Why is Ethnicity Important to Cessation?

Ethnic Groups

Recent research suggests that cigarette smoking among US adults has been declining in the general population, from 18.1% in 2012 to 14% in 2019.^1,2 Despite these advances, some racial and ethnic groups face relatively higher rates of cigarette smoking. For example, American Indians/Alaskan Natives are estimated to make up 1.3% of the US population but make up 20.9% of cigarette smokers.^2,3 Thus, in the interest of driving down such disparities, it is critical for current health care providers and public health entities to address tobacco use among different ethnic groups by offering educational, pharmacological, and behavioral interventions. 

Influencing factors for smoking among different ethnicities

The significant variation in smoking rates among different ethnic groups and disparities in tobacco related health issues among minority ethnic groups, has warranted active effort among researchers for correlates and causes. Some of the most common factors that have been shown to influence smoking rates among different ethnic groups are socioeconomic status (SES), reduced access to health care, language barriers, and stress levels.  

For example, while a majority (68%) of smokers want to quit, low SES smokers often don’t have access to the cessation resources typically provided by a health care provider.⁴ In addition, researchers have found that individuals with lower SES are more likely to struggle in following cessation instructions and less likely to successfully complete an intervention program.⁴ 

Smoking prevalence by ethnicity

The following data represents the percentages of adult cigarette smokers in the United States by ethnicity in 2019 with comparison data from 2012. 

Ethnicity	Percentage of US adult cigarette smokers
	20121	2019 2
American Indian/Alaska Natives	25.5%	20.9%
White*	17.2%	15.5%
Black	19.7%	14.9%
Hispanic**	14.6%	8.8%
Asian***	10.7%	7.2%
Other	26.1%	19.7%

*Whites are not considered an ethnic minority in the US; information included on the table is to be used as a comparison. 

**All groups besides Hispanic report on non-Hispanic data  

*** Asian here excludes Native Hawaiians and Pacific Islanders 

American Indians/Alaska Natives

American Indians and Alaska Natives have the highest rates of cigarette smoking (20.9%) compared to other ethnic groups.² Several explanations have been postulated to explain this disparity. One potential reason being that cigarettes are sold at a lower price on reservations as states cannot regulate tobacco sales on tribal lands.⁵ Lower socioeconomic status may also account for some of the disparity seen in this group as American Indians and Alaska Natives experience the US’s highest poverty rate by race at 25.4%.⁶ 

Certain cultural practices may also explain why Native Americans have higher rates of cigarette smoking. Tobacco is sometimes used during religious ceremonies and as medicine.⁷  Additionally, research has found that commercial tobacco products, heavy with additives and high nicotine levels, are increasingly being used in religious ceremonies as opposed to traditional preparations.⁷ 

African American

In 2019, 14.9% of Black US adults smoked cigarettes.² Cigarette companies are known to more aggressively market cigarettes, particularly menthol cigarettes, in predominantly Black communities.⁸ Even though Black smokers use fewer cigarettes per day, they have lower rates of successful quit attempts compared to White smokers.^2,4 Menthol flavored cigarettes have a higher rate of usage by Black smokers compared to other ethnic groups. and menthol is thought to make cigarettes more addictive.⁹ Black smokers additionally utilize less counseling and/or medication (28.9%) compared to White smokers (34.3 %).² Additionally, while White adults consume more cigarettes overall, Black smokers have a higher mortality rate from smoking related diseases.¹⁰  

Hispanic/ Latinos

In 2019, 8.8% of Hispanic U.S. adults smoked cigarettes. ² Despite the lower smoking rates among Hispanics, it has been shown that Hispanic smokers report less usage of cessation counseling and/or medication (19.2%) than White smokers (34.3%).⁴ Hispanic adults are the largest racial and/or ethnicity group of uninsured individuals in the U.S. making it less likely that they will be advised by a health care provider to quit smoking cigarettes. ^4,11 There are also several variations amongst Hispanic sub-groups. For instance, Puerto Ricans have the highest smoking rate (28.5%) followed by Cubans (19.8%), Mexicans (19.1%), and Central/South Americans (15.6%).¹² 

Asian Americans and Native Hawaiian/Pacific Islanders

Rates of cigarette smoking are lowest among adult Asian Americans and Native Hawaiian/Pacific Islanders compared to other ethnicities. In 2019, 7.2% of this population smoked cigarettes.² Asian smokers report less usage of cessation counseling or medication (20.5%) than white smokers (34.3%).² Unfortunately, how Asian-American population data is collected can mask meaningful differences in health and health risks among Asian ethnicities. For example, Koreans have the highest rate of smoking (20.0%), followed by Vietnamese (16.3%), Filipino (12.6%), Japanese (10.2%), Asian Indian (7.6%), and Chinese (7.6%).¹² 

Health Effects

Because smoking rates vary by ethnicity, there is variation in the way each ethnic group is affected by cigarette smoking. Cigarette smoking has been found to increase the risk of developing several diseases, exacerbating current health conditions, and reduces the overall life-span of a smoker by roughly 10 years.² Among the most common diseases that are caused by or affected by smoking include:¹³ 

• Cardiovascular disease 

• Respiratory disease 

• Cancer (various types) 

• Diabetes 

• Adverse reproductive issues 

• Rheumatoid arthritis 

Cancer, cardiovascular disease, respiratory disease and diabetes are leading causes of death among all racial groups and all are made worse or acquired through smoking.¹³ The most common disease often associated with cigarette smoking is lung cancer, with smoking accounting for about 80% of lung cancer deaths in the U.S. among all racial and ethnic groups.¹⁰ However, consumption level may not correlate to health effects. Specifically, even though American Indians have the highest smoking rates, Black smokers are more likely to develop and die from lung cancer than and other racial or ethnic group.¹⁴ 

Culturally Appropriate Prevention and Intervention Efforts

As research has highlighted, there are various factors that influence smoking behavior among different ethnic groups and differences in the way it affects their health.  It is important to approach and be mindful how a patient’s cultural views influence their health behaviors. Historically, most cessation programs in the United States have focused on “one size fits all programs” and have viewed smokers as a homogenous population as opposed to individuals with unique cultural and ethnic backgrounds. Research stresses the need for culturally adapted interventions and prevention strategies which have been found to produce higher abstinence rates.^3,15 

Studies have looked at the efficacy of different approaches among ethnicities: 

• American Indian participants in a culturally tailored smoking cessation program were approximately twice as likely to quit smoking at 6 months compared with those enrolled in a current best practices program, using self-reported abstinence.¹⁶ 

• A study comparing cessation rates among of White (52%), Black (32%) and Latino (56%, any race) smokers utilizing motivational interviewing, found that the odds of quitting increased by 17% for each encounter participants had with a peer coach that had cultural competency knowledge and was a previous smoker.¹⁷ 

• One study demonstrated that Hispanics who receive culturally specific smoking cessation interventions that are in their preferred language are more likely to quit smoking than those receiving standard interventions.¹⁸ 

Current guidelines for healthcare practitioners operating cessation clinics advise using a combination of brief interventions/cessation advice, motivational interviewing, group/individual therapy, education, Nicotine Replacement Therapy (NRT), and/or pharmacotherapy to promote cessation among smokers.¹⁹ In addition, taking advantage of “teachable moments” i.e. life changes, new health diagnoses, etc. to provide cessation advice and intervention is being increasingly used by health practitioners and shows some efficacy in motivating patients to quit.⁹ Tailoring these approaches to individual’s specific cultural backgrounds can aid in creating the best intervention.¹⁵ 

Quitlines

Quitlines are telephone-based support programs that provide efficacious treatment for people who want to quit smoking.¹⁹ Quitlines are a convenient and helpful way to initiate the quitting process as they are accessible from anywhere smokers may be, as long as they have access to a telephone. 

    Research has shown that minority groups are benefiting from Quitlines: 

• One study found that African American smokers are more likely to use Quitlines compared to other ethnic groups. In addition, Asian language speakers are reaching out to Quitlines just as much as Whites.²⁰ 

• Another study, examining differences in Quitline utilization across the U.S., found similar, and in some cases higher utilization of Quitlines by ethnic minorities compared to Whites. Utilization ranged (by state) from 0.08% - 3.42% among non-Hispanic whites, 0.17% - 3.85% among non-Hispanic Blacks, 0.27% - 9.98% among non-Hispanic American Indians/Alaska Natives, 0.03% - 2.43% among non-Hispanic Asian/Pacific Islanders, and 0.08% - 3.18% among Hispanics.²¹ 

Helpful Links

• CDC-funded National Networks: This website provides information on the CDC-funded National Networks for tobacco prevention and control initiative. http://www.ttac.org/resources/specific_populations.html
• Tobacco Research Network on Disparities: http://www.tobaccodisparities.org/
• Asian Smokers Quitline: http://www.asiansmokersquitline.org/
• Asian Pacific Partners for Empowerment, Advocacy and Leadership (APPEAL): "A national network of organizations and individuals working towards social justice and a tobacco-free Asian American and Pacific Islander (AAPI) community. Here you will find information and resources about tobacco control issues in Asian American & Pacific Islander communities and other priority populations.": http://www.appealforcommunities.org/
• The National African American Tobacco Education Network (NAATEN) "NAATEN is a collaborative of national, state and community based organizations serving the African American/Black community.": http://www.naatpn.org/​
• National Tribal Tobacco Prevention Network: Their mission is "to enhance the wellness of American Indian and Alaska Native communities by providing culturally appropriate tobacco education and prevention resources, technical support, training, networking opportunities and advocacy.": http://keepitsacred.itcmi.org/
• The Intercultural Cancer Council (ICC) "The Intercultural Cancer Council (ICC) promotes policies, programs, partnerships, and research to eliminate the unequal burden of cancer among racial and ethnic minorities and medically underserved populations in the United States and its associated territories. ": http://iccnetwork.org/who/