- Email: [email protected]
Populations at risk for tobacco-related diseases
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Seminars in Oncology Nursing, Vol 19, No 4 (November), 2003: pp 276-283
OBJECTIVES: To provide an overview of US population groups at particular risk for tobacco-related diseases.
DATA SOURCES: Surgeon General’s reports, other official reports, published articles, research studies.
CONCLUSION: The burden of tobacco-related health alterations in known and less known population groups with reduced or absent access to primary health care services, infer that epidemiologic measures may be underestimated. Underestimations of these persons at risk have implications for future resource planning, allocation, and service.
IMPLICATIONS PRACTICE:
FOR
NURSING
Nurses can assist in the identification of and access to at-risk populations before morbidities are at a late stage of diagnosis.
From the Department of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, NC; and the Department of Physiological Nursing, School of Nursing and Department of Epidemiology and Biostatistics School of Medicine, San Francisco, CA. Kim M. Hutchinson, RN, MSN, MS, EdD: National Cancer Institute Fellow, Wake Forest University Health Sciences, Department of Public Health Sciences, Winston-Salem, NC. Erika Froelicher, RN, MA, MPH, PhD: Professor, Department of Physiological Nursing, School of Nursing and Department of Epidemiology and Biostatistics School of Medicine, San Francisco, CA. Address reprint requests to Kim Hutchinson, RN, MSN, EdD, Wake Forest University Health Sciences Department of Public Health Sciences, 2000 W First St, Suite 244, Winston-Salem, NC 27157.
© 2003 Elsevier Inc. All rights reserved. 0749-2081/03/1904-0007$30.00/0 doi:10.1053/S0749-2081(03)00103-7
POPULATIONS AT RISK FOR TOBACCORELATED DISEASES KIM M. HUTCHINSON AND ERIKA A. SIVARAJAN FROELICHER
M
ANY REPORTS illuminate disparities in the cancer experience of underserved populations and ethnic group members.1-8 The national policy agenda cites “a health disparity is an inequality or gap that exists between two or more groups. Health disparities are believed to be the result of the complex interaction of personal, societal, and environmental factors.”9 This complex interaction, marred by disadvantages and discrimination (racism, sexism, classism, ageism),10,11 compounds a cancer disease experience and culminates in poorer prognoses, poorer quality of life, decreased 5-year survival rates, and excess mortality.2 Goals to improve the health of all Americans are to: (1) increase years of healthy life and (2) eliminate health disparities. Tobacco use is the major contributor for up to 87% of lung cancers, emphysema, and chronic bronchitis combined, and an estimated 430,000 annual cancer deaths.6 The affirmation that approximately one half11 to one third12 of cancers could be prevented if smoking were eliminated may actually be a smaller fraction than suggested if greater surveillance of at risk groups were optimized. Recognition of factors that may be associated with differential risk provides a benefit to the entire population. This article reviews current state-of-the-art knowledge about nicotine exposure and tobacco-related diseases among at-risk population subgroups in the United States.
SOCIODEMOGRAPHIC
C
AND
CULTURAL DIFFERENTIAL
urrent census estimates show that non-white citizens constitute 30.9% of the US population.13 Therefore, cultural competency, or the ability to see the world through the lens of a particular culture, not just cultural awareness, is a critical skill for
POPULATIONS AT RISK FOR TOBACCO-RELATED DISEASE
understanding the context of health disparity experienced among ethnic and underserved communities. Implicit to the success of national goal attainment is a requisite need for a multidisciplinary and concerted approach among communities, state, and national organizations in partnership with health care providers and systems. Disparate health outcomes experienced by population subgroups at particular risk for tobaccorelated diseases is an issue that needs to be addressed from several perspectives: the individual/ patient, health care provider, institution/system, and societal/family.2,5,9,14 Current nomenclature references “underserved populations” as persons who fall into low socioeconomic, underinsured, and uninsured categories, which describes the experience of greater than 41 million Americans today.15 Further, persons described as “hidden,” “invisible,” “vulnerable,” “marginalized,” or “disenfranchised” refers to a distinct subset of the general population whose membership may not be readily distinguished or enumerated based on existing knowledge and/or sampling capabilities.16,17 Thus, because of reduced visibility and correspondingly, census count underestimation, difficulties arise in health services planning. The oncology nurse will recognize the fetus, children and adolescents, women, ethnic minorities, older adults, and urban or rural communityresidents as obvious persons at risk. Less obvious are groups functioning on the fringes of society: prostitutes, school drop-outs, incarcerated, homeless, substance addicted, functionally impaired, recent immigrant groups, and lesbian, gay, bisexual, and transgender members of the population for whom little tobacco-specific data relative to prevalence, prevention, and treatment efforts exists.18,19 Despite this paucity, acknowledgement of these groups serves as a call for improved surveillance for identification and outreach to highlight indices that could be targeted for promotion or change intervention. The term “ethnic group” more appropriately considers cultural and behavioral factors, beliefs, lifestyle patterns, diet, environmental living conditions, and other factors that may selectively impact the experience of cancer. Subgroup populations (described below) who, additionally, are ethnic minorities and underserved are exponentially at risk for tobaccorelated diseases. Because recent reports of tobacco-related health consequences point to the
277
importance of studies of gender-specific effects and ethnic variations,8 special attention will be devoted to current knowledge as it relates to these issues.
THE VERY YOUNG
T
he fetus, children, and adolescents are particularly vulnerable to the effects of tobacco exposure early in life through the womb (via the pregnant smoker) and through environmental tobacco smoke (also referred to as second-hand or passive smoke). Other research indicates that an increased susceptibility to the effects of smoking and exposure to environmental tobacco smoke may exist among those with specific genetic polymorphisms.8 In 1999, 21% of women smoked during pregnancy,20 but estimates vary among subgroups. In one study, 60% of the 123 pregnant 13to 19-year-old low socioeconomic level adolescents in Allegheny County, PA were smokers.21 Clear associations have been established between pregnant women who smoke cigarettes and adverse placental development, premature separation of the placenta from the uterine wall, increased risk of multiple births, and reduced fertility.8 In addition, smoking cigarettes during pregnancy accounts for a 1.5 to 3.5 times greater likelihood of bearing a low birth weight infant,20 a higher risk for perinatal (28 week old fetus to within 7 days of neonatal life) mortality, neonatal infections, growth retardation, persistent hypertension of the newborn, increased risk for cleft lip or cleft palate, sudden infant death syndrome, and asthma.4,8 A recent study has linked nicotine exposure with the growth of bacteria that causes tooth decay in young children.22 A long-term implication of this smoking behavior results in an increased risk of smoking by their offspring through modeling, exposure, and access. Touted as the next generation of smokers, a new report asserts that 41.3% of the 15 million 18- to 24-year-old college students had used cigarettes at some point in 2000. Further, rates are increasing faster in public versus private schools, and meal card purchases of tobacco products are allowed on some campuses.23 New data suggests that late (postadolescent) smoking initiation occurs among many African American women with health implications extending into the child-bearing and child-rearing years.24
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TABLE 1. Tobacco Use Prevalence for Nine Subgroups of US Ethnic Women (Rank Ordered From Highest to Lowest) Tobacco Use in % American Indian (tribal variations exist) Alaska Native Puerto Rican Native Hawaiian Cuban American African American Asian American Mexican American American Samoan
20-37 35.6 30.3 30.0 24.4 21.0 7-19 13.6 11.0
Source: Department of Health and Human Services, National Cancer Institute. (January 2003). Cancer in Women of Color Monograph. Bethesda, MD: Glanz, K. Retrieved from: http:// dccps.nci.nih.gov on April 3, 2003.3
1930s and 1940s, therefore, the sharp rise in lung cancer rates that was so apparent in men before 1964 was delayed in women until the 1970s. Presently, lung cancer is the most common cause of cancer death among women.8 An estimated 27,000 more women died of lung cancer than breast cancer in 2000, and since 1980, three million women have died prematurely from a smoking-related disease.8 As shown in Fig 2, by 1987 the age-adjusted lung cancer death rates surpassed breast cancer death rates in women in the US.8 While the statistics are not provided separately by ethnicity or education, it is likely that those less educated and poor comprise a larger proportion of the premature deaths. The gravity of the situation is reflected in a comment by former US Surgeon General Antonio Novello, “the Virginia Slims woman is catching up to the Marlboro man”.26
OTHER HIDDEN GROUPS WOMEN
T
AND
ETHNIC MINORITIES
he National Center for Health Statistics cites that in 2000, 23% to 25% of the total population and, on average, 20.6% of adult women are current smokers.25 To contextualize the unique cancer experiences for the four major ethnic groups (African Americans, American Indians/ Alaska Natives, Asian/Pacific Islanders, and Hispanic Americans) and nine subgroups of ethnic women, the Cancer in Women of Color monograph3 addresses all-cause and site–specific cancer statistics (incidence, prevalence, mortality, survival) juxtaposed with characteristics, such as respective population size, geographical location, demographic and social indicators, key historical events that have influenced overall health (prevalent health issues, particular risk factors, and early detection behaviors), health care utilization patterns (health insurance/sources of regular care), health care perspectives, core cultural values, and sources of surveillance data. Table 1 presents tobacco use frequency for nine subgroups of US ethnic women.3 Figure 1 depicts the 1998 smoking prevalence rate among the major ethnic groups of women. Lung cancer risk increases with amount, length of time, and intensity of smoking, with the mortality risk 20 times higher among women who smoke two or more packs per day.8 Historically, women started smoking in large numbers in the
B
ecause transience and high mobility characterize the life experience of many marginalized groups (ie, substance addicted, incarcerated, prostitutes, or homeless), accurate enumeration of the tobacco problem is a moving target and impairs our ability to hold confidence in reported estimates. However, research suggests higher tobacco use rates in these groups. Buchting’s review of the literature showed 50% higher smoking and 33.7% higher rates of smokeless tobacco use among both adult and adolescent lesbian, gay, and bisexual persons than for those in the general population.19 Additionally, studies have shown a 57% higher prevalence of smoking among HIV-positive persons compared with the general population.18 According to a March 2003 report from US Department of Health and Human Services Secretary Tommy Thompson, homeless persons
FIGURE 1. 1998.
Smoking prevalence among women in
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represent an extremely difficult-to-reach population, with annual counts hovering around 2 to 3 million individuals.27 No current data are available that estimate tobacco use among this hidden group; however, Butler et al27 cite one epidemiologic study that suggest that of the 19 million homeless adults and children, upwards of 5 million of them smoke.28 Previous studies have linked users of illicit drugs with correspondingly high rates of cigarette smoking,29 and high rates of illicit drug use are found among homeless persons.28 One study showed that a higher percentage (66%) of depression, more daily cigarette consumption, younger age of smoking initiation, longer smoking periods, greater likelihood to be white, and greater likelihood to smoke non-mentholated brands was found among homeless smokers (those living in a shelter or on the street, n ⫽ 107), compared with a convenience sample of non-homeless smokers (n ⫽ 491) living in an urban, lowincome, predominantly African American community. Homeless persons reported using smoking for calming and relaxation, while readiness to quit measures were lower among homeless versus the nonhomeless men. Alternative smoking behaviors used by some homeless smokers (eg, smoking discarded cigarette butts and mouthing used filters) further increases the potential for intake of toxins and infectious agents.28
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FIGURE 3.
Age-adjusted lung incident and mortality cases by ethnicity per 100,000 between 1996 and 2000. Incidence, slashed bars; mortality, dotted bars. (Reprinted from Weir et al.7)
According to Krane et al,17 the deficit of information on the health status of incarcerated persons poses ethical concerns. Although correctional facility practitioners acknowledge that incarcerated persons have a disproportionate number of health problems,17 a 1997 self-reported survey of State and Federal inmate populations indicated cancer prevalence rates of 0.2% and 0.3%, respectively.30 However, an estimated 75% of inmates use tobacco, with rates as high as 90% in juvenile correctional facilities.31 Many persons with mental illness are addicted to nicotine.32 Among persons diagnosed with psychiatric disorders, those with schizophrenia have the highest smoking rates. The prevalence rate of smoking among clients with schizophrenia ranges upwards of 80% to 90% in some studies, while 20% or more may have a history of alcohol abuse or dependence, and as many as 30% may have a history of depression.
HEALTH CONSEQUENCES AND TOBACCO TARGETING
S FIGURE 2. Age-adjusted death rates for lung cancer and breast cancer among women, United States, 1930-1997. (Source: Women and Smoking: A report of the Surgeon General. Rockville, MD, US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, Washington, DC.)
moking varys among ethnic women; African Americans bear the greatest tobacco-related disease burden and represent the ethnic group with the highest lung cancer incidence.2,5 Figure 3 shows the age-adjusted lung cancer incident and mortality cases by ethnicity between 1996 and 2000.6,7 Several smoking behaviors may account for increased dependence and higher measures of smoke-related toxins experienced among African Americans. Although African American smokers generally smoke fewer cigarettes per day, and take
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fewer puffs per cigarette5 than white smokers, they tend to inhale deeper, and are more likely to prefer mentholated brands, which potentiate carbon monoxide, and have higher cotinine (a biochemical marker of tobacco use and environmental exposure), and tar levels. By inhaling at deeper levels, African American smokers absorb 30% more nicotine, resulting in a 2-hour longer metabolic bloodstream clearance rate.33-35 This physiologic factor, in turn, may explain the fundamental difference in the higher prevalence of smoking-related diseases and higher mortality experienced in African Americans.4-6 The success of tobacco marketing campaigns is noted by increased smoking initiation and prevalence rates among US populations and subgroups. Targeted marketing by the tobacco industry continues. Health and policy voices have called to light specific outreach activities directed at youth (ie, the Joe Camel campaign with T-shirts, sandals, or hats that smokers could buy with Camel cash or Marlboro miles; the appeal of a fun cartoon character), at women (ie, Virginia Slims – “You’ve Come a Long Way, Baby” and the “Find Your Voice” campaigns using watercolor and pastel images, perfumed scents, and exotic flavors; capitalizing on psychosocial concerns, such as body weight and liberation concerns), at African American and other ethnic groups (ie, Uptown and “X” brands, which promote an attraction to the classy and “good life”).5,7,25,36 Youth are three times more sensitive to advertising, and 86% of underage smokers preferred the three most heavily advertised cigarette brands – Marlboro, Newport, or Camel.26 Likewise, African American-owned and oriented popular press publications receive more revenue from cigarette advertising than do other consumer sources, and tobacco billboards are located in African American communities four or five times more often than in white communities.36 Former DC Health Commissioner Reed Tuckson described the tobacco industries marketing practices as “the subjugation of people of color through disease.” Further, a strong tobacco presence has been maintained in the African American community through relationships with high visibility groups such as the National Association for the Advancement of Colored People.37 Low income Hispanics and non-Hispanic Blacks have been heavily targeted through tobacco industry sponsorships of community-based events, festivals, and annual fairs because the industry believes that they tend to be more brand-loyal.26
Perfumed scented and exotic flavors with associated terms such as, “slims” and “lights” and use of watercolors and pastels are particularly appealing to women.
POVERTY DIFFERENTIAL
U
S demographers report that the greater numbers of poor persons is an emerging health threat.15 Although life at the poverty level tends to even the playing field for all persons,2 tobaccorelated disease burden among particularly lowincome African Americans is marked by higher overall cancer incidence (132,700 cases estimated for 2003), mortality (63,100 deaths estimated for 2003), and lower survival (53% for African Americans v 64% for whites).6 High rates of tobacco exposure and reduced access to quality services and treatment2,6,38 can further exacerbate health disparities. Approximately one fourth of African Americans live in poverty, 17% do not have the financial means to seek good health care, and 19% have no usual source of health care.6 Approximately 50% greater smoking prevalence is seen among Medicaid recipients.39 Smoking prevalence is three times higher among women with 9 to 11 years of education (30.9%) versus 10.6% among women with 16 years or more education.7 In the Women’s Initiative for Non-Smoking, a randomized clinical trial of older women smokers (mean age, 61 years) hospitalized with a cardiovascular diagnosis, 27% had an income of less than $15,000 and half had an income below $35,000. Overall, in comparison to similar studies using male participants, these women generally tended to be older, more often widowed, divorced, single, or living by themselves, depressed, and had limited financial and social resources.40-45 Furthermore, they were reluctant to use nicotine replacement when offered,44 yet when offered a smoking cessation intervention, their smoking rates were high and sustained over 30 months of follow-up. A disproportionate number of African Americans and Hispanics are poor. For example, African Americans are three times more likely than whites to be poor (ie, below the poverty level), although larger actual numbers of whites are poor.2,13 Immigrant groups, especially those with limited English proficiency (ie, Vietnamese, Chinese, Hispanic, and Southeast Asians) were more likely to be unemployed or have incomes below poverty
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TABLE 2. Prevention and Education Resources Harvard Center for Cancer Prevention: Collaboration with Black Entertainment Network (BET) National Association of African Americans for Positive Imagery National African American Tobacco Prevention Network The Onyx Group National African American Tobacco Education Network Surgeon General Report on Tobacco Use Among US Racial/Ethnic Minority Groups
level, and lacked knowledge about smoking and cancer, had incomes below the poverty level, and were more likely to be unemployed.5 Furthermore, the prevalence of smoking in immigrant groups is reflective of the higher rates in their native country and tends to be higher than the rates in the United States. Although the degree of acculturation plays a key role in smoking prevalence, the rates among Asian/Pacific Islander immigrant groups, when disaggregated by country of origin, ranged from a low of 4.6% among Indian immigrants to a high of 21.4% among Japanese immigrants.46
CANCER CONTROL STRATEGIES
E
fforts to disseminate information about cancer and tobacco-related diseases have to be addressed to minority subgroups though multiple channels. Cancer screening fails as a priority among African Americans, often because of a tendency toward fatalistic attitudes, which promote images of pain, mutilation, suffering, and death.6 Health promotional behavior change is a particular challenge and poses a unique barrier with populations constrained by the confluence of poverty or low income and low education or health illiteracy. The Treating Tobacco Use and Dependency Clinical Practice Guideline asserts that when women stop smoking, they greatly reduce their risk of premature death, and quitting smoking is beneficial at all ages.47 Although some studies show that women may have more difficulties quitting smoking than men,7 it may be partially because of the circumstances of low education and
http://www.bet.com/health/cancercenter http://www.naaapi.org http://www.naatpn.org http://www.onyx-group.com/TheOnyxGroup.htm Email:[email protected] www.cdc.gov
low income placing them in a vulnerable risk group,5,40-43 in addition to fears related to weight gain.7 Improved access to quality care, utilization, and delivery of preventative cancer care are challenges that could be addressed if current knowledge, medical expertise, and resources were more readily available.6
CONSIDERATIONS
O
FOR
ONCOLOGY NURSES
ncology nurse clinicians need to be attuned to structural limitations that are barriers to assessment and care delivery to disenfranchised communities. Interventions with at-risk populations are couched in an understanding of the effects of racism and discrimination and how these experiences have shaped a cautious, mistrustful, and avoidance response to the health care system. Fearing discrimination, lacking health care access, insurance, public transportation, and language/communication barriers and misaccord (tendency to misinterpret signs and symptoms especially with non-acculturated or recent immigrants/non-Westernized people of color) represents the day-to-day obstacles that many subgroups must navigate. Despite the barriers, research suggests that evidenced-based smoking cessation interventions are effective regardless of gender, age, ethnicity, or health condition (ie, pregnancy, psychiatric co-morbidity and/or chemical dependency) in the hospital, outpatient, or clinic settings. Numerous health care specialists, especially nurses, must play a key role in addressing these issues.47 Additionally, since the 1992 Joint Commission on the Accreditation of Hospitals and Health care Organization estab-
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lished standards for smoke-free hospital environments,48 it is a particularly opportune time to intervene during a patient’s hospital stay and nurses might leverage smokers toward motivation for smoking cessation efforts, particularly if the admission diagnosis is associated with smoking. Additional resources (courses, minority organization contacts, and assessment exercises) are available that provide cultural guidelines designed specifically for nurses.49 A series of educational activities that examines the intersection of culture and care is available through the Cancer, Culture, and Literacy Institute.50 Oncology nurse clinicians must remain astute and positioned to impart high-quality and equitable care to effectively em-
brace the changing face of ill populations. Table 2 provides several website references that may direct the reader to additional information on cancer control initiatives and tobacco control in ethnic communities.
ACKNOWLEDGMENTS Dr Hutchinson wishes to acknowledge support from the Substance Abuse Policy Research Program of the Robert Wood Johnson Foundation, and from the National Cancer Institute (training grant no. CA57707-07) for support of studies in the Clinical Epidemiology and Health Services Research program at Wake Forest University Graduate School of Arts and Sciences.
REFERENCES 1. Glanz K, Croyle RT, Chollette VY, et al: Cancer-related health disparities in women. Am J Public Health 93:292-298, 2003 2. Haynes MA, Smedley BE (eds), for the Committee on Cancer Research Among Minorities and the Medically Underserved: The unequal burden of cancer: An assessment of NIH research and programs for ethnic minorities and the medically underserved. Washington, DC, Institute of Medicine, 1999 3. Glanz K: Cancer in Women of Color Monograph. Bethesda, MD, Department of Health and Human Services, National Cancer Institute, January 2003. Available at: http:// dccps.nci.nih.gov (accessed April 3, 2003) 4. Tobacco-Related Disease Research Program. Ten Year Summary. Research from 1990-2000. University of California Office of the President, Oakland, CA 5. US Department of Health and Human Services: Tobacco use among US racial/ethnic minority groups–African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A report of the Surgeon General. Atlanta, GA, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 1998 6. Underwood SM: Reducing the burden of cancer borne by African Americans: If not now, when? Cancer Epidemiol Biomarkers Prev 12:270s-276s, 2003 (suppl) 7. Weir HK, Thun MJ, Hankey BF, et al: Annual report of the nation on the status of cancer, 1975-2000, featuring the uses of surveillance data for cancer prevention and control. J Natl Cancer Inst 95:1276-1299, 2003 8. US Department of Health and Human Services: Women and smoking: A report of the Surgeon General. Atlanta, GA, US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001 9. US Department of Health and Human Services: Healthy People 2010. Available at http://www.health.gov/healthypeople/Document/ HTML/Volume1/tobacco.htm (accessed March 15, 2000) 10. Gaston MH: We need a revolution. (On-line slides from the National Colloquium on Black Women’s Health.) Available
at: http://www.kaisernetwork.org/health_cast/hcast_index.cfm? display⫽detail&hc⫽833 (accessed April 16, 2003) 11. National Cancer Policy Board: Executive Summary: Fulfilling the potential of cancer prevention and early detection. Washington, DC, Institute of Medicine, National Research Council, 2003 12. Willett W: Cancer prevention and early detection. Cancer Epidemiol Biomarkers Prev 12:252s, 2003 13. US Bureau of the Census 2000. Summary File 3 (SF 3). Detailed Tables. American Fact Finder. Available at: http:// www.census.gov (accessed March 4, 2001) 14. Van Ryn M, Fu SS: Paved with good intentions: Do public health and human service providers contribute to racial/ ethnic disparities in health? Am J Public Health 93:248-255, 2003 15. The Commonwealth Fund 2002 Annual Report. New York, 2002. Available at: www.cmwf.org. 16. Wiebel WW: Identifying and gaining access to hidden populations: NIDA Research Monograph Series 98: The Collection and Interpretation of Data from Hidden Populations. US Department of Health and Human Services Pub. no. (ADM) 90-1678, 1990 17. Krane KM, Parece MS, Miles JR: Intervening among the invisible population. Corrections Today 60:122-196, 1998 18. Casey MM, Call KT, Klingner JM: Are rural residents less likely to obtain recommended preventive healthcare services? Am J Prev Med 21:182-188, 2001 19. Buchting F: Tobacco and the LGBT community. Reprinted from Tobacco-Related Disease Research Program Newsletter 5:1-3, 2002 20. Centers for Disease Control and Prevention: Health and economic impact: Smoking cessation for pregnant women. Atlanta, GA, Center for Disease Control, 2002 21. Albrecht SA, Taylor MV, Braxter BJ, et al: A descriptive study of smoking patterns among two racial groups of pregnant adolescents. J Addict Nurs 13:19-30, 2001 22. Aligne CA, Moss ME, Auinger P, et al: Association of pediatric dental caries with passive smoking. JAMA 289:12581264, 2003 23. Gardiner P: College students: The next generation of
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replacement smokers. Reprinted from Tobacco-Related Disease Research Program Newsletter 5:1-7, 2002 24. Moon-Howard J: African American Women and smoking: Starting later. Am J Public Health 93:418-420, 2003 25. Centers for Disease Control and Prevention: Cigarette smoking among adults–US,2000. MMWR Morb Mortal Wkly Rep 51:642-645, 2002 26. American Heart Association Advocacy Position. Tobacco industry’s targeting of youth, minorities and women. Available at: http://americanheart.org/Heart_and_Stroke_ A_Z_Guide/tobta.htm (accessed July, 10, 2000) 27. US Department of Health and Human Services. Ending chronic homelessness: Strategies for action. US Department of Health and Human Services. Available at: http://aspe.hhs.gov/ hsp/homelessness/strategies03/ (accessed April 1, 2003) 28. Butler J, Okuyemi KS, Jean S, et al: Smoking characteristics of a homeless population: Substance Abuse. J Assoc Med Educ Res Substance Abuse 23:223-231, 2002 29. US Department of Health and Human Services: 2001 National Household Survey on Drug Abuse. Chapter 4. Tobacco use. Rockville, MD, Office of Applied Studies 30. Maruschak LM, Beck AJ: Medical problems of inmates, 1997. US Department of Justice. Office of Justice Programs. Bureau of Justice Statistics. NCJ 181644. Available at: http:// www.ojp.usdoj.gov/bjs/pub/pdf/mpi97.pdf (accessed February 17, 2003) 31. Lewis SG, Kicking the tobacco habit: Correctional health pros share smoke-free stories. National Commission on Correctional Health Care. Available at: http://www.ncchc.org/ pubs/CC_archive/smoke-free.html (accessed May 23, 2003) 32. Smith RC, Infante M, Ali A, et al: Effects of cigarette smoking on psychopathology scores in patients with schizophrenia: An experimental study. Substance Abuse: J Assoc Med Educ Res Substance Abuse 22:175-186, 2001 33. Henningfield JE, Benowitz NL, Ahijevych K, et al: Does menthol enhance the addictiveness of cigarettes? An agenda for research. Nicotine Tobacco Res 5:9-11, 2003 34. Perez-Stable EJ, Herrera B, Jacob P, et al: Nicotine metabolism and intake in African American and white smokers. JAMA 280:152-156, 1998 35. Gardiner P: Researchers zero in on menthol. Reprinted from Tobacco-Related Disease Research Program Newsletter 3:1-7, 2000 36. Balbach ED, Gasior RJ, Barbeau EM: R.J. Reynolds’ targeting of African Americans: 1988-2000. Am J Public Health 93:822-827, 2003
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37. Join Together Online summary. Report: Big tobacco major supporter of black groups. Available at: http://www. jointogether.org/sa/news/summaries/print/0,1856,555420,00. html (accessed December 20, 2002) 38. Prothrow-Stith D, Gibbs B, Allen A: Reducing health disparities: From theory to practice. Cancer Epidemiol Biomarkers Prev 12:256s-260s, 2003 (suppl) 39. Centers for Disease Control and Prevention: State Medicaid coverage for tobacco-dependence treatments–US, 19982000. MMWR Morb Mortal Wkly Rep 50:979-982, 2001 40. Froelicher ES, Christopherson DJ: Women’s initiative for nonsmoking (WINS) I: Design and methods. Heart Lung 29:429-437, 2000 41. Martin K, Froelicher ES, Miller NH: Women’s initiative for nonsmoking (WINS) II: The intervention. Heart Lung 29: 438-445, 2000 42. Froelicher ES, Christopherson DJ, Miller NH, et al: Women’s initiative for nonsmoking (WINS) IV: Description of 277 women smokers hospitalized with cardiovascular disease. Heart Lung 31:3-14, 2002 43. Maher-Imhof R, Froelicher ES, Li WW, et al: Women’s initiative for nonsmoking (WINS) V: Use of nicotine replacement therapy. Heart Lung 31:368-373, 2002 44. Froelicher ES, Li WW, Maher-Imhof R, et al: Women’s initiative for nonsmoking (WINS) IV: Health and psychosocial measures in a smoking cessation study. J Cardiovasc Pulm Rehab (in press) 45. Froelicher ES, Miller NH, Christopherson DJ, et al: Efficacy of smoking cessation interventions in women hospitalized with cardiovascular disease (CVD): Women’s initiative for nonsmoking. Circulation (in press) 46. Baluja KF, Park J, Myers D: Inclusion of immigrant status in smoking prevalence statistics. Am J Public Health 93:642-646, 2003 47. US Department of Health and Human Services: Clinical practice guideline: Treating tobacco use and dependence. Washington, DC, Public Health Service, 2000 48. Samet DH: Scoring clarifications for the no-smoking standard. Oakbrook Terrace, IL, The Official Joint Commission Environment of Care News Source, Sept/Oct 4:2001 49. Oncology Nursing Society: Oncology nursing society multicultural outcomes: Guidelines for cultural competence. Pittsburg, PA, Oncology Nursing Society, 1999 50. Cancer, Culture and Literacy Institute: Available at: http://www.moffitt.usf.edu/promotions/cclinstitute/index.htm (accessed August 29, 2002)
Seminars in Oncology Nursing, Vol 19, No 4 (November), 2003: pp 276-283
OBJECTIVES: To provide an overview of US population groups at particular risk for tobacco-related diseases.
DATA SOURCES: Surgeon General’s reports, other official reports, published articles, research studies.
CONCLUSION: The burden of tobacco-related health alterations in known and less known population groups with reduced or absent access to primary health care services, infer that epidemiologic measures may be underestimated. Underestimations of these persons at risk have implications for future resource planning, allocation, and service.
IMPLICATIONS PRACTICE:
FOR
NURSING
Nurses can assist in the identification of and access to at-risk populations before morbidities are at a late stage of diagnosis.
From the Department of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, NC; and the Department of Physiological Nursing, School of Nursing and Department of Epidemiology and Biostatistics School of Medicine, San Francisco, CA. Kim M. Hutchinson, RN, MSN, MS, EdD: National Cancer Institute Fellow, Wake Forest University Health Sciences, Department of Public Health Sciences, Winston-Salem, NC. Erika Froelicher, RN, MA, MPH, PhD: Professor, Department of Physiological Nursing, School of Nursing and Department of Epidemiology and Biostatistics School of Medicine, San Francisco, CA. Address reprint requests to Kim Hutchinson, RN, MSN, EdD, Wake Forest University Health Sciences Department of Public Health Sciences, 2000 W First St, Suite 244, Winston-Salem, NC 27157.
© 2003 Elsevier Inc. All rights reserved. 0749-2081/03/1904-0007$30.00/0 doi:10.1053/S0749-2081(03)00103-7
POPULATIONS AT RISK FOR TOBACCORELATED DISEASES KIM M. HUTCHINSON AND ERIKA A. SIVARAJAN FROELICHER
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ANY REPORTS illuminate disparities in the cancer experience of underserved populations and ethnic group members.1-8 The national policy agenda cites “a health disparity is an inequality or gap that exists between two or more groups. Health disparities are believed to be the result of the complex interaction of personal, societal, and environmental factors.”9 This complex interaction, marred by disadvantages and discrimination (racism, sexism, classism, ageism),10,11 compounds a cancer disease experience and culminates in poorer prognoses, poorer quality of life, decreased 5-year survival rates, and excess mortality.2 Goals to improve the health of all Americans are to: (1) increase years of healthy life and (2) eliminate health disparities. Tobacco use is the major contributor for up to 87% of lung cancers, emphysema, and chronic bronchitis combined, and an estimated 430,000 annual cancer deaths.6 The affirmation that approximately one half11 to one third12 of cancers could be prevented if smoking were eliminated may actually be a smaller fraction than suggested if greater surveillance of at risk groups were optimized. Recognition of factors that may be associated with differential risk provides a benefit to the entire population. This article reviews current state-of-the-art knowledge about nicotine exposure and tobacco-related diseases among at-risk population subgroups in the United States.
SOCIODEMOGRAPHIC
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CULTURAL DIFFERENTIAL
urrent census estimates show that non-white citizens constitute 30.9% of the US population.13 Therefore, cultural competency, or the ability to see the world through the lens of a particular culture, not just cultural awareness, is a critical skill for
POPULATIONS AT RISK FOR TOBACCO-RELATED DISEASE
understanding the context of health disparity experienced among ethnic and underserved communities. Implicit to the success of national goal attainment is a requisite need for a multidisciplinary and concerted approach among communities, state, and national organizations in partnership with health care providers and systems. Disparate health outcomes experienced by population subgroups at particular risk for tobaccorelated diseases is an issue that needs to be addressed from several perspectives: the individual/ patient, health care provider, institution/system, and societal/family.2,5,9,14 Current nomenclature references “underserved populations” as persons who fall into low socioeconomic, underinsured, and uninsured categories, which describes the experience of greater than 41 million Americans today.15 Further, persons described as “hidden,” “invisible,” “vulnerable,” “marginalized,” or “disenfranchised” refers to a distinct subset of the general population whose membership may not be readily distinguished or enumerated based on existing knowledge and/or sampling capabilities.16,17 Thus, because of reduced visibility and correspondingly, census count underestimation, difficulties arise in health services planning. The oncology nurse will recognize the fetus, children and adolescents, women, ethnic minorities, older adults, and urban or rural communityresidents as obvious persons at risk. Less obvious are groups functioning on the fringes of society: prostitutes, school drop-outs, incarcerated, homeless, substance addicted, functionally impaired, recent immigrant groups, and lesbian, gay, bisexual, and transgender members of the population for whom little tobacco-specific data relative to prevalence, prevention, and treatment efforts exists.18,19 Despite this paucity, acknowledgement of these groups serves as a call for improved surveillance for identification and outreach to highlight indices that could be targeted for promotion or change intervention. The term “ethnic group” more appropriately considers cultural and behavioral factors, beliefs, lifestyle patterns, diet, environmental living conditions, and other factors that may selectively impact the experience of cancer. Subgroup populations (described below) who, additionally, are ethnic minorities and underserved are exponentially at risk for tobaccorelated diseases. Because recent reports of tobacco-related health consequences point to the
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importance of studies of gender-specific effects and ethnic variations,8 special attention will be devoted to current knowledge as it relates to these issues.
THE VERY YOUNG
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he fetus, children, and adolescents are particularly vulnerable to the effects of tobacco exposure early in life through the womb (via the pregnant smoker) and through environmental tobacco smoke (also referred to as second-hand or passive smoke). Other research indicates that an increased susceptibility to the effects of smoking and exposure to environmental tobacco smoke may exist among those with specific genetic polymorphisms.8 In 1999, 21% of women smoked during pregnancy,20 but estimates vary among subgroups. In one study, 60% of the 123 pregnant 13to 19-year-old low socioeconomic level adolescents in Allegheny County, PA were smokers.21 Clear associations have been established between pregnant women who smoke cigarettes and adverse placental development, premature separation of the placenta from the uterine wall, increased risk of multiple births, and reduced fertility.8 In addition, smoking cigarettes during pregnancy accounts for a 1.5 to 3.5 times greater likelihood of bearing a low birth weight infant,20 a higher risk for perinatal (28 week old fetus to within 7 days of neonatal life) mortality, neonatal infections, growth retardation, persistent hypertension of the newborn, increased risk for cleft lip or cleft palate, sudden infant death syndrome, and asthma.4,8 A recent study has linked nicotine exposure with the growth of bacteria that causes tooth decay in young children.22 A long-term implication of this smoking behavior results in an increased risk of smoking by their offspring through modeling, exposure, and access. Touted as the next generation of smokers, a new report asserts that 41.3% of the 15 million 18- to 24-year-old college students had used cigarettes at some point in 2000. Further, rates are increasing faster in public versus private schools, and meal card purchases of tobacco products are allowed on some campuses.23 New data suggests that late (postadolescent) smoking initiation occurs among many African American women with health implications extending into the child-bearing and child-rearing years.24
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TABLE 1. Tobacco Use Prevalence for Nine Subgroups of US Ethnic Women (Rank Ordered From Highest to Lowest) Tobacco Use in % American Indian (tribal variations exist) Alaska Native Puerto Rican Native Hawaiian Cuban American African American Asian American Mexican American American Samoan
20-37 35.6 30.3 30.0 24.4 21.0 7-19 13.6 11.0
Source: Department of Health and Human Services, National Cancer Institute. (January 2003). Cancer in Women of Color Monograph. Bethesda, MD: Glanz, K. Retrieved from: http:// dccps.nci.nih.gov on April 3, 2003.3
1930s and 1940s, therefore, the sharp rise in lung cancer rates that was so apparent in men before 1964 was delayed in women until the 1970s. Presently, lung cancer is the most common cause of cancer death among women.8 An estimated 27,000 more women died of lung cancer than breast cancer in 2000, and since 1980, three million women have died prematurely from a smoking-related disease.8 As shown in Fig 2, by 1987 the age-adjusted lung cancer death rates surpassed breast cancer death rates in women in the US.8 While the statistics are not provided separately by ethnicity or education, it is likely that those less educated and poor comprise a larger proportion of the premature deaths. The gravity of the situation is reflected in a comment by former US Surgeon General Antonio Novello, “the Virginia Slims woman is catching up to the Marlboro man”.26
OTHER HIDDEN GROUPS WOMEN
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ETHNIC MINORITIES
he National Center for Health Statistics cites that in 2000, 23% to 25% of the total population and, on average, 20.6% of adult women are current smokers.25 To contextualize the unique cancer experiences for the four major ethnic groups (African Americans, American Indians/ Alaska Natives, Asian/Pacific Islanders, and Hispanic Americans) and nine subgroups of ethnic women, the Cancer in Women of Color monograph3 addresses all-cause and site–specific cancer statistics (incidence, prevalence, mortality, survival) juxtaposed with characteristics, such as respective population size, geographical location, demographic and social indicators, key historical events that have influenced overall health (prevalent health issues, particular risk factors, and early detection behaviors), health care utilization patterns (health insurance/sources of regular care), health care perspectives, core cultural values, and sources of surveillance data. Table 1 presents tobacco use frequency for nine subgroups of US ethnic women.3 Figure 1 depicts the 1998 smoking prevalence rate among the major ethnic groups of women. Lung cancer risk increases with amount, length of time, and intensity of smoking, with the mortality risk 20 times higher among women who smoke two or more packs per day.8 Historically, women started smoking in large numbers in the
B
ecause transience and high mobility characterize the life experience of many marginalized groups (ie, substance addicted, incarcerated, prostitutes, or homeless), accurate enumeration of the tobacco problem is a moving target and impairs our ability to hold confidence in reported estimates. However, research suggests higher tobacco use rates in these groups. Buchting’s review of the literature showed 50% higher smoking and 33.7% higher rates of smokeless tobacco use among both adult and adolescent lesbian, gay, and bisexual persons than for those in the general population.19 Additionally, studies have shown a 57% higher prevalence of smoking among HIV-positive persons compared with the general population.18 According to a March 2003 report from US Department of Health and Human Services Secretary Tommy Thompson, homeless persons
FIGURE 1. 1998.
Smoking prevalence among women in
POPULATIONS AT RISK FOR TOBACCO-RELATED DISEASE
represent an extremely difficult-to-reach population, with annual counts hovering around 2 to 3 million individuals.27 No current data are available that estimate tobacco use among this hidden group; however, Butler et al27 cite one epidemiologic study that suggest that of the 19 million homeless adults and children, upwards of 5 million of them smoke.28 Previous studies have linked users of illicit drugs with correspondingly high rates of cigarette smoking,29 and high rates of illicit drug use are found among homeless persons.28 One study showed that a higher percentage (66%) of depression, more daily cigarette consumption, younger age of smoking initiation, longer smoking periods, greater likelihood to be white, and greater likelihood to smoke non-mentholated brands was found among homeless smokers (those living in a shelter or on the street, n ⫽ 107), compared with a convenience sample of non-homeless smokers (n ⫽ 491) living in an urban, lowincome, predominantly African American community. Homeless persons reported using smoking for calming and relaxation, while readiness to quit measures were lower among homeless versus the nonhomeless men. Alternative smoking behaviors used by some homeless smokers (eg, smoking discarded cigarette butts and mouthing used filters) further increases the potential for intake of toxins and infectious agents.28
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FIGURE 3.
Age-adjusted lung incident and mortality cases by ethnicity per 100,000 between 1996 and 2000. Incidence, slashed bars; mortality, dotted bars. (Reprinted from Weir et al.7)
According to Krane et al,17 the deficit of information on the health status of incarcerated persons poses ethical concerns. Although correctional facility practitioners acknowledge that incarcerated persons have a disproportionate number of health problems,17 a 1997 self-reported survey of State and Federal inmate populations indicated cancer prevalence rates of 0.2% and 0.3%, respectively.30 However, an estimated 75% of inmates use tobacco, with rates as high as 90% in juvenile correctional facilities.31 Many persons with mental illness are addicted to nicotine.32 Among persons diagnosed with psychiatric disorders, those with schizophrenia have the highest smoking rates. The prevalence rate of smoking among clients with schizophrenia ranges upwards of 80% to 90% in some studies, while 20% or more may have a history of alcohol abuse or dependence, and as many as 30% may have a history of depression.
HEALTH CONSEQUENCES AND TOBACCO TARGETING
S FIGURE 2. Age-adjusted death rates for lung cancer and breast cancer among women, United States, 1930-1997. (Source: Women and Smoking: A report of the Surgeon General. Rockville, MD, US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, Washington, DC.)
moking varys among ethnic women; African Americans bear the greatest tobacco-related disease burden and represent the ethnic group with the highest lung cancer incidence.2,5 Figure 3 shows the age-adjusted lung cancer incident and mortality cases by ethnicity between 1996 and 2000.6,7 Several smoking behaviors may account for increased dependence and higher measures of smoke-related toxins experienced among African Americans. Although African American smokers generally smoke fewer cigarettes per day, and take
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fewer puffs per cigarette5 than white smokers, they tend to inhale deeper, and are more likely to prefer mentholated brands, which potentiate carbon monoxide, and have higher cotinine (a biochemical marker of tobacco use and environmental exposure), and tar levels. By inhaling at deeper levels, African American smokers absorb 30% more nicotine, resulting in a 2-hour longer metabolic bloodstream clearance rate.33-35 This physiologic factor, in turn, may explain the fundamental difference in the higher prevalence of smoking-related diseases and higher mortality experienced in African Americans.4-6 The success of tobacco marketing campaigns is noted by increased smoking initiation and prevalence rates among US populations and subgroups. Targeted marketing by the tobacco industry continues. Health and policy voices have called to light specific outreach activities directed at youth (ie, the Joe Camel campaign with T-shirts, sandals, or hats that smokers could buy with Camel cash or Marlboro miles; the appeal of a fun cartoon character), at women (ie, Virginia Slims – “You’ve Come a Long Way, Baby” and the “Find Your Voice” campaigns using watercolor and pastel images, perfumed scents, and exotic flavors; capitalizing on psychosocial concerns, such as body weight and liberation concerns), at African American and other ethnic groups (ie, Uptown and “X” brands, which promote an attraction to the classy and “good life”).5,7,25,36 Youth are three times more sensitive to advertising, and 86% of underage smokers preferred the three most heavily advertised cigarette brands – Marlboro, Newport, or Camel.26 Likewise, African American-owned and oriented popular press publications receive more revenue from cigarette advertising than do other consumer sources, and tobacco billboards are located in African American communities four or five times more often than in white communities.36 Former DC Health Commissioner Reed Tuckson described the tobacco industries marketing practices as “the subjugation of people of color through disease.” Further, a strong tobacco presence has been maintained in the African American community through relationships with high visibility groups such as the National Association for the Advancement of Colored People.37 Low income Hispanics and non-Hispanic Blacks have been heavily targeted through tobacco industry sponsorships of community-based events, festivals, and annual fairs because the industry believes that they tend to be more brand-loyal.26
Perfumed scented and exotic flavors with associated terms such as, “slims” and “lights” and use of watercolors and pastels are particularly appealing to women.
POVERTY DIFFERENTIAL
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S demographers report that the greater numbers of poor persons is an emerging health threat.15 Although life at the poverty level tends to even the playing field for all persons,2 tobaccorelated disease burden among particularly lowincome African Americans is marked by higher overall cancer incidence (132,700 cases estimated for 2003), mortality (63,100 deaths estimated for 2003), and lower survival (53% for African Americans v 64% for whites).6 High rates of tobacco exposure and reduced access to quality services and treatment2,6,38 can further exacerbate health disparities. Approximately one fourth of African Americans live in poverty, 17% do not have the financial means to seek good health care, and 19% have no usual source of health care.6 Approximately 50% greater smoking prevalence is seen among Medicaid recipients.39 Smoking prevalence is three times higher among women with 9 to 11 years of education (30.9%) versus 10.6% among women with 16 years or more education.7 In the Women’s Initiative for Non-Smoking, a randomized clinical trial of older women smokers (mean age, 61 years) hospitalized with a cardiovascular diagnosis, 27% had an income of less than $15,000 and half had an income below $35,000. Overall, in comparison to similar studies using male participants, these women generally tended to be older, more often widowed, divorced, single, or living by themselves, depressed, and had limited financial and social resources.40-45 Furthermore, they were reluctant to use nicotine replacement when offered,44 yet when offered a smoking cessation intervention, their smoking rates were high and sustained over 30 months of follow-up. A disproportionate number of African Americans and Hispanics are poor. For example, African Americans are three times more likely than whites to be poor (ie, below the poverty level), although larger actual numbers of whites are poor.2,13 Immigrant groups, especially those with limited English proficiency (ie, Vietnamese, Chinese, Hispanic, and Southeast Asians) were more likely to be unemployed or have incomes below poverty
POPULATIONS AT RISK FOR TOBACCO-RELATED DISEASE
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TABLE 2. Prevention and Education Resources Harvard Center for Cancer Prevention: Collaboration with Black Entertainment Network (BET) National Association of African Americans for Positive Imagery National African American Tobacco Prevention Network The Onyx Group National African American Tobacco Education Network Surgeon General Report on Tobacco Use Among US Racial/Ethnic Minority Groups
level, and lacked knowledge about smoking and cancer, had incomes below the poverty level, and were more likely to be unemployed.5 Furthermore, the prevalence of smoking in immigrant groups is reflective of the higher rates in their native country and tends to be higher than the rates in the United States. Although the degree of acculturation plays a key role in smoking prevalence, the rates among Asian/Pacific Islander immigrant groups, when disaggregated by country of origin, ranged from a low of 4.6% among Indian immigrants to a high of 21.4% among Japanese immigrants.46
CANCER CONTROL STRATEGIES
E
fforts to disseminate information about cancer and tobacco-related diseases have to be addressed to minority subgroups though multiple channels. Cancer screening fails as a priority among African Americans, often because of a tendency toward fatalistic attitudes, which promote images of pain, mutilation, suffering, and death.6 Health promotional behavior change is a particular challenge and poses a unique barrier with populations constrained by the confluence of poverty or low income and low education or health illiteracy. The Treating Tobacco Use and Dependency Clinical Practice Guideline asserts that when women stop smoking, they greatly reduce their risk of premature death, and quitting smoking is beneficial at all ages.47 Although some studies show that women may have more difficulties quitting smoking than men,7 it may be partially because of the circumstances of low education and
http://www.bet.com/health/cancercenter http://www.naaapi.org http://www.naatpn.org http://www.onyx-group.com/TheOnyxGroup.htm Email:[email protected] www.cdc.gov
low income placing them in a vulnerable risk group,5,40-43 in addition to fears related to weight gain.7 Improved access to quality care, utilization, and delivery of preventative cancer care are challenges that could be addressed if current knowledge, medical expertise, and resources were more readily available.6
CONSIDERATIONS
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ONCOLOGY NURSES
ncology nurse clinicians need to be attuned to structural limitations that are barriers to assessment and care delivery to disenfranchised communities. Interventions with at-risk populations are couched in an understanding of the effects of racism and discrimination and how these experiences have shaped a cautious, mistrustful, and avoidance response to the health care system. Fearing discrimination, lacking health care access, insurance, public transportation, and language/communication barriers and misaccord (tendency to misinterpret signs and symptoms especially with non-acculturated or recent immigrants/non-Westernized people of color) represents the day-to-day obstacles that many subgroups must navigate. Despite the barriers, research suggests that evidenced-based smoking cessation interventions are effective regardless of gender, age, ethnicity, or health condition (ie, pregnancy, psychiatric co-morbidity and/or chemical dependency) in the hospital, outpatient, or clinic settings. Numerous health care specialists, especially nurses, must play a key role in addressing these issues.47 Additionally, since the 1992 Joint Commission on the Accreditation of Hospitals and Health care Organization estab-
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lished standards for smoke-free hospital environments,48 it is a particularly opportune time to intervene during a patient’s hospital stay and nurses might leverage smokers toward motivation for smoking cessation efforts, particularly if the admission diagnosis is associated with smoking. Additional resources (courses, minority organization contacts, and assessment exercises) are available that provide cultural guidelines designed specifically for nurses.49 A series of educational activities that examines the intersection of culture and care is available through the Cancer, Culture, and Literacy Institute.50 Oncology nurse clinicians must remain astute and positioned to impart high-quality and equitable care to effectively em-
brace the changing face of ill populations. Table 2 provides several website references that may direct the reader to additional information on cancer control initiatives and tobacco control in ethnic communities.
ACKNOWLEDGMENTS Dr Hutchinson wishes to acknowledge support from the Substance Abuse Policy Research Program of the Robert Wood Johnson Foundation, and from the National Cancer Institute (training grant no. CA57707-07) for support of studies in the Clinical Epidemiology and Health Services Research program at Wake Forest University Graduate School of Arts and Sciences.
REFERENCES 1. Glanz K, Croyle RT, Chollette VY, et al: Cancer-related health disparities in women. Am J Public Health 93:292-298, 2003 2. Haynes MA, Smedley BE (eds), for the Committee on Cancer Research Among Minorities and the Medically Underserved: The unequal burden of cancer: An assessment of NIH research and programs for ethnic minorities and the medically underserved. Washington, DC, Institute of Medicine, 1999 3. Glanz K: Cancer in Women of Color Monograph. Bethesda, MD, Department of Health and Human Services, National Cancer Institute, January 2003. Available at: http:// dccps.nci.nih.gov (accessed April 3, 2003) 4. Tobacco-Related Disease Research Program. Ten Year Summary. Research from 1990-2000. University of California Office of the President, Oakland, CA 5. US Department of Health and Human Services: Tobacco use among US racial/ethnic minority groups–African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A report of the Surgeon General. Atlanta, GA, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 1998 6. Underwood SM: Reducing the burden of cancer borne by African Americans: If not now, when? Cancer Epidemiol Biomarkers Prev 12:270s-276s, 2003 (suppl) 7. Weir HK, Thun MJ, Hankey BF, et al: Annual report of the nation on the status of cancer, 1975-2000, featuring the uses of surveillance data for cancer prevention and control. J Natl Cancer Inst 95:1276-1299, 2003 8. US Department of Health and Human Services: Women and smoking: A report of the Surgeon General. Atlanta, GA, US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001 9. US Department of Health and Human Services: Healthy People 2010. Available at http://www.health.gov/healthypeople/Document/ HTML/Volume1/tobacco.htm (accessed March 15, 2000) 10. Gaston MH: We need a revolution. (On-line slides from the National Colloquium on Black Women’s Health.) Available
at: http://www.kaisernetwork.org/health_cast/hcast_index.cfm? display⫽detail&hc⫽833 (accessed April 16, 2003) 11. National Cancer Policy Board: Executive Summary: Fulfilling the potential of cancer prevention and early detection. Washington, DC, Institute of Medicine, National Research Council, 2003 12. Willett W: Cancer prevention and early detection. Cancer Epidemiol Biomarkers Prev 12:252s, 2003 13. US Bureau of the Census 2000. Summary File 3 (SF 3). Detailed Tables. American Fact Finder. Available at: http:// www.census.gov (accessed March 4, 2001) 14. Van Ryn M, Fu SS: Paved with good intentions: Do public health and human service providers contribute to racial/ ethnic disparities in health? Am J Public Health 93:248-255, 2003 15. The Commonwealth Fund 2002 Annual Report. New York, 2002. Available at: www.cmwf.org. 16. Wiebel WW: Identifying and gaining access to hidden populations: NIDA Research Monograph Series 98: The Collection and Interpretation of Data from Hidden Populations. US Department of Health and Human Services Pub. no. (ADM) 90-1678, 1990 17. Krane KM, Parece MS, Miles JR: Intervening among the invisible population. Corrections Today 60:122-196, 1998 18. Casey MM, Call KT, Klingner JM: Are rural residents less likely to obtain recommended preventive healthcare services? Am J Prev Med 21:182-188, 2001 19. Buchting F: Tobacco and the LGBT community. Reprinted from Tobacco-Related Disease Research Program Newsletter 5:1-3, 2002 20. Centers for Disease Control and Prevention: Health and economic impact: Smoking cessation for pregnant women. Atlanta, GA, Center for Disease Control, 2002 21. Albrecht SA, Taylor MV, Braxter BJ, et al: A descriptive study of smoking patterns among two racial groups of pregnant adolescents. J Addict Nurs 13:19-30, 2001 22. Aligne CA, Moss ME, Auinger P, et al: Association of pediatric dental caries with passive smoking. JAMA 289:12581264, 2003 23. Gardiner P: College students: The next generation of
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replacement smokers. Reprinted from Tobacco-Related Disease Research Program Newsletter 5:1-7, 2002 24. Moon-Howard J: African American Women and smoking: Starting later. Am J Public Health 93:418-420, 2003 25. Centers for Disease Control and Prevention: Cigarette smoking among adults–US,2000. MMWR Morb Mortal Wkly Rep 51:642-645, 2002 26. American Heart Association Advocacy Position. Tobacco industry’s targeting of youth, minorities and women. Available at: http://americanheart.org/Heart_and_Stroke_ A_Z_Guide/tobta.htm (accessed July, 10, 2000) 27. US Department of Health and Human Services. Ending chronic homelessness: Strategies for action. US Department of Health and Human Services. Available at: http://aspe.hhs.gov/ hsp/homelessness/strategies03/ (accessed April 1, 2003) 28. Butler J, Okuyemi KS, Jean S, et al: Smoking characteristics of a homeless population: Substance Abuse. J Assoc Med Educ Res Substance Abuse 23:223-231, 2002 29. US Department of Health and Human Services: 2001 National Household Survey on Drug Abuse. Chapter 4. Tobacco use. Rockville, MD, Office of Applied Studies 30. Maruschak LM, Beck AJ: Medical problems of inmates, 1997. US Department of Justice. Office of Justice Programs. Bureau of Justice Statistics. NCJ 181644. Available at: http:// www.ojp.usdoj.gov/bjs/pub/pdf/mpi97.pdf (accessed February 17, 2003) 31. Lewis SG, Kicking the tobacco habit: Correctional health pros share smoke-free stories. National Commission on Correctional Health Care. Available at: http://www.ncchc.org/ pubs/CC_archive/smoke-free.html (accessed May 23, 2003) 32. Smith RC, Infante M, Ali A, et al: Effects of cigarette smoking on psychopathology scores in patients with schizophrenia: An experimental study. Substance Abuse: J Assoc Med Educ Res Substance Abuse 22:175-186, 2001 33. Henningfield JE, Benowitz NL, Ahijevych K, et al: Does menthol enhance the addictiveness of cigarettes? An agenda for research. Nicotine Tobacco Res 5:9-11, 2003 34. Perez-Stable EJ, Herrera B, Jacob P, et al: Nicotine metabolism and intake in African American and white smokers. JAMA 280:152-156, 1998 35. Gardiner P: Researchers zero in on menthol. Reprinted from Tobacco-Related Disease Research Program Newsletter 3:1-7, 2000 36. Balbach ED, Gasior RJ, Barbeau EM: R.J. Reynolds’ targeting of African Americans: 1988-2000. Am J Public Health 93:822-827, 2003
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37. Join Together Online summary. Report: Big tobacco major supporter of black groups. Available at: http://www. jointogether.org/sa/news/summaries/print/0,1856,555420,00. html (accessed December 20, 2002) 38. Prothrow-Stith D, Gibbs B, Allen A: Reducing health disparities: From theory to practice. Cancer Epidemiol Biomarkers Prev 12:256s-260s, 2003 (suppl) 39. Centers for Disease Control and Prevention: State Medicaid coverage for tobacco-dependence treatments–US, 19982000. MMWR Morb Mortal Wkly Rep 50:979-982, 2001 40. Froelicher ES, Christopherson DJ: Women’s initiative for nonsmoking (WINS) I: Design and methods. Heart Lung 29:429-437, 2000 41. Martin K, Froelicher ES, Miller NH: Women’s initiative for nonsmoking (WINS) II: The intervention. Heart Lung 29: 438-445, 2000 42. Froelicher ES, Christopherson DJ, Miller NH, et al: Women’s initiative for nonsmoking (WINS) IV: Description of 277 women smokers hospitalized with cardiovascular disease. Heart Lung 31:3-14, 2002 43. Maher-Imhof R, Froelicher ES, Li WW, et al: Women’s initiative for nonsmoking (WINS) V: Use of nicotine replacement therapy. Heart Lung 31:368-373, 2002 44. Froelicher ES, Li WW, Maher-Imhof R, et al: Women’s initiative for nonsmoking (WINS) IV: Health and psychosocial measures in a smoking cessation study. J Cardiovasc Pulm Rehab (in press) 45. Froelicher ES, Miller NH, Christopherson DJ, et al: Efficacy of smoking cessation interventions in women hospitalized with cardiovascular disease (CVD): Women’s initiative for nonsmoking. Circulation (in press) 46. Baluja KF, Park J, Myers D: Inclusion of immigrant status in smoking prevalence statistics. Am J Public Health 93:642-646, 2003 47. US Department of Health and Human Services: Clinical practice guideline: Treating tobacco use and dependence. Washington, DC, Public Health Service, 2000 48. Samet DH: Scoring clarifications for the no-smoking standard. Oakbrook Terrace, IL, The Official Joint Commission Environment of Care News Source, Sept/Oct 4:2001 49. Oncology Nursing Society: Oncology nursing society multicultural outcomes: Guidelines for cultural competence. Pittsburg, PA, Oncology Nursing Society, 1999 50. Cancer, Culture and Literacy Institute: Available at: http://www.moffitt.usf.edu/promotions/cclinstitute/index.htm (accessed August 29, 2002)