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Commentary: Tobacco Control/Underserved Populations

Cigarette Smoking Interventions


Among
Diverse Populations
Anita Fernander, PhD; Ken Resnicow, PhD; K. Viswanath; Eliseo J. PerezStable, MD
One of the greatest public health success stories of the past

50 years has been the reduction in cigarette smoking in the United States. Smoking
prevalence has decreased by 50% or more in the United States since the 1960s, and although
recent reports indicate a plateau in this decline, the longterm downward trend has resulted in
an overall smoking prevalence rate of 20.6% in 2009. Despite this success, the Healthy
People 2010 objective of reducing the prevalence of cigarette smoking among adults to 12%
or less has not been realized. This is, in large part, due to the fact that tobacco control efforts
have not impacted population subgroups equally. In general, racial/ethnic minority groups
and persons of lower socioeconomic status (SES) have not benefited as much as whites and
those of higher SES from smoking prevention and cessation programs. If we are to meet the
goal of 12% or less smoking prevalence among the overall adult population, more effort is
needed to influence tobacco use behaviors among racial/ethnic and low SES populations.
Articles in this special issue of the American Journal of Health Promotion address how and to
what extent tobacco control efforts can be implemented to reduce the burden of cigarette
smoking among racial/ethnic minority and low SES groups. Understanding how to effectuate
behavior change in these populations is paramount if we are to achieve both our national
health objective of reducing cigarette smoking and improve the nations health status overall.
Reductions in the prevalence of cigarette smoking have occurred because of multiple
strategies, which include (1) policy changes such as bans on indoor smoking; (2) increased
cigarette taxes; (3) clinical interventions; and (4) dedicated population-based tobacco control
programs, such as mass media campaigns, quit lines, and Web-based interventions.

These tobacco control strategies have also resulted in the reduction of secondhand
smoke exposure, more frequent quit attempts, and fewer cigarettes smoked per day among
persons continuing to smoke.
Recommendations to promote cessation include brief clinical interventions such as
individual, telephone, and group counseling and pharmacotherapy, including five types of
nicotine replacement products and two other classes of medications.6 However, specific
recommendations for racial/ ethnic minorities were omitted in the most recent clinical
practice guidelines6 because of lack of evidence that culturally specific interventions are
more efficacious than general population approaches. This suggests that evidence-based
strategies and programs known to be effective at reducing smoking within the general
population should be tested in randomized clinical trials with sufficient samples of racial/
ethnic minority and low SES participants to determine their efficacy within these groups and
where indicated, programs should be developed specifically for these groups.

Tobacco-Related Disparities by SES and Race/Ethnicity


Low SES continues to be a significant predictor of smoking behavior. Individuals
with a general equivalency diploma (GED) or high school diploma have significantly higher
levels of smoking (49.1%) than those who are college educated (11.1%)1; and individuals
below the poverty level are significantly more likely to smoke (31.1%) compared with those
at or above the poverty level (19.4%).1 Race and ethnicity are also significant predictors of
smoking. For example, American Indians/Alaska Natives (23.2%) are more likely to smoke
than other racial and ethnic groups, although with considerable variations by tribe.1,7 Even
though adult Latinos (14.5%) and Asians (12.0%) are less likely to smoke than other groups,
regional data reveal much higher smoking levels among selected national origin groups such
as Puerto Ricans, Koreans, and Filipinos.
Race/ethnicity and social position are also associated with other important tobaccorelated disparities. Secondhand smoke exposure, determined both by self-report surveys and
cotinine testing, has consistently been found to be higher in African-Americans compared
with whites and Mexican- Americans.9 Secondhand smoke exposure also tends to be higher
among individuals with lower income,9 and blue-collar workers experience particularly high
levels of secondhand smoke exposure relative to other workers.9 Recognizing that a serious

attempt to quit smoking is a predictor of successful long-term cessation, one of the Healthy
People 2010 objectives
Anita Fernander, PhD, is with the Department of Behavioral Science, University of Kentucky,
Lexington, Kentucky. Ken Resnicow, PhD, is with the School of Public Health, University of
Michigan, Ann Arbor, Michigan. K. Viswanath is with the Harvard School of Public Health
and the Dana-Farber Cancer Institute, Boston, Massachusetts. Eliseo J. Perez-Stable, MD,
is with the Department of Medicine, UCSF Helen Diller Family Comprehensive Cancer
Center, San Francisco, California.
Send reprint requests to Anita F. Fernander, PhD, 103 Medical Behavior
Science Building, Lexington, KY 40536-0086; afern2@ky.uky.edu.
Copyright E 2011 by American Journal of Health Promotion, Inc.
0890-1171/11/$5.00 + 0
DOI: 10.4278/ajhp.25.5.c1
American Journal of Health Promotion May/June 2011, Vol. 25, No. 5 Supplement S1

called for an increase in smoking cessation attempts by adult smokers to 75%. Unfortunately,
this goal does not appear feasible for most smokers, including minority groups, because the
percentage of smokers who quit for at least 1 day was only 41.1%, 49%, and 48% among
Latinos,

African-Americans,

and

Asian-Americans,

respectively,

compared

with

approximately 41% among whites.9 Cessation attempts are also significantly lower among
those with a GED (39.9%) compared with those with a graduate degree (80.7%).9 These
disparities are particularly striking because the desireto quit smoking does not vary
significantly by race/ethnicity or SES.
Disparities in smoking and secondhand smoke exposure by race/ethnicity and SES are
influenced by direct and indirect social, biologic, psychologic, and cultural factors.11,12 As
such, it is critical that these factors be taken into account when interventions are targeted and
tailored for specific populations. Perhaps new prevention and treatment strategies may be
required to address the needs of underserved groups. To date, few data exist that demonstrate
the efficacy of recommended interventions among racial/ethnic minority groups and low-SES
smokers, and it remains unclear whether and/or what type of tailored and/or targeted smoking
interventions are effective for these population groups.

References
1. Centers for Disease Control and Prevention. Vital signs: current
smoking among adults aged 18 yearsUnited States, 2009. MMWR.
2010;59:11351140.
2. Institute of Medicine. Ending the Tobacco Problem: A Blueprint for the
Nation. Washington, DC: Institute of Medicine of the National
Academies; 2007.
3. US Dept of Health and Human Services. The Role of the Media in
Promoting and Reducing Tobacco Use: Monograph 19. Bethesda, Md:
National Institutes of Health; 2008. NIH publication 07-6242.
4. Dinno A, Glantz S. Tobacco control policies are egalitarian: a
vulnerabilities perspective on clean indoor air laws, cigarette prices,
and tobacco use disparities. Soc Sci Med. 2009;68:14391447.
5. Farrelly MC, Pechacek TF, Thomas KY, Nelson D. The impact of
tobacco control programs on adult smoking. Am J Public Health.
2008;98:304309.
6. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and
Dependence: 2008 Update. Rockville, Md: US Dept of Health and
Human Services; 2008.
7. US Dept of Health and Human Services. Tobacco Use Among U.S.
Racial/Ethnic Minority GroupsAfrican Americans, American Indians, and
Alaska Natives, Asian Americans and Pacific Islanders, and

Komentar : Pegawasan Tembakau / Populasi Terlayani


Merokok intervensi di antara berbagai popuiations
Anita Fernander, PhD; Ken Resnicow, PhD; K. Viswanath; Eliseo J. Perez-Stable, MD

Salah satu kisah sukses terbesar kesehatan masyarakat dari 50 tahun telah
pengurangan Merokok di Amerika Serikat. Prevalensi Rokok telah menurun sebesar 50%
atau lebih di Amerika Serikat sejak 1960-an, dan meskipun laporan terakhir menunjukkan
sebuah dataran tinggi dalam penurunan ini, tren jangka panjang telah mengakibatkan
keseluruhan tingkat prevalensi Rokok 20.6% di Designer.web 2009. Walau demikian, rakyat
sehat 2010 tujuan mengurangi prevalensi Rokok Merokok antara orang dewasa dengan 12%
atau kurang belum terealisasi. Hal ini, sebagian besar, karena fakta bahwa upaya
pengendalian tembakau tidak berdampak populasi subkumpulan sama. Secara umum,
ras/etnis minoritas dan orang-orang yang lebih rendah status sosial ekonomi (SES) tidak
memiliki manfaat sebanyak putih dan orang-orang dari SES lebih tinggi dari Rokok
pencegahan dan penghentian program. Jika kita untuk memenuhi tujuan dari 12% atau
kurang Rokok prevalensi di antara populasi orang dewasa secara keseluruhan, lebih banyak
usaha diperlukan untuk mempengaruhi perilaku penggunaan tembakau antara populasi SES
ras/etnis dan rendah. Artikel dalam edisi khusus ini Alamat jurnal Amerika promosi
kesehatan bagaimana dan apa upaya pengendalian tembakau sejauh dapat diimplementasikan
untuk mengurangi beban Merokok antara ras/etnis minoritas dan kelompok-kelompok SES
rendah. Memahami bagaimana untuk menyelenggarakan perubah

an perilaku dalam populasi tersebut sangat penting jika kita ingin mencapai kedua tujuan
kesehatan nasional kami mengurangi Merokok dan meningkatkan bangsa % u2019s status
kesehatan secara keseluruhan.
Penurunan prevalensi Merokok telah terjadi karena beberapa strategi, yang meliputi
(1) perubahan kebijakan seperti larangan indoor Rokok; (2) peningkatan Rokok pajak; (3)
klinis intervensi; dan (4) program kontrol khusus berdasarkan populasi tembakau, seperti
kampanye media massa, berhenti garis, dan interventions.2,3 berbasis Web.
Anita Fernander, PhD, is with the Department of Behavioral Science,
University of Kentucky, Lexington, Kentucky. Ken Resnicow, PhD, is
with the School of Public Health, University of Michigan, Ann Arbor,
Michigan. K. Viswanath is with the Harvard School of Public Health
and the Dana-Farber Cancer Institute, Boston, Massachusetts. Eliseo J.
Perez-Stable, MD, is with the Department of Medicine, UCSF Helen
Diller Family Comprehensive Cancer Center, San Francisco, California.
Send reprint requests to Anita F. Fernander, PhD, 103 Medical Behavior
Science Building, Lexington, KY 40536-0086; afern2@ky.uky.edu.
Copyright E 2011 by American Journal of Health Promotion, Inc.
0890-1171/11/$5.00 + 0
DOI: 10.4278/ajhp.25.5.c1

Ini strategi pengendalian tembakau juga telah mengakibatkan upaya pengurangan


asap rokok eksposur, lebih sering berhenti, dan lebih sedikit Rokok Merokok setiap hari
antara orang-orang yang terus Merokok.
Rekomendasi untuk mempromosikan penghentian termasuk singkat intervensi klinis
seperti individu, telepon, dan kelompok konseling dan Intracavernous, termasuk lima jenis
produk pengganti nikotin dan dua kelas-kelas lain dari medications.6 Namun, rekomendasi
khusus untuk ras / etnis minoritas dihilangkan dalam praktek klinis guidelines6 Pemesanan
karena kurangnya bukti bahwa budaya tertentu intervensi lebih mujarab daripada populasi
umum pendekatan. Hal ini menunjukkan bahwa strategi berbasis bukti dan program yang
dikenal sebagai efektif dalam mengurangi Rokok dalam populasi umum harus diuji dalam uji
klinis acak dengan cukup sampel ras / etnis minoritas dan peserta SES rendah untuk
menentukan keampuhan mereka dalam kelompok-kelompok ini dan diindikasikan, program
harus dikembangkan secara khusus untuk kelompok.

Tembakau berhubungan dengan kesenjangan oleh SES dan Ras / Etnis.


SES rendah terus menjadi prediktor signifikan Rokok perilaku. Individu dengan
kesetaraan umum diploma (GED) atau ijazah sekolah tinggi memiliki tingkat signifikan lebih

tinggi Rokok (49.1%) daripada mereka yang berpendidikan college (11,1%) 1; dan individu
di bawah tingkat kemiskinan secara signifikan lebih mungkin untuk Merokok (31.1%)
dibandingkan dengan mereka pada atau di atas tingkat kemiskinan (19.4%).1 ras dan etnis
juga signifikan prediksi Merokok. Sebagai contoh, American Indian/Alaska pribumi (23.2%)
lebih mungkin untuk Merokok daripada kelompok ras dan etnis lainnya, walaupun dengan
variasi yang cukup oleh tribe.1,7 meskipun dewasa Latin (14.5%) dan Asia (12,0%) yang
kurang mungkin untuk Merokok daripada kelompok lain, regional data mengungkapkan
Rokok tingkat jauh lebih tinggi di antara kelompok-kelompok asal-usul kebangsaan yang
dipilih seperti Puerto Ricans, Korea, dan Filipina.
Ras/etnis dan posisi sosial juga dikaitkan dengan kesenjangan berhubungan dengan
tembakau penting lainnya. Paparan asap rokok, ditetapkan baik oleh self-report survei dan
cotinine pengujian, secara konsisten telah ditemukan lebih tinggi di Afrika-Amerika
dibandingkan dengan putih dan Meksiko - Americans.9 bekas paparan asap juga cenderung
lebih tinggi di antara individu dengan pendapatan lebih rendah, 9 dan kerah biru pekerja
mengalami tingkat tinggi terutama paparan asap rokok relatif terhadap workers.9 lain
mengakui bahwa upaya serius untuk berhenti merokok adalah prediktor sukses jangka
panjang penghentian salah satu tujuan rakyat sehat 2010 menyerukan peningkatan Merokok
berhentinya upaya oleh perokok dewasa hingga 75%. Sayangnya, tujuan ini ternyata tidak
layak untuk kebanyakan perokok, termasuk kelompok-kelompok minoritas, karena persentase
perokok yang berhenti selama setidaknya 1 hari hanya 41,1%, 49%, dan 48% antara Latin,
Afrika-Amerika, dan Asia-Amerika, masing-masing dibandingkan dengan sekitar 41% antara
whites.9 penghentian upaya juga secara signifikan lebih rendah antara mereka dengan GED
(39,9%) dibandingkan dengan orang-orang dengan gelar sarjana (80,7%).9 perbedaan ini
terutama yang mencolok karena keinginan untuk berhenti merokok tidak bervariasi secara
signifikan oleh ras/etnis atau SES.
Kesenjangan dalam rokok dan paparan asap rokok oleh ras/etnis dan SES dipengaruhi
oleh langsung dan tidak langsung sosial, biologis, psychologic, dan factors.11,12 budaya
seperti itu, sangat penting bahwa faktor-faktor ini diperhitungkan ketika intervensi
ditargetkan dan disesuaikan untuk populasi tertentu. Mungkin strategi baru pencegahan dan
pengobatan mungkin diperlukan untuk mengatasi kebutuhan kelompok-kelompok yang
terlayani.

Sampai

saat

ini,

ada

beberapa

data

yang

menunjukkan

kemanjuran

direkomendasikan intervensi antara ras/etnis minoritas dan rendah-SES perokok, dan masih

belum jelas apakah dan/atau apa jenis intervensi disesuaikan dan/atau bertarget Rokok efektif
untuk kelompok-kelompok penduduk ini.

Referensi
1. Centers for Disease Control and Prevention. Vital signs: current
smoking among adults aged 18 yearsUnited States, 2009. MMWR.
2010;59:11351140.
2. Institute of Medicine. Ending the Tobacco Problem: A Blueprint for the
Nation. Washington, DC: Institute of Medicine of the National
Academies; 2007.
3. US Dept of Health and Human Services. The Role of the Media in
Promoting and Reducing Tobacco Use: Monograph 19. Bethesda, Md:
National Institutes of Health; 2008. NIH publication 07-6242.
4. Dinno A, Glantz S. Tobacco control policies are egalitarian: a
vulnerabilities perspective on clean indoor air laws, cigarette prices,
and tobacco use disparities. Soc Sci Med. 2009;68:14391447.
5. Farrelly MC, Pechacek TF, Thomas KY, Nelson D. The impact of
tobacco control programs on adult smoking. Am J Public Health.
2008;98:304309.
6. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and
Dependence: 2008 Update. Rockville, Md: US Dept of Health and
Human Services; 2008.
7. US Dept of Health and Human Services. Tobacco Use Among U.S.
Racial/Ethnic Minority GroupsAfrican Americans, American Indians, and
Alaska Natives, Asian Americans and Pacific Islanders, and