Racial/Ethnic Minorities

The research presented here focuses on tobacco use among the following racial/ethnic groups: NH Black/African American, NH Asian American and Pacific Islander (AAPI), Hispanic/Latino, American Indian or Alaska Native (AI/AN), and Non-Hispanic (NH) White individuals. Race is a social construct, and many individuals may identify with multiple or none of the racial categories presented in this research. Patterns of tobacco use among racial and ethnic groups are influenced by intersectional factors, including but not limited to socioeconomic status, access to healthcare, education, stress, psychosocial factors, environmental conditions, and cultural norms and practices. This literature review summarizes current rates of tobacco use in adults and youth racial/ethnic minoritized populations with some examples of promising treatment approaches in these populations.

Tobacco use associated morbidity and mortality

  • According to data from the 2020 National Health Interview Survey, smoking rates vary significantly across racial and ethnic groups:1
    • NH American Indian/Alaska Native (AI/AN) adults: 27.1%
    • NH Black adults: 14.4%
    • NH White adults: 13.3%
    • NH Asian adults: 8.0%
    • Hispanic adults: 8.0%
  • The prevalence of current smoking has decreased linearly among all racial categories except among AI/AN adults, where smoking rates have increased.1
  • Smoking rates vary at the intersections of race and ethnicity and are not monolithic across the complex racial and ethnic diversity of the United States.2
    • Relative to the general population, smoking prevalence is higher among multiracial NH AI/AN/White (24.4%), NH AI/AN/Black (22.4%), and NH Asian/Black (34.8%) individuals.2
    • Smoking rates vary among Asian adults (aged 45-84) in California, from 3.0% among South Asians, 4.8% among Chinese, 7.6% among Southeast Asians, inclusive of Vietnamese adults, 7.7% among Koreans, and 10.4% among Pacific Islanders. Across all Asian groups, there is also a difference in smoking prevalence by gender; women have a prevalence of 2.6%, while men have a prevalence of 9.5%.3
    • Nicotine exposure among people who have recently quit, who are currently smoking and among those living with people who smoke varies across Hispanic/Latine subgroups from 59.1% among Puerto Ricans, 64.8% among Cubans, 74.1% among Mexicans, 77.8% among South Americans, 78.4% among Central Americans, to 83.3% among Dominicans. 4
  • Quit ratios are low in Black/African American adults (40.0%), AI/AN adults (43.3%) and Hispanic/Latine adults (53.2%) relative to White (59.1%) and Asian adults (70.5%). 5
  • There are disparities in tobacco-related morbidity and mortality.
    • Black men and women have a higher mortality rate for tobacco-related cancers, coronary heart disease, and stroke compared to white counterparts.6
    • Among AI/AN, lung cancer is 5.8% more common as compared to White counterparts.7
  • Secondhand smoke exposure is higher among non-smoking NH Black individuals relative to other racial/ethnic groups.8  
  • Among US adults who smoke and attempted to quit in the past year, 41.7% of Black/African American, 77.3% of Hispanic/Latine, and 62.4% of White adults reported a home smoking ban.5 Black/African American and White children have the highest rates of exposure to either thirdhand smoke (THS) alone or secondhand (SHS) and THS exposure.9 Children exposed to SHS and THS have increased odds of experiencing food insecurity.9

Youth and tobacco use

  • In 2023, the most common tobacco products used by high school students include e-cigarettes (10%), cigarettes (1.9%), cigars (1.8%), tobacco pouches (1.7%) and smokeless tobacco (1.5%.)10
  • In 2023, the prevalence of tobacco use, including use of e-cigarettes, among middle and high school students varied by race and ethnicity:10
    • NH Multiracial: 27.9%
    • NH White 23.1%
    • American Indian/Alaska Native 22.7%
    • Hispanic/Latino: 23.8%
    • NH Black/African American: 20.1%
    • NH Asian: 12.1%
  • Although, e-cigarette use has declined among middle and high school students from 2023 to 2024, use of any tobacco pouches remained the same.11
  • AI/AN middle and high school students reported the highest prevalence of current use of any tobacco product, however current use of any combustible tobacco product, specifically cigar and hookah use, was highest among Black/African American middle and high school students. 12

Patterns of tobacco use

  • Menthol cigarette use is disproportionately higher among some race/ethnicities due to targeted marketing by the tobacco industry.
    • The overall use of menthol cigarettes has increased from 33.8% in 2008 to 40.6% in 2019.  According to national data, 80.9% of Black/African American adults and 51.3% of Hispanic/Latine adults report smoking menthol cigarettes in the past 30 days compared to 33.8% of Whites.13
    • Over the last decade, use of menthol has increased significantly more rapidly among younger, minoritized race/ethnicity groups and adults with mental health problems. 13
    • Among Black/African Americans, menthol cigarette smoking reduces the likelihood of smoking cessation (quit ratio of menthol vs non-menthol users is 34% vs 49%).14-15
  • Compared to Whites, minoritized individuals are more likely to smoke intermittently (non-daily) and less than 5 cigarettes per day. Despite lighter smoking habits, racial/ethnic minority groups have less success quitting.16
  • Tobacco use or exposure to tobacco is often linked with financial and food insecurity. Between 2011-17, Black/African Americans were 1.7 times more likely to experience food insecurity compared to Whites.17 Up to half of U.S. adults with food insecurity smoke cigarettes, and tobacco prevalence increases as food insecurity grows more severe. 18

Reasons for high rates of tobacco use

  • The tobacco industry has strategically targeted racial and ethnic minority communities to increase sales.
    • Tobacco marketing density is greater in neighborhoods with a higher percentage of Black/African American and Hispanic/Latine residents. 19 Flavored tobacco marketing especially for cigars are more likely to be found in predominantly Black/African American communities compared to other communities. 20
    • Tobacco retailers are closer to schools that had higher percentages of students enrolled in the free and reduced-priced lunch program impacting Black/African American students and Hispanic/Latine students and are farther from schools with higher percentages of White students.21
    • Multiple studies have shown that minoritized adolescents are disproportionately exposed to various forms of e-cigarette marketing (including internet, store, print, and outdoor advertising), increasing their risk of initiating smoking.23-25
      • Exposure to e-cigarette advertisements also varies with 61.5% of bisexual Black young women (18-24) reporting exposure to e-cigarette advertisements in the past 12 months compared with 39.0% of heterosexual White young women. 22
      • Black/African American and NH Asian youth (13-17) self-reported higher exposure to e-cigarette marketing on television and social media, compared to NH White youth.23
  • The tobacco industry strategically targets AI/AN communities.
    • The tobacco industry leverages sovereign status to skirt State taxes on tobacco products and sell their products at a cheaper price on Tribal lands.26
    • The tobacco industry partners with Tribal Councils to push Youth Smoking Prevention programs under the guise of Corporate Social Responsibility.26
    • Natural American Spirit (NAS) cigarettes, marketed to AI/AN communities with packaging featuring an American Indian logo and labels like "additive-free" and "natural," have led many AI/AN individuals to incorrectly believe that NAS are tribally affiliated. This misconception has reduced perceptions of harm and increased intentions to purchase NAS cigarettes among AI/AN people who smoke.27
    • Tobacco has a longstanding role in the traditional beliefs and ceremonies of many AI/AN communities and is considered sacred.The tobacco industry exploits these traditions to market commercial tobacco for use in spiritual ceremonies. 26
  • Racism at the interpersonal and structural levels is associated with increased psychosocial stress and risk for tobacco use.28-30
    • Discrimination due to race/ethnicity and sexual orientation was associated with moderate to severe tobacco use for older adults who identify as sexual minorities.30
    • Racial/ethnic discrimination, a type of structural racism, has also been associated with increased tobacco use and lower odds of tobacco cessation among NH Black compared to NH White adults.31,32

Barriers to quitting

  • Reduced access to healthcare and health information, financial strain, and distrust in healthcare services due to historical mistreatment of racial/ethnic minority patients in healthcare settings have led to disparities in access to treatment. 5
    • Using wave four of the Population Assessment of Tobacco and Health (PATH), compared to NH White people who smoke, Hispanic adults who smoke were less likely to receive advice to quit but more likely to attempt quitting. NH Black adults who smoke were more likely to receive advice to quit and attempt to quit.32
  • Racial/ethnic minorities who smoke are less likely to use FDA-approved smoking cessation medications, such as nicotine replacement therapies (e.g., nicotine patches) and prescription medications (e.g., varenicline) than White counterparts.5
    • Hispanics who smoke are less likely to use pharmacological treatment and e-cigarettes than NH Whites potentially due to cultural perceptions and values around personal responsibility and its role in cessation. 32
  • Quitlines can be a low-cost resource to assist people who smoke with accessing cessation resources; however, digital enhancements to these services may further racial and ethnic disparities.
    • Web-based state quitlines were less accessible to,Hispanics, AI/AN, and “other” race/ethnicity compared to NH Whites. African Americans were least likely to enter via the web or enroll in the web-only program.33,34
  • Nicotine consumption and metabolism can vary across racial and ethnic groups and may pose barriers to cessation. Black/African Americans who smoke and who smoke lightly have a higher intake of nicotine per cigarette compared to their white counterparts. If Black/African Americans who smoke manage to lower cigarette dependence, their incremental risk per cigarette may not proportionally decrease as it does for whites who smoke. 35 

Promising approaches

  • This section will highlight some cultural adaptations and communication strategies tailored to racial/ethnic minorities. Cultural adaptations to tobacco cessation interventions can occur at the surface level via language translations or at a deeper level incorporating cultural factors that resonate with racial/ethnic groups.36  
    • An example of a surface-level adaptation is a translated and culturally adapted Spanish-language self-help booklet that produced greater self-reported abstinence rates (33.1%) compared to a standard Spanish self-help booklet (24.3%).37
    • An example of a deeper level adaptation includes a youth cessation program for AI/AN that incorporated culturally informed activities such as talking circles and the distinction between commercial and traditional tobacco resulting in a 37% quit rate at 3-month follow-up.38 Among AI/AN adult populations, contingency management with family-based cessation services also hold promise.39
    • Tailoring of cessation interventions to align with the cultural beliefs, values, and norms of Asian American communities can enhance the relevance and acceptance of the cessation programs. Interventions that pair traditional NRT with acupuncture and emphasize the role of familial support in cessation efforts have been shown to be effective in Asian American communities.40
    • A mobile health intervention, iQuit Mindfully, which is a personalized interactive text message program that encourages mindfulness around smoking cessation in combination with in-person group sessions about mindfulness. The intervention was widely accessible and feasible among low-income African Americans and provided insight on best practices for working with this community.41
    • Among the Chinese immigrant population, a WeChat peer group included daily text messages building awareness of the health effects of smoking, challenging social norms associated with smoking, improving self-efficacy for cessation, and referring participants to Chinese language tobacco treatment programs. The combination of the online peer support groups and program referrals helped alleviate barriers to accessing and utilizing NRT, leading to higher smoking abstinence rates over 6 months.42

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