NIMHD Director Addresses Smoking Cessation Challenges in Minority Populations

In recognition of National Hispanic Heritage Month, NIMHD Director Dr. Eliseo J. Pérez-Stable presented a special lecture, Tobacco Use Behavior and Health Consequences among U.S. Racial/Ethnic Minorities, on October 13 in the Lipsett Amphitheater at the Clinical Center.

Program participants

In his presentation, Dr. Pérez-Stable discussed smoking prevalence rates by race and ethnicity, light and non-daily smoking, the health effects of second-hand smoke, cessation patterns and interventions, and biological factors in smoking behavior.

According to the 2013 National Health Interview Survey, less educated groups tend to smoke more—those with a GED have the highest smoking rates—and women tend to smoke less than men. For example, 7 percent of Latino women smoke compared with 17.3 percent of Latino men, and 4.8 percent of Asian women smoke compared with 15.1 percent of Asian men.

One study suggests that among Latinos, the association of acculturation and smoking is gender-specific. Latino women who adapt toward English-speaking mainstream society tend to smoke more and pick up other unhealthy behaviors, such as drinking alcohol and eating a poor diet, said Pérez-Stable. Among men, smoking rates decrease and binge drinking behavior decreases with increased acculturation.

In his research, Pérez-Stable found that in comparison to Whites, Latinos are more likely to want to quit because of cigarette smoke effects on others, especially loved ones and family members, and smoking effects on interpersonal relationships and on their own health. Reasons for quitting include family pressure, criticism from family, their children’s health, wanting to set a good example, and even eliminating bad breath and the holes burned in clothes among smokers. Not gaining weight, however, was not a concern for Latinos compared to their White counterparts.

"The United States has come a long way in reducing tobacco use," said Pérez-Stable. "It’s not fast enough for some people, but it is progress."

Lung cancer rates in the U.S. have decreased among all population groups, and the percentage of minorities who are very light (smoke one to five cigarettes per day) and non-daily smokers (has smoked at least 100 cigarettes in their lifetime and fewer than 30 of the past 30 days), has increased. More than 50 percent of Latinos, 44 percent of Asians, and 36 percent of African Americans who smoke cigarettes are very light and non-daily smokers, according to one national study.

"Smoking patterns have changed and will continue to change," said Pérez-Stable. "But the patterns don’t fit with how we have dealt with tobacco use in the last 40 years. We treat smoking as an addiction. Cessation strategies are based on an addiction model. Rather than the exception, very light and non-daily has become the predominant type of smoker."

Because light smokers are less addicted and non-daily smokers are not addicted by definition, pharmaceutical treatment should be modified for these smokers and behavioral interventions directed at light smokers should be adapted for use in self-help, Internet, and quit lines, said Pérez-Stable. No clinical trials have been tested or funded for this type of smoker, he added.

Pérez-Stable pointed out that tobacco companies have traditionally used highly effective advertising campaigns to target youth, women, and minority populations, especially African Americans, in order to gain greater market share. Menthol cigarettes, which are heavily marketed to African Americans, may help explain why this group has a more difficult time quitting, even though they make as many attempts to quit and show the same interest in quitting as Whites. An increased smoking dependence may be caused by cooling the smoke sensation attributed to menthol, but more research is needed, he said.

In addition, nicotine intake (the addictive chemical found in the smoke from tobacco products) per cigarette is 30 percent greater in African Americans, which may explain higher rates (50 percent) of lung cancer in this population. This may also be due to other biological factors such as genetic, environmental, and higher metabolic differences than other groups leading to greater intake of carcinogens.

The dangers of tobacco affect non-smokers, as well. Second-hand smoke is associated with increased risk of attention deficit hyperactivity disorder among children, cervical cancer, and myocardial infarction, and exacerbates asthma and COPD (chronic obstructive pulmonary disease). Further, in utero second-hand smoke tobacco exposure can affect development of the respiratory tract and is related to persistent asthma in children and adolescents, more emergency room visits, and daily and nighttime symptoms such as wheezing, chest tightness, shortness of breath, and cough.

To decrease second-hand smoke exposure, indoor smoking bans are effective and have wide health benefits, said Pérez-Stable. Complete smoking bans in households are more common among Latinos and Asians and less common among African Americans.

"Simple banning of smoking in the home helps people quit," said Pérez-Stable. "There is evidence that this is an efficacious intervention that community groups should promote and advocate. There are two potential benefits—increased cessation and decreased second-hand smoke, especially among children."

While minorities tend to smoke fewer cigarettes and less frequently, this has not translated to more smoking cessation success. In order to increase success, clinicians must be persistent in advising patients, such as making referrals to self-help resources such as quitlines; greater access to health care is needed; more minorities must be recruited for clinical trials and research studies; and self-help, culturally appropriate interventions should be promoted.

For example, the Guia Para Dejar de Fumar, a self-help pamphlet, was the main component in an intervention community study conducted in San Francisco. The Guia is a culturally and linguistically tailored Spanish-language self-help guide written at a 6th grade reading level with color photographs modeling cessation behavior. As a result of the intervention, smoking prevalence decreased and quit attempts increased among both men and women who were less acculturated.

"Clinicians have to play an essential role and we need greater access to health care," said Pérez-Stable. "It’s not just policies about indoor smoking. We need all of these approaches. Over time, we will see people successful at quitting."