1998 Surgeon General’s Report – Highlights

“Cigarette smoking is the leading preventable cause of disease and death in the United States. We have an enormous opportunity to reduce heart disease, cancer, stroke, and respiratory disease among members of racial and ethnic minority groups, who make up a rapidly growing segment of the U.S. population.”
—David Satcher, MD, PhD, Surgeon General

Major Conclusions of the Surgeon General’s Report

• Cigarette smoking is a major cause of disease and death in each of the four population groups studied in this report. African Americans currently bear the greatest health burden. Differences in the magnitude of disease risk are directly related to differences in patterns of smoking.
• Tobacco use varies within and among racial/ethnic minority groups; among adults, American Indians and Alaska Natives have the highest prevalence of tobacco use, and African American and Southeast Asian men also have a high prevalence of smoking. Asian American and Hispanic women have the lowest prevalence.
• Among adolescents, cigarette smoking prevalence increased in the 1990s among African Americans and Hispanics after several years of substantial decline among adolescents of all four racial/ethnic minority groups. This increase is particularly striking among African American youths, who had the greatest decline of the four groups during the 1970s and 1980s.
• No single factor determines patterns of tobacco use among racial/ethnic minority groups; these patterns are the result of complex interactions of multiple factors, such as socioeconomic status, cultural characteristics, acculturation, stress, biological elements, targeted advertising, price of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives.
• Rigorous surveillance and prevention research are needed on the changing cultural, psychosocial, and environmental factors that influence tobacco use to improve our understanding of racial/ethnic smoking patterns and identify strategic tobacco control opportunities. The capacity of tobacco control efforts to keep pace with patterns of tobacco use and cessation depends on timely recognition of emerging prevalence and cessation patterns and the resulting development of appropriate community-based programs to address the factors involved.

Trends in Tobacco Use Vary

African Americans

• In the 1970s and 1980s, death rates from respiratory cancers (mainly lung cancer) increased among African American men and women. In 1990–1995, these rates declined substantially among African American men and leveled off in African American women.
• Middle-aged and older African Americans are far more likely than their counterparts in the other major racial/ethnic minority groups to die from coronary heart disease, stroke, or lung cancer.
• Smoking declined dramatically among African American youths during the 1970s and 1980s, but has increased substantially during the 1990s.
• Declines in smoking have been greater among African American men with at least a high school education than among those with less education.

American Indians and Alaska Natives

• Nearly 40% of American Indian and Alaska Native adults smoke cigarettes, compared with 25% of adults in the overall U.S. population. They are more likely than any other racial/ethnic minority group to smoke tobacco or use smokeless tobacco.
• Since 1983, very little progress has been made in reducing tobacco use among American Indian and Alaska Native adults. The prevalence of smoking among American Indian and Alaska Native women of reproductive age has remained strikingly high since 1978.
• American Indians and Alaska Natives were the only one of the four major U.S. racial/ethnic groups to experience an increase in respiratory cancer death rates in 1990–1995.

Asian Americans and Pacific Islanders

• Estimates of the smoking prevalence among Southeast Asian American men range from 34% to 43%—much higher than among other Asian American and Pacific Islander groups. Smoking rates are much higher among Asian American and Pacific Islander men than among women, regardless of country of origin.
• Asian American and Pacific Islander women have the lowest rates of death from coronary heart disease among men or women in the four major U.S. racial/ethnic minority groups.
• Factors associated with smoking among Asian Americans and Pacific Islanders include having recently moved to the United States, living in poverty, having limited English proficiency, and knowing little about the health effects of tobacco use.

Hispanics

• After increasing in the 1970s and 1980s, death rates from respiratory cancers decreased slightly among Hispanic men and women from 1990–1995.
• In general, smoking rates among Mexican American adults increase as they learn and adopt the values, beliefs, and norms of American culture.
• Declines in the prevalence of smoking have been greater among Hispanic men with at least a high school education than among those with less education.
• Factors that are associated with smoking among Hispanics include drinking alcohol, working and living with other smokers, having poor health, and being depressed.

Choosing Health

• More than 10 million African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics smoke cigarettes. Without intervention, this number may swell in the coming decade.
• Both direct and passive exposure to tobacco smoke poses special hazards to pregnant women, babies, and young children. Babies and children who are exposed to tobacco smoke have more ear infections and asthma and die from SIDS more often. Mothers who smoke during pregnancy are more likely to have low birthweight babies and put their babies at increased risk of SIDS.
• Smoking trends today will determine how heavy the health burden will be among communities tomorrow. Programs that reflect cultural diversity will be the cornerstone in the battle against tobacco use.

Powerful Influences Undermine Public Health Efforts

• Smoking is associated with depression, psychological stress, and environmental factors such as peers who smoke and tobacco marketing practices.
• Tobacco advertisements promote the perception of cigarette smoking as safe and far more widespread and socially acceptable than is actually the case.
• Tobacco companies garner community loyalty by hiring community members, providing communities with tobacco sales and advertising revenues, funding community organizations, and supporting educational, political, cultural, and sports activities.

Helping People Enjoy Smoke-Free Lives

• Group approaches for quitting smoking generally have not been successful with members of racial/ethnic minority groups, possibly because the processes used have not been culturally relevant or because of a lack of transportation, money, or access to health care.
• To be effective in discouraging tobacco use among young people, strategies should include restricted access to tobacco products, school-based prevention programs, and mass media campaigns geared to young people’s interests, attitudes, and cultural values.
• Most successful programs for quitting smoking do more than deliver culturally appropriate messages. They provide practical information about the health consequences of tobacco use, resources to help people quit, and specific techniques for quitting.

Facts At-A-Glance

• In the 1970s and 1980s, smoking rates declined substantially among African American youths, regardless of gender, self-reported school performance, parental education, and personal income, but have increased markedly since 1992.
• If current patterns continue, an estimated 1.6 million African Americans who are now under the age of 18 will become regular smokers. About 500,000 of those smokers will die of a smoking-related disease.
• Studies show that adverse infant health outcomes (e.g., the likelihood of pregnant women delivering low birthweight babies, SIDS, and high infant mortality) are especially high for African Americans and American Indians and Alaska Natives. Cigarette smoking also increases these risks, especially for SIDS, among Asian Americans and Pacific Islanders and among Hispanics.
• In all four racial/ethnic minority groups, the percentage of persons who have ever smoked and have quit increases with increasing age.
• In all racial/ethnic minority groups except African Americans, men are more likely than women to use smokeless tobacco.
• Asian Americans and Pacific Islanders are the least likely of the four U.S. racial/ethnic minority groups to smoke, but several local surveys report very high smoking rates among recent male immigrants from Southeast Asia.
• Most African American, Asian American and Pacific Islander, and Hispanic smokers smoke fewer than 15 cigarettes a day. Heavy smoking—25 or more cigarettes a day—is most common among American Indians and Alaska Natives, but still lower than among whites who smoke.

Both complete and summary versions of Tobacco Use Among U.S. Racial/Ethnic Groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General are available.

Health Effects

• Stroke is associated with cerebrovascular disease and is a major cause of death in the United States. Smoking significantly elevates the risk for stroke. Cerebrovascular disease is twice as high among African-American men (53.1 per 100,000) as among white men (26.3 per 100,000) and twice as high among African-American women (40.6 per 100,000) as among white women (22.6 per 100,000).

Cigarette Smoking Behavior

• Approximately three of every four African-American smokers prefer menthol cigarettes. Among whites, approximately a quarter of smokers prefer menthol cigarettes. Menthol may facilitate absorption of harmful cigarette smoke constituents.
• Among adult African-American smokers, the most popular brands are Newport, Kool, and Salem. Similar brand preference was found among African-American teens with 61.3% preferring Newport, 10.9% preferringg Kool, and 9.7% preferring Salem.

Prevalence of Other Forms of Tobacco Use

• Aggregated National Health Interview Survey data from 1987 and 1991 show that more white men (4.8%) smoked cigars than did African-American men (3.9%).
• African-American men (3.1%) use chewing tobacco or snuff less than white men (6.8%).

African Americans and Quitting

• Prevalence of cessation (the percentage of persons who have smoked at least 100 cigarettes and quit) is higher among whites (50.5%) than among African Americans (35.4%).
• Of current African-American adult smokers, more than 70% indicated that they want to quit smoking completely. African-American smokers are more likely than white smokers to have quit for at least one day during the previous year (29.7% compared with 26.0%).

Tobacco Industry Economic Influence

• A one-year study found that three major African-American publications—Ebony, Jet, and Essence—received proportionately higher profits from cigarette advertisements than did other magazines.
• The tobacco industry attempts to maintain a positive image and public support among African Americans by supporting cultural events and making contributions to minority higher education institutions, elected officials, civic and community organizations, and scholarship programs.

Although many tribes consider tobacco a sacred gift and use it during religious ceremonies and as traditional medicine, the tobacco-related health problems they suffer are caused by chronic cigarette smoking and spit tobacco use. Because of the cultural and geographic diversity of American Indians and Alaska Natives, tobacco use often varies widely by region or subgroup.

Health Effects of Tobacco

• Nationally, lung cancer is the leading cause of cancer death among American Indians and Alaska Natives.
• Smoking-attributable deaths from cancers of the lung, trachea, and bronchus were slightly higher among American-Indian and Alaska-Native men (33.5 per 100,000) and women (18.4 per 100,000) than those among Asian-American and Pacific-Islander men (27.9 per 100,000) and women (11.4 per 100,000) and Hispanic men (23.1 per 100,000) and women (7.7 per 100,000) but lower than rates among African-American men (81.6 per 100,000) and women (27.2 per 100,000) and white men (54.9 per 100,000) and women (27.9 per 100,000).
• Cardiovascular disease is the leading cause of death among American Indians and Alaska Natives, and tobacco use is an important risk factor for this disease.

Cigarette Smoking Prevalence

• Smoking rates and consumption among American Indians and Alaska Natives vary by region and state. Smoking rates are highest in Alaska (45.1%) and the North Plains (44.2%) and lowest in the Southwest (17.0%). The prevalence of heavy smoking (25 or more cigarettes per day) is also highest in the North Plains (13.5%).
• Since 1978, the prevalence of cigarette smoking has declined for African-American, Asian-American and Pacific-Islander, Hispanic, and white women of reproductive age (18–44 years) but not for American-Indian and Alaska-Native women. In 1994–1995, the rate of smoking among American-Indian and Alaska-Native women of reproductive age was 44.3%, compared with white (29.4%), African-American (23.4%), Hispanic (16.4%), and Asian-American and Pacific-Islander (5.7%) women of reproductive age.
• Aggregated 1990–1994 Monitoring the Future Survey data show that racial/ethnic smoking prevalence is highest among American Indian and Alaska Native high school seniors (males, 41.1%; females, 39.4%) followed by white high school seniors (males, 33.4%; females, 33.1%), Hispanics (males, 28.5%; females, 19.2%), Asian Americans and Pacific Islanders (males, 20.6%; females, 13.8%), and African Americans (males, 11.6%; females, 8.6 %).

Cigarette Smoking Behavior

• Compared with whites, American Indians and Alaska Natives smoke fewer cigarettes each day. In 1994–1995, the percentage of American Indians and Alaska Natives who reported that they were light smokers (smoking fewer than 15 cigarettes per day) was 49.9%, compared with 35.3% for whites.

Prevalence of Other Forms of Tobacco Use

• Aggregated National Health Interview Survey data from 1987 and 1991 show that 5.3% of American-Indian and Alaska-Native men smoked cigars, compared with 4.8% of white men and 3.9% of African-American men.
• Pipe smoking prevalence was higher among American Indians and Alaska Natives (6.9%), compared with whites (2.9%), African American (2.4%), and Asian Americans and Pacific Islanders (2.3%), who smoked pipes at nearly similar rates.
• Among men and women combined, the use of chewing tobacco or snuff was 4.5% among American Indians and Alaska Natives, compared with 3.4% for whites, 3.0% for African Americans, 0.8% for Hispanics, and 0.6% for Asian Americans and Pacific Islanders.
• The use of smokeless tobacco among American-Indian and Alaska-Native men varies by state and region. The prevalence among men is highest in the Northern Plains (24.6%) and lowest in the Pacific Northwest (1.8%).

Tobacco Industry Influence

• To build its image and credibility in the community, the tobacco industry targets American Indians and Alaska Natives by funding cultural events such as powwows and rodeos.
• The tobacco industry commonly uses cultural symbols and designs to target racial/ethnic populations that include American Indians and Alaska Natives. American Spirit™ cigarettes were promoted as “natural” cigarettes; the package featured an American Indian smoking a pipe. In addition, certain tobacco product advertisements have used visual images, such as American-Indian warriors, to target their product.

Health Effects

• Smoking is responsible for 87% of the lung cancer deaths in the United States. In 1993, lung cancer was the leading cause of cancer death (22.3%) among Asian Americans and Pacific Islanders.
• The death rate for lung cancer was 27.9 per 100,000 for Asian-American and Pacific-Islander men and 11.4 per 100,000 for women. Among subgroups, both Hawaiian men (88.9 per 100,000) and women (44.1 per 100,000) had the highest rate of lung cancer deaths, and Filipino men (29.8 per 100,000) and women (10.0 per 100,000) had the lowest.
• Asian Americans and Pacific Islanders had the lowest rates of death from coronary heart disease among the primary racial/ethnic groups in the United States. Among Asian-American and Pacific-Islander subgroups, Koreans (82 per 100,000) had the lowest death rates for cardiovascular diseases and Japanese (162 per 100,000) had the highest death rates.

Cigarette Smoking Prevalence

• In 1997, 21.6% of Asian-American and Pacific-Islander men smoked, compared with 27.4% of white men. However, Asian-American and Pacific-Islander women (12.4%) were significantly less likely to smoke than white women (23.3%). Smoking rates are much higher among Asian-American and Pacific-Islander men than among Asian-American and Pacific-Islander women, regardless of country of origin.
• A 1990–1991 California survey estimated that smoking rates for men were 35.8% for Korean Americans, 24% for Filipino Americans, 20.1% for Japanese Americans, and 19.1% for Chinese Americans. Among women, smoking prevalence was 14.9% for Japanese Americans, 13.6% for Korean Americans, 8.9% for Filipino Americans, and 4.7% for Chinese Americans.
• Among high school seniors, aggregated 1990–1994 Monitoring the Future Survey data show that for racial/ethnic groups, smoking prevalence was highest among American Indians and Alaska Natives (males, 41.1%; females, 39.4%) followed by whites (males, 33.4%; females, 33.1%), Hispanics (males, 28.5%; females, 19.2%), Asian Americans and Pacific Islanders (males, 20.6%; females, 13.8%), and African Americans (males, 11.6%; females, 8.6%).
• Among Asian-American and Pacific-Islander high school seniors 4.4% of male students and 4.5% of females students reported smoking one-half pack or more per day.

Cigarette Smoking Behavior

• Research shows an association between cigarette smoking and acculturation among Asian American and Pacific Islander adults from Southeast Asia. Those who had a higher English-language proficiency and those living in the United States longer were less likely to be smokers.
• Among Chinese men, the average number of cigarettes smoked per day increased with the percentage of their lifetime spent in the United States.
• Among Viet Namese, the prevalence of smoking was higher among men who immigrated to the United States in 1981 or later and who were not fluent in English.

Asian Americans and Pacific Islanders and Quitting

• Among current smokers, Asian Americans and Pacific Islanders were slightly more likely than white smokers to have quit for at least one day during the previous year (32.0%, compared with 26.0%). Asian Americans and Pacific Islanders (2.5%), however, are less likely than whites (3.4%) to remain abstinent for 1 to 90 days.
• According to aggregated 1994–1995 National Health Interview Survey data, the prevalence of cessation among Asian Americans and Pacific Islanders aged 55 years and older was higher than among younger Asian Americans and Pacific Islanders.
• A community intervention trial for Viet Namese men conducted in San Francisco significantly increased the likelihood of quitting smoking. This program included a long-running anti-tobacco media campaign and school- and family-based components.

Tobacco Industry Influence

• Studies have found a higher density of tobacco billboards in racial/ethnic minority communities. For example, a 1993 study in San Diego, California, found the highest proportion of tobacco billboards were posted in Asian-American communities and the lowest proportion were in white communities.
• Among racial/ethnic minority communities in San Diego, the highest average number of tobacco displays was found in Asian-American stores (6.4), compared with Hispanic (4.6) and African-American (3.7) stores.

Health Effects

• Smoking is responsible for 87% of the lung cancer deaths in the United States. Overall, lung cancer is the leading cause of cancer deaths among Hispanics.
• Lung cancer deaths are about three times higher for Hispanic men (23.1 per 100,000) than for Hispanic women (7.7 per 100,000). The rate of lung cancer deaths per 100,000 were higher among Cuban-American men (33.7) than among Puerto-Rican (28.3) and Mexican-American (21.9) men.
• Coronary heart disease is the leading cause of death for Hispanics living in the United States. Among Hispanic subgroups in 1992–1994, death rates for coronary heart disease were 82 per 100,000 for Mexican-American men and 44.2 per 100,000 for Mexican-American women, 118.6 per 100,000 for Puerto-Rican men and 67.3 per 100,000 for Puerto-Rican women, and 95.2 per 100,000 for Cuban men and 42.4 per 100,000 for Cuban women.

Prevalence of Other Forms of Tobacco Use

• Aggregated National Health Interview Survey data from 1987 and 1991 show that more Cuban-American men (2.5%) smoked cigars than Mexican-American (1.5%) and Puerto-Rican (1.3%) men.

Tobacco Industry Influence

• Tobacco products are advertised and promoted disproportionately to racial/ethnic minority communities. Examples of target promotions include the introduction of a cigarette product with the brand name “Rio” and an earlier cigarette product named “Dorado,” which was advertised and marketed to the Hispanic-American community.
• To increase its credibility in the Hispanic community, the tobacco industry has contributed to programs that aim to enhance the primary and secondary education of children, has funded universities and colleges, and has supported scholarship programs targeting Hispanics. Tobacco companies have also placed advertising in many Hispanic publications. The industry also contributed to cultural Hispanic events and provide significant support to the Hispanic art community.