferences within the African American community: Newport, Kools and Marlboro are the most advertised and therefore the most popular brands; 40% of African American adults smoke Newport cigarettes; and 79.2% of African American youth prefer the Newport brand.

Community advocacy and mobilization efforts have helped African Americans to fight back. Ms. Watson Hyde used the example of the X Menthol cigarette, produced in the mid-1990s, to illustrate a successful example of fighting back. At the time that the X cigarette was being marketed, smoking rates among African American youth were at an all time low. The perception was that this cigarette was intended to bring Malcolm X to mind and the packaging was red, black and green which are Africa's liberation colors. The cost was also low — $1.04 a pack — which was reasonable to attract minors. In response, a national coalition led by Boston's African American community reacted. Because of the success of this coalition the cigarettes were pulled from the shelves in less then one month, although the tobacco industry continued to deny that African Americans were being targeted by this brand.

A second example of how the African American community has mobilized around tobacco use prevention is through the use of the Pathways to Freedom: Winning the Fight Against Tobacco program within churches. This program, developed first by the Fox Chase Cancer Center in Philadelphia and revised in 2004 by the CDC, helped to introduce cessation and educational approaches into the African American community and offered an effective community competent tool for "fighting back."

In elaborating on remaining gaps and potential solutions to these gaps, Ms. Watson Hyde reiterated the challenges that minority communities face in gaining the necessary support and resources to develop effective tobacco control programs and policies. Advocates working in these communities are often not part of the networks where the paid advocates work. For this reason, networks such as the National African American Tobacco Prevention Network (NAATPN) and the National African American Tobacco Education Network (NAATEN) have formed and more are still needed. Of utmost importance is that funding should be tied to those with the greatest need which has not historically been the case.

Ms. Watson Hyde briefly summarized several recommendations previously developed by African American leaders and stakeholders in the tobacco control field:

In closing, Ms. Watson Hyde emphasized how important it is that we continue to move efforts forward so that the progress that has been made will not be undone.

Wisconsin Case Study

Denise Carty, MA, MS, RN, Minority Health Officer, Division of Public Health, Wisconsin Department of Health and Family Services

Ms. Carty described a CDC-sponsored pilot project in Wisconsin to address tobacco-related disparities that included the development of a statewide strategic plan. Wisconsin assessed that although significant interest had been generated in the state regarding tobacco-related disparities, there were a number of inconsistent approaches, lack of coordination, and limited statewide communication and guidance for our partners on this critical issue. Wisconsin wanted to ensure that key state and local stakeholders would come together with a common vision, shared understanding, leveraged resources, and a commitment to sustained action in order to successfully reach the goal to eliminate tobacco-related disparities. Toward this end, the strategic planning process was necessary to set a solid foundation to help prioritize tobacco-related disparities in the state, and it resulted in the development of a meaningful and practical tool for action to eliminate the disparities.

The first crucial step of this process was "Getting Organized." Participants in the strategic planning process included a cohesive group of: racial/ethnic community representatives; state tobacco control staff; state minority health program staff; Medicaid program staff; social service agencies serving low Socioeconomic status and underserved communities; the Technical College system; state tobacco quitline staff; state tobacco control advocates; representatives from the former Tobacco Control Board; manufacturing and business industry representatives; and others.

The next step, "Taking Stock," included both quantitative and qualitative data analysis. Ms. Carty shared a data grid which aptly reflected the breadth and depth of the problem of disparities across multiple groups and issues. This grid was used to organize the data that were gathered and helped members of the Wisconsin workgroup better understand the disparities and how they might prioritize the needs of diverse communities. Gathering qualitative data on the context of tobacco use and its impact in communities was found to be essential to help understand and address the root causes of tobacco-related disparities. Neighborhood and population assessments that were completed by participants became important sources of data. In addition, the group completed a SWOT analysis to strategically assess Strengths, Weaknesses, Opportunities and Threats to addressing tobacco-related disparities. Step 2 emphasized that tobacco use prevalence data was not enough to document disparities.

The third step "Setting the Direction" identified six critical priorities (outlined below) to include in the plan from an original list of 30. The fourth step was to "Adopt and Refine the Plan" by deciding clear goals and strategies for each priority area. The fifth and final step, "Getting Ready for Action," was to plan and institute a process to disseminate and get further buy-in for the plan.

The strategic planning process took nine months and resulted in six major areas of focus: (data; partnerships, tobacco programming; advocacy; capacity and infrastructure; and population-specific interventions) on which to focus. They are summarized as follows:

Ms. Carty re-emphasized how important strategic planning is to setting a solid foundation and encouraged other state (and/or local) tobacco control programs and partners to follow Wisconsin's lead. She shared a website* that others could visit to learn in more detail about the process and results.

One of the major successes of this process included compiling comprehensive data on tobacco-related disparities on prevalence, disease burden, access to care, relapse rates, and secondhand smoke exposure by race, ethnicity, income, education and age. Though gaps in the data exist, gathering this kind of comprehensive information sets a good precedent for the state to continue to add to the information. In addition, the first ever survey of tobacco use and attitudes among the Southeast Asian Hmong population was implemented. A second major success of this effort was that the Workgroup brought together representatives from each of the four major ethnic organizations in Wisconsin to form a statewide collaborative focused on tobacco control and disparities – a novel event in the state. Finally, this process has resulted in additional funding for tobacco control advocacy efforts within minority communities.

Ms. Carty closed by reminding the committee that the strategic planning process had been documented by CDC and was available both in hard copy and electronic formats. She once again urged other states and local communities to consider replication of this process to successfully address tobacco-related disparities.

Following Ms. Carty's presentation, Dr. Carmona thanked the presenters for the valuable information, and asked the Committee to break for lunch. Following the lunch break there would be an opportunity to ask questions and begin discussion of the issues.

Following the lunch break, Rosemarie Henson asked the Committee for questions and or comments about the morning presentations.


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