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are other reasons not to make tobacco taxes almost the entire focus of tobacco control policy, whether we are talking about youth smoking or adult smoking. These taxes, in the end, burden adult smokers, who increasingly come from the ranks of the working class and the poor, most of whom are addicted. And while it is true that lower-income people are disproportionately influenced by cigarette price increases, I believe that most people would nonetheless consider the net tax consequence as regressive rather than progressive. In any event, as nonsmokers become an increasing majority of the voting public, the ease with which they can push more of the regular costs of government onto smokers is worrying as a matter of fairness. In turn, that makes public spending dependent on continued substantial rates of smoking. Higher tobacco taxes also can bring with them in-
creased tobacco smuggling and the possible involvement of organized crime or other dangerous criminal elements. These points are not meant to be an argument against moderate or even substantial tobacco taxes. But they are meant as a caution against excessive reliance on this one policy instrument. Of course, in a state like California that has been successful in reducing smoking rates, tobacco control policy is by no means restricted to tobacco tax increases. The other most effective policies seem to be very tough controls on indoor smoking at both work and leisure venues and a very aggressive antismoking advertising program (even if some of the advertisements strike me as unseemly propagandistic). A supposedly conservative US Supreme Court has recently given an extraordinarily liberal interpretation of the First Amendment and an extraordinarily
anti–states’ rights interpretation of the federal law on cigarette warnings. These rulings have precluded California and other states from strongly curbing tobacco industry advertising and promotional campaigns. Yet, even in California, considerably more could be done to promote the free or inexpensive availability of effective smoking cessation (or smoking reduction) products and programs. Indeed, the ready availability of such programs and products may be thought a precondition for the fair imposition of high tobacco taxes on addicted smokers. After all, the strongest ethical justification for public health intervention to reduce smoking (putting aside the consequences of secondhand smoke) is that children are duped into starting to smoke and become hooked before they realize what they are getting into. But then to impose pain in the form of higher taxes on those
very victims seems harsh, especially if those most burdened by tobacco taxes also find cessation programs and products financially daunting.
About the Author Stephen D. Sugarman is with the School of Law, University of California, Berkeley. Requests for reprints should be sent to Stephen D. Sugarman, JD, 327 Boalt Hall, University of California, Berkeley, CA 94720-7200 (e-mail: sugarman@ law.berkeley.edu). This article was accepted October 4, 2002.
References 1. Glied S. Is smoking delayed smoking averted? Am J Public Health. 2003; 93:412–416. 2. Glied S. Youth tobacco control: reconciling theory and empirical evidence. J Health Econ. 2002;21:117–135. 3. Gruber J, Zinman J. Youth smoking in the US: evidence and implications. In: Gruber J, ed. Risky Behavior Among Youths. Chicago, Ill: University of Chicago Press; 2001:69–120.
African American Women and Smoking: Starting Later | Joyce Moon-Howard, DrPH
It is commonly accepted that adolescence is the period for initiation into smoking and other tobacco use behaviors. However, evidence is increasing that the set of presumptions about adolescent onset of tobacco use may not be true for all cultural or subpopulation groups. Secondary analysis of data from the 2000 National Health
Interview Survey (NHIS) was used to examine ethnic differences in smoking patterns among African American and White women. Results showed a striking racial/ ethnic difference in age of onset; African American women initiate smoking later than White women at each age group. Prevention interventions need to continue beyond adolescence
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well into the adult years, especially for African American women. Late onset for these women represents an often missed window of opportunity for prevention. (Am J Public Health. 2003;93: 418–420)
IT IS COMMONLY ACCEPTED that tobacco use has an age-
defined period of onset: adolescence is the period for initiation into smoking and other tobacco use behaviors.1 Surveillance data show a relatively narrow age range for smoking onset, after which the presumed risk of initiation decreases. A number of studies conclude that very few people begin to use tobacco as
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adults; they note that most adult smokers report that first use had occurred by the time they graduated from high school.1,2 In addition, several studies have shown that adolescent onset is strongly associated with continued use throughout the life course.1 Health problems associated with smoking are a function of the duration (years) and the intensity (amount) of use. Thus, earlier onset would provide more time and opportunity for the risk of more serious health consequences.3,4 These research findings have influenced tobacco control proponents who have strongly urged that prevention efforts be targeted at preadolescents and young teens (< 18 years old), reasoning that postponing the onset of tobacco use in adolescence makes it less likely that initiation will occur. The overwhelming majority of tobacco education and prevention initiatives target youths aged younger than 18 years. These efforts include school-based education and prevention programs, banning billboard advertisement of tobacco within 1000 feet of schools, enforcing laws restricting minors’ access to tobacco products, and youth-oriented mass media campaigns.5 However, there is increasing evidence that the set of presumptions about adolescent onset and duration of tobacco use may not be true for all cultural or subpopulation groups. It is encouraging that smoking prevalence has decreased in the United States.2 However, a focus on overall prevalence masks im-
portant differences within racial/ ethnic, sex, and age-specific groups.6,7 A case in point is smoking patterns among White and Black women, especially at younger ages.
ETHNIC/RACIAL DIFFERENCES IN SMOKING PATTERNS FOR WOMEN Several studies have shown that African Americans are more likely than not to begin smoking beyond the “typical” age of onset in early adolescence. Smoking rates among Black women continue to increase through the 20s and then plateau.8 Rates of smoking are higher for White women than for Black women at each age group up to the mid-30s, after which rates for Black women rise above those for White women until the late 40s. For example, 28% of young White women aged 18 to 20 years reported current smoking in the 2000 Na-
tional Health Interview Survey (NHIS), compared with 15% of Black women in this age group (Figure 1). In contrast, at ages 41 to 43, more Black women (36%) than White women (28%) are current smokers. A number of factors could influence prevalence rates by age, including differences in quitting patterns as well as differences in age of onset. The racial/ethnic differences in quit rates and cessation efforts have been discussed at length elsewhere.6,10–12,13 Less attention has been paid to racial/ ethnic differences in age at onset of smoking. The 2000 NHIS also collected data on age of smoking onset. The mean age of onset for Black women was 19.28 years (SD = 5.60), more than a year older than the age of onset for White women, 18.21 years (SD = 5.56). The difference in initiation rates shows that nearly two thirds (65%) of the White women who ever smoked began
FIGURE 1—Smoking prevalence for women, by current age: 2000 National Health Interview Survey.9
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smoking by age 18, while slightly more than half (54%) of the Black women had begun smoking by 18. As other researchers have pointed out, overall population prevalence rates can mask trends affecting younger age groups. Figure 2 shows the mean age of smoking onset by current age at time of interview for all women who ever smoked. As the trend line shows, there are striking racial/ethnic difference in age of onset; African American women initiate smoking later than White women at each age group. Clearly, age of onset is younger for women in more recent birth cohorts. However, at each age group, African American women report later age of smoking initiation.
IMPLICATIONS FOR TOBACCO PREVENTION Different patterns in age of onset have implications for tobacco prevention and education. Age of initiation for Black women is well beyond the target of most prevention initiatives. School-based programs, for example, would not reach young women aged older than 18 years, which is past the age of high school completion. It is not clear what factors are associated with late smoking initiation among African American women. In general, little is known about adult smoking initiation, and very little attention has been given to prevention of adult smoking onset. However, understanding later onset among women is an especially urgent public health issue.
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References 1. Kandel DB, Warner LA, Kessler RC. The epidemiology of substance use and dependence among women. In: Wetherington CL and Roman AB, eds. Drug Addiction Research and the Health of Women. Rockville, MD: National Institute of Drug Abuse Research Monograph; 1998. 2. Women and Smoking: A Report of the Surgeon General. Atlanta, Ga: Office of Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; 2001.
FIGURE 2—Mean age of smoking onset for women, by current age: 2000 National Health Interview Survey.9
Postadolescence onset occurs during peak childbearing and child-rearing ages, when the health risk from tobacco affects not only the women but their children as well.2 The assumptions of prevention campaigns focused on adolescents (i.e., smokers start in their teen years; teen smokers are more likely to continue) appear not to be valid for many, if not most, African American women. This raises the question of whether a “one size fits all” approach to prevention initiatives has more than limited utility for Black women. Indeed, prevention messages that target only youths may miss a significant at-risk population. Smoking and smoking-related cancers are major sources of excess mortality in African American communities,10,12,13,15 and African Americans die disproportionately more from smoking-related cancers than any other population group in the United States. 8 Research is needed to further clarify not
only patterns of smoking, including onset and cessation efforts, but also differential risks for smoking among different racial/ ethnic, sex, and age groups. Tobacco control efforts have made great strides, and we must take every opportunity to continue the progress. It is clear that prevention interventions need to continue beyond adolescence and well into the adult years, especially for African American women. Given that smoking is more persistent among African American women, preventing onset is critical. Late onset for these women represents an often missed window of opportunity for prevention.
About the Author Requests for reprints should be sent to Joyce Moon-Howard, Department of Sociomedical Sciences, Center for Applied Public Health, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 (e-mail:
[email protected]). This article was accepted November 8, 2002.
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3. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Ga: Office of Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; 1994. 4. Centers for Disease Control and Prevention (CDC). Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services; 1989. CDC publication 89-8411. 5. National Center for Tobacco Free Kids. Campaign for Tobacco Free Kids. Available at: http://tobaccofreekids.org/ reports/tobacctoll.php3?stateID=ny. Accessed September 2002.
for smoking onset. Health Psychol. 1997;16:499–505. 11. Morabia A, Costanza MC. Ages at initiation of cigarette smoking and quit attempts among women: a generation effect. Am J Public Health. 2002;92: 71–74. 12. Manfredi C, Lacey L, Warnecke R, Balch G. Method effects in survey and focus group findings: understanding smoking cessation in low-SES African American women. J Health Educ Behav. 1997;24:786–800. 13. Griesler PC, Kandel DB. Ethnic differences in correlates of adolescent cigarette smoking. J Adolesc Health. 1998; 23:167–180. 14. McGrady GA, Pederson LL. Do sex and ethnic differences in smoking initiation mask similarities in cessation behavior? Am J Public Health. 2002;92: 961–965. 15. Shervington DO. Attitudes and practices of African-American women regarding cigarette smoking: implications for interventions. J Natl Med Assoc. 1994;86:337–343.
6. Geronimus AT, Neidert LJ. Age patterns of smoking in US black and white women of childbearing age. Am J Public Health. 1993;83:1258–1264. 7. Centers for Disease Control and Prevention. Current trends [and] differences in the age of smoking initiation between blacks and whites—United States. MMRW Morb Mortal Wkly Rep. 1991;44:754–757. 8. 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: Office of Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; 1998. 9. 2000 National Health Interview Survey. National Center for Health Statistics, Division of Data Services. Hyattsville, Md. Available at: http://www.cdc. gov/nchs/nhis.htm. Accessed February 4, 2003. 10. Robinson LA, Klesges. RC. Ethnic and gender differences in risk factors
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