SIX. Special Populations

What are the differences between men and women regarding rates of tobacco use, history of tobacco use, and their health risks?

There are many differences between men and women regarding smoking and tobacco addiction. Men start smoking earlier than women, usually in their early teens, inhale more deeply, but have an easier time quitting. They often quit while they are still relatively young. Women, on the other hand, start smoking later, usually in their late teens or early twenties, smoke less, do not inhale as deeply as men, tend to smoke "lighter" or filtered cigarettes, but have a much harder time quitting.

Both physiological and social factors may contribute to a woman's greater dependence on nicotine. Physiological factors include the body weight/mass index (women carry more body fat than men). When examining social factors related to gender differences of smoking behaviors, male smokers tend to be loners while female smokers tend to gather in groups and socialize while they smoke. When it comes to treatment, women using nicotine gum therapy reported greater withdrawal symptoms than men. (See Question 63 for more information about medication therapy for women.) More research is needed to better understand such gender differences. Results from gender-based studies might provide guidelines that tailor effective smoking cessation treatment strategies for each gender.

What are the differences in the rates of tobacco use among different ethnic groups?

Native Americans and Alaskan Natives

Men start smoking earlier than women, usually in their early teens, inhale more deeply, but have an easier time quitting.

Today there are 562 federally recognized Native American tribes in the United States. Each tribe has its own language, customs, and rituals, particularly regarding the use of tobacco. Prevalence rates of smoking vary among tribes from region to region. The highest tobacco use is in Alaskan Natives; and the next region with a high rate of smoking is the Northern Plains tribes, while the lowest rate of tobacco use is found in the Southwestern tribes.

Native Americans have a high rate of addiction to alcohol and drugs of all types, including tobacco. Alcoholism among Native Americans may be due to a genetic vulnerability. Drinking alcohol and smoking are behaviors that frequently go hand-in-hand. Thus, alcoholism may be a contributory factor in the rate of heavy smoking among Native Americans and Alaskans. Poverty and a lack of education are also strongly associated with smoking. Native Americans tend to be less educated and tend to be poorer than other U.S. ethnic minorities. Many live at or below the poverty line because of a lack of economic opportunities on reservations. A higher percentage of smokers exist across all socioeconomic groups. Forty-one to forty-two percent of Native Americans and Alaskan natives smoke, which is a much higher statistic than all other Americans. Consequently, there is a high mortality rate from smoking among them, two times greater than among other Americans. Native Americans frequently die of cardiovascular diseases, lung cancer, and cancers of the bronchus^[1] and trachea.

Cultural and Spiritual Factors

Tobacco was used for spiritual, social, and political purposes. Tobacco also was used for medicinal healing and in agriculture. Tobacco is considered a sacred gift and has played an important role in Native American culture throughout history. (Questions 2 and 3 discuss the many uses of tobacco.) During the fur trading era of the seventeenth and eighteenth centuries, traditional uses of tobacco became combined with commercial uses. The importance of tobacco as central to many sacred ceremonial events has diminished since Indians became acculturated into the dominant European culture. The current use of tobacco does not resemble how it was used in the past.

Native American Women

The rate of smoking is also higher among Native American women (34.5%) than the rest of American women. This percentage is even higher among those living in the Northern Plains states (43.5%). Pregnant women who are smokers tend to continue to smoke while pregnant, which results in underweight newborns or miscarriages.

Native American Teens

The number of Native American teens who smoke is more than double the number of all other high school students from other ethnic groups. Indian Reservations are considered sovereign states and therefore are not subject to state laws that prohibit the sale of tobacco products to minors. Indian nation states do not levy taxes on cigarette sales, which may contribute to the higher prevalence of smoking. Easy access to low-cost tobacco products probably contributes to the numbers of teens who use tobacco products.

Besides smoking, the use of smokeless tobacco is more prevalent among Native American teens. A significant number of young Native Americans age 15 to 24 use smokeless tobacco products. Fourteen percent of males and 2% of females use smokeless tobacco, compared to 5.2% of American males and 1.5% of American females from other ethnic groups.

The Elderly

The rate of Native American smokers who are over 65 is the highest in the nation, 20% higher than in the general population. As a result, tobacco use has resulted in a high rate of tobacco-related diseases among Native Americans, which kills close to 10,000 Native Americans yearly. This is double the death rate for all other Americans dying from tobacco use.

Prevention and Smoking Cessation Programs

Concerted efforts by the Indian Health Service and the American Cancer and Lung Associations are underway to assist Native American communities to establish smoking cessation and primary prevention programs. Prevention strategies involve peer-to-peer counseling and changes in advertising and access to tobacco products. Teens are trained by tribal leaders to be peer counselors. Native American communities have passed anti-tobacco policies to reduce the incidence of smoking and the exposure of their citizens to secondhand smoke. Billboards advertising tobacco products are banned. Culturally sensitive smoking prevention materials are handed out during community events, such as pow-wows, potlatches, health fairs, rodeos, sporting events, and festivals. School programs similar to other school programs on tobacco prevention are taught in the public and private schools. Media campaigns targeting high-risk youth are aired on the radio and TV to reduce the initiation of new smokers.

Hispanics

Among Hispanic smokers living on the U.S. mainland, Cubans comprise 61.5% of the smokers and Puerto Rican Americans amount to 4.2% of the smokers. Mexican Americans are lighter smokers than other Hispanics, Anglos, and Blacks. More Hispanic men smoke than women, by 21.1%. Those Hispanics who do smoke are able to quit more easily than their non-Hispanic counterparts. Many of the women stop smoking during pregnancy. If Hispanic women smoke at all, they begin later in life. Generally, all Hispanics consume fewer cigarettes each day compared to other ethnic groups. Twenty-two percent of Hispanic high school students are smokers. Many of the Hispanic male smokers are among the more poorly educated, and have jobs such as day laborers or migrant workers. Being Hispanic appears to be a protection against a smoking addiction.

Asian Americans

Asian Americans are among the smallest group of smokers in the United States. However, even though the overall rates of smoking among Asian Americans are low, the rate of smoking among Asian American men is significantly higher than the rate of smoking among Asian American women. Only 13.3% of Asian Americans currently smoke, and of those who do smoke, only 6.1% of the smokers are women.

African Americans

During the twentieth century, African Americans began smoking later than Caucasians in the history of tobacco use. Many black women have never smoked, but men who are poor, uneducated, and work in low paying jobs have a higher rate of smoking than their better educated and employed counterparts. By the 1960s, rates of smoking among blacks and whites were similar. Mentholated cigarettes were heavily advertised in the black media as being safer (Kools, Newport, Salems). As rates of smoking began to decline in the 1970s and early 1980s, advertising agencies for the tobacco companies began to devote more money to promote sales among black teens. Billboards targeting African American communities were concentrated in poorer urban neighborhoods. A 1987 survey of St. Louis found that black neighborhoods had three times as many billboards as white neighborhoods advertising cigarettes.

Disproportionately, black men are more likely to develop lung cancer than white men, even though black men smoke fewer cigarettes. African Americans may have metabolic differences that are genetically based, which leads to an inability to detoxify the carcinogens in tobacco. The menthol in mentholated cigarettes has numbing properties so that the smoker inhales the smoke more deeply into the lungs. African Americans' preference for mentholated cigarettes may explain why they are more prone to lung cancer.

• [1] The large airway of the lungs. No gas exchange between the lungs and the bloodstream occurs here.