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1. PRESS RELEASE

2. KEY FINDINGS AT A GLANCE

3. FORWARD AND PREFACE

4. FOR EVEN MORE INFORMATION

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PRESS RELEASE:

SURGEON GENERAL'S REPORT WARNS OF HEALTH REVERSALS
AS MINORITY TEEN SMOKING INCREASES

First Report on Tobacco and Minorities Is Issued

Rapid increases in smoking by minority teenagers threaten to reverse the progress against lung cancer among minority populations which was made during the early 1990s, according to a new Surgeon General’s report released today. Today’s report is the first in the 34-year history of Surgeon General studies on tobacco and health to focus on tobacco use among ethnic and racial minorities.

"We are witnessing the first steps of a potentially tragic reversal for the health of American minorities," said Dr. David Satcher in releasing his first report as Surgeon General, and the 24th Surgeon General’s report to focus on tobacco use since 1964. "Where we once saw hopeful signs of declining lung cancer among minorities in the early years of this decade, we now see striking increases in smoking by minority youth. Unless we can reverse these trends, they are bound to result in more lung disease and early death for these populations.

"We cannot sit by and let these disturbing trends occur unchallenged. We must call attention to this threat, and we must fight it," Dr. Satcher said.

"This new report clearly shows tobacco’s increasing grip on racial and ethnic minorities -- the fastest growing segments of the American population," said HHS Secretary Donna E. Shalala. "This new report underscores the need for Congress to pass comprehensive tobacco legislation this year based on the President’s five key principles that includes a significant price increase and a plan to dramatically reduce youth tobacco use."

Today’s report surveys tobacco use and its health consequences among all four major U.S. racial and ethnic minority groups: African-American, American Indian/Alaska Native, Asian American/Pacific Islander, and Hispanic. According to the report, cigarette smoking is a major cause of death and disease in all four groups. African-American men bear one of the greatest health burdens of the four ethnic groups, with death rates from lung cancer that are 50 percent higher than those of white men.

Dr. Satcher noted that the four groups studied by his new report make up about one-fourth of the U.S. population and are growing rapidly. By the year 2050, members of these racial/ethnic minority groups will comprise close to one-half of the United States population.

"This report sounds an urgent alarm," said Dr. Satcher. "We must use every tool at our disposal to reduce tobacco use among racial and ethnic minorities -- especially among adolescents -- and to reverse these frightening trends."

From 1990-1995, death rates from respiratory cancers declined substantially among African-American men, declined to a lesser extent among Hispanic men and women, and leveled off among African-American women. Death rates increased only among American Indians/Alaska Natives -- the only group for which smoking rates increased during this period.

In recent years, however, tobacco use among adolescents from racial and ethnic minority groups has begun to increase rapidly, threatening to reverse the progress made against lung cancer among adults in these minority groups. Though their rates remain considerably lower than those of whites, cigarette smoking among African-American and Hispanic adolescents has increased in the 1990s after several years of substantial declines among adolescents of the major racial and ethnic groups. This increase is particularly striking among African-American youths, who had the greatest decline of the four groups during the 1970s and 1980s, but the steepest increase in use in the 1990s. Cigarette smoking among African-American teens has increased 80 percent over the last six years -- three times as fast as among white teens.

"Unless they are reversed, these increases in tobacco use are a time-bomb for the health of our minority populations," Dr. Satcher said. "If tobacco use continues to increase among minority adolescents, we can expect severe health consequences to begin to be felt in the early part of the next century."

In releasing the new report, Dr. Satcher also emphasized the implications of increased tobacco use on children’s health.

"Not only does tobacco shorten the lives of kids who start smoking, but babies and children who are exposed to tobacco smoke have more ear infections, asthma, and a higher incidence of Sudden Infant Death Syndrome. Mothers who smoke during pregnancy are more likely to have a low birthweight baby and put their babies at increased risk of SIDS," emphasized Dr. Satcher.

The Surgeon General’s report notes that prevalence of tobacco use varies among and within racial and ethnic groups. For example, American Indians/Alaska Natives have the highest rates of tobacco use, and African-American and Southeast Asian men also have a high prevalence of smoking. Asian American women and Hispanic women have the lowest levels of smoking. The report also shows that, in general, smoking rates among Mexican-American adults increase as they learn and adopt the values, beliefs, and norms of American culture.

According to the report, more prevention research is needed to understand patterns of tobacco use and factors that affect tobacco use. Questions also remain about differences in tobacco-related disease and death rates among racial/ethnic minority groups.

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Surgeon General's Report AT-A-GLANCE:

Tobacco Use Among U.S. Racial/Ethnic Minority Groups

A Report of the Surgeon General

"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 percent of American Indian and Alaska Native adults smoke cigarettes, compared with 25 percent 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 percent to 43 percent—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. American Indians and Alaska Natives

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.

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FOREWORD AND PREFACE

Foreword

The United States of America is a rich blend of cultures. This diversity demands close attention from the agencies and individuals responsible for protecting the public’s health. For too long in tobacco control, attention to diversity has been less consistent than is necessary for planning and developing effective health programs. As a result, we sometimes lack sufficient information on which to base tobacco control interventions. With this report, we begin to address such problems and point the way to filling these gaps in knowledge.

Tobacco use causes devastating disease and premature death in every population in the United States. For four major U.S. racial/ethnic minority groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics—patterns of tobacco use, adverse health effects, and the effectiveness of interventions need to be understood in terms of tobacco’s cultural and socioeconomic effects on the members of these groups. This report describes the complex factors that play a part in the growing epidemic of diseases caused by tobacco use in these four groups.

Since 1964 when the first Surgeon General’s report on smoking and health was released, this report is the first to focus exclusively on tobacco use among members of these four racial/ethnic groups. Together these groups constitute about 25 percent of the U.S. population, and that proportion is growing rapidly. Public health programs must effectively address the health needs of this significant proportion of people. Such action is of paramount importance to reducing tobacco use in the United States and meeting national health objectives for the year 2000. We hope that this report will provide the basis for renewing our commitment to develop more effective tobacco control programs and policies for people of every racial and ethnic background. In addition, the report can be used by parents and communities as a tool to develop their own solutions. With continued diligence, we shall strive to reach and exceed whenever possible our stated health goals by the year 2000 and reduce the enormous health burden caused by tobacco products.

Claire V. Broome, M.D., Acting Director Centers for Disease Control and Prevention, and Acting Administrator, Agency for Toxic Substances and Disease Registry

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Preface from the Surgeon General, U.S. Department of Health and Human Services

Effective strategies are needed to reduce tobacco use among members of U.S. racial/ethnic groups and thus diminish their burden of tobacco-related diseases and deaths. Cigarette smoking is the leading cause of preventable disease and death in the United States. There is enormous potential to reduce heart disease, cancer, stroke, and respiratory disease among members of racial and ethnic groups, who make up the most rapidly growing segment of the U.S. population.

This Surgeon General’s report is the first to address the diverse tobacco control needs of the four major U.S. racial/ethnic minority groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. This report is also the only single, comprehensive source of data on each group’s patterns of tobacco use, physical effects related to tobacco smoking and chewing, and societal and psychosocial factors associated with tobacco use.

The findings detailed in this report indicate that if tobacco use is not reduced among members of these four racial/ethnic groups, they will experience increasing morbidity and mortality from tobacco use. The toll is currently highest for African American adults. Findings also suggest that some close, long-term relationships between tobacco companies and various racial/ethnic communities could hamper U.S. efforts to lower rates of tobacco use by the year 2000. Also notable is the support that members of racial/ethnic groups have shown for legislative efforts to control tobacco use, sales, advertising, and promotion.

As this report goes to press, discouraging news comes from a report published by the Centers for Disease Control and Prevention on the Youth Risk Behavior Survey about tobacco use among African American and Hispanic high school students. Past-month smoking increased among African American students by 80 percent and among Hispanic students by 34 percent from 1991 through 1997. The consistent decline once seen among young African Americans has sharply reversed in recent years. Past-month smoking prevalence increased from 13 percent to 23 percent among African Americans and from 25 percent to 34 percent among Hispanics.

Although cancer remains common in Americans of all racial and ethnic groups, the pattern of increasing lung cancer deaths in the 1970s and 1980s among African American, Hispanic, and some American Indian and Alaska Native subgroups has been halted or reversed for some groups from 1990 through 1995. Some encouraging news from Cancer Incidence and Mortality, 1973–1995: A Report Card for the U.S. was just published by the American Cancer Society, the National Cancer Institute, and the Centers for Disease Control and Prevention. The report described lung cancer trend data from 1990 through 1995 for African Americans, Asian Americans and Pacific Islanders, and Hispanics. Lung cancer death rates declined significantly for African American men and for Hispanic men and women from 1990 through 1995; death rates did not change significantly for African American women or for Asian American and Pacific Islander men or women. Although lung cancer trends may continue to decline among some racial/ethnic groups for several more years, recent increases in smoking prevalence among adolescent African Americans and Hispanics and among Asian American and Pacific Islander adolescent males, coupled with the lack of decline among American Indian and Alaska Native adults, do not bode well for long-term trends in lung cancer.

One purpose of this report is to guide researchers in their future efforts to garner more information needed to develop effective prevention and control programs. Several significant research questions need to be addressed. For example, why are African American youths smoking cigarettes in lower proportions than youths in other racial/ethnic groups? How does acculturation affect patterns of tobacco use among immigrants to the United States? What are the differential effects of gender on tobacco use among members of certain racial/ethnic groups? What racial- and ethnic-specific protective factors and risk factors will promote the development of culturally appropriate interventions to prevent and control tobacco use? And to what extent are culturally specific tobacco control programs necessary to curb tobacco use among racial/ethnic populations? While researchers are redirecting their focus, federal, state, and private tobacco control partners need to address program issues, such as how to develop and evaluate culturally appropriate prevention and cessation interventions.

This report includes examples of numerous racial- and ethnic-specific tobacco control programs used in communities across the country. These and other racial/ethnic group-specific programs must be disseminated to all areas of the country, where program planners can develop their own strategies, taking into consideration the cultural attitudes, norms, expectations, and values of the targeted cultural groups.

In each of these endeavors, we will succeed only if we are sensitive to our cultural differences and similarities. I challenge federal and state agencies as well as researchers and practitioners in the social, behavioral, public health, clinical, and biomedical sciences to join me in the pursuit of effective strategies to prevent and control tobacco use among racial/ethnic groups. By meeting this challenge, we will progress toward achieving the nation’s year 2000 tobacco-related health objectives and will help to prevent the unnecessary disability, disease, and deaths that result from tobacco use.

David Satcher, M.D., Ph.D., Surgeon General and Assistant Secretary for Health

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