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Fighting Back Against Joe Camel
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Smoking
Cessation and Ethnic Minorities:
Smoking kills. Tobacco products are the only commercially available products in the US which are life-threatening when used in the manner in which they are intended to be used.1 One in five Americans eventually dies from tobacco use. Tobacco claims more than 418,000 lives of Americans annually, a number about equal to the population of Atlanta, Georgia. Imagine that a nuclear power plant accident were to occur every year in a different American city, each about the size of Atlanta, killing all of the inhabitants. Imagine too that the company responsible for building and maintaining these plants were not only permitted to continue to do business but also to take out billboard advertising promoting their products, especially in minority communities, and to underwrite professional sporting events. The hue and cry in the population would be deafening, I suspect. Yet we accept as a way of life the manufacture, distribution and sale of tobacco products which kill just as many people annually. Few American families have been untouched by the early death of loved ones due to tobacco-related diseases; many times families don't recognize that tobacco is the culprit. Most people know that smoking causes lung cancer and chronic obstructive pulmonary diseases such as emphysema and chronic bronchitis, but many do not realize that it causes some 180,000 deaths annually due to coronary heart disease, which is about one in every five CHD deaths, and causes or contributes to many forms of cancer, including oral and throat cancers, bladder cancer, cancer of the pancreas and kidney cancer. Lighting a cigarette sets off a chemical reaction that changes many of the natural substances in tobacco into more than 4,000 distinct compounds that enter the body through the lungs, many of which are carcinogenic. If you smoke, you have more than twice the risk of dying from cancer as nonsmokers. If you are a heavy smoker, your risk is four times as great.2 All together, one in three cancer deaths in the US is related to smoking. Smoking in pregnancy raises additional health concerns for the mother and baby, and is a leading cause of low birth weight, premature births and miscarriages.3 We could prevent as many as one in four cases of low birth weight in newborns if mothers avoided smoking during pregnancy. Children exposed to cigarette smoke in the home are at greater risk of respiratory infections, asthma and lung disease, including lung cancer, later in life. We are outraged when we see cases of child abuse slipping through the cracks in the system. Yet we turn the other way when we see parents smoking in the presence of their children and failing to take any precautions to protect their children, such as opening a window or stepping outside to smoke. Consider some other smoking-related statistics. Smoking results in nearly eight times as many deaths as all types of motor-vehicle accidents combined. For each death due to drunk driving, 74 people die prematurely as the result of smoking.4 The nation's leading cancer killer of women is no longer breast cancer; it is now lung cancer. Lung cancer is also the leading cancer killer of men, not prostate cancer. Nearly 90% of the 150,000 lung cancer deaths in this country annually could be prevented if smoking were eliminated. In one fell-swoop we could make major inroads in the war against cancer if Americans who smoke stopped and those who didn't smoke avoided taking up the habit. Smoking, especially among men, is a worldwide health problem, indeed a health crisis of staggering proportions. The World Health Organization estimates that more than 60% of men from China, Indonesia and the Philippines smoke, as do more than 70% of Korean men, as compared to 28% of men in the US.5 Across Latin America and East Asia, about one in two men smoke.6 In China alone, 300 million people smoke, which is more people than the entire US population! Worldwide, more than three million people die annually from smoking, which amounts to one smoking-related death every 10 seconds.7 Smoking related deaths are expected to nearly triple by the year 2020, which will make smoking the world's leading killer.8 This is a good news, bad news situation. We have made substantial progress in the war against tobacco since the landmark 1964 Surgeon General's report on smoking and health.9 More than 35 million smokers have quit smoking, myself included. By 1987, nearly one in two people who had ever smoked had stopped. Smoking rates among adults dropped from about 40 percent in 1964 to about 25 percent today. The body count in the government's war against smoking can be measured in terms of the numbers of premature deaths, about three million strong, either avoided or delayed due to quitting smoking or never smoking in the first place. Increasing percentages of smokers are joining the ranks of the nonsmokers every day. Better educated smokers are more likely than their less well educated counterparts to quit smoking, which is perhaps another reason supporting the value of a college education. Nearly six in ten college educated people who once smoked no longer do so. Now for the bad news. Smoking rates in the general population have leveled off in recent years, and have started to climb sharply among teenagers, reversing an earlier steady decline.10 By 1995, nearly 35% of teenagers 17 years of age or younger were smoking, up from 27.5% in 1991.11 Estimates are that 3,000 young people take up smoking each day. About one in three will eventually die of smoking-related diseases. Despite our progress in the war against smoking, fifty million Americans, about one in four, continue to smoke. Americans smoke more than 500 billion cigarettes each year, which works out to more than 2,500 cigarettes a day for every person 18 years of age or older, smokers and nonsmokers alike. Smoking is becoming increasingly concentrated among the poorer and less well educated segments of our society. In the recent presidential campaign, former Senator Bob Dole ignited a controversy when he said that he wasn't sure whether cigarette smoking was addictive. Yes, Mr. Dole, smoking is addictive. It meets every accepted criterion of addiction, as documented in a 1988 Surgeon General's report. But I think Mr. Dole's comment really begs the question. The question Mr. Dole should have addressed is whether he believes tobacco kills. Drugs such as caffeine are addictive but not harmful to most people when used in moderation. Mr. Dole, if cigarettes kill, does not the government have a responsibility to curb its use, especially among young people? The nicotine in the tobacco may get you hooked, but it is the tar and carbon monoxide in cigarette smoke which eventually kills you. Cigarettes
not only kill, but also cost, some $50 billion dollars annually in direct
medical costs according to a recent estimate, accounting for at least
7% of the nation's total health care costs.12
That's the equivalent of more than two dollars in health-related costs
for each pack of cigarettes sold. These are costs borne by us all, not
just smokers, in the form of higher taxes and increased costs for health
insurance. If you take into account the full economic burden of cigarette
smoking, which includes costs associated with smoking-related sick days
and premature deaths, the bill exceeds $100 billion annually. Smoking in Ethnic Minorities Smoking is more common and quitting less frequent among the unemployed and people from the lower socioeconomic strata. Thus, it is not surprising that economically disadvantaged ethnic minority groups have higher than average rates of smoking, especially African American men. The anti-smoking message that has prompted millions of Americans to quit does not seem to be getting through as strongly with poorer, less well educated people. Cigarette companies have also targeted much of their advertising effort toward minority communities, especially African American and Hispanic communities. African Americans African American men have the highest smoking rates in the US among the major racial/ethnic groups. Not so for African American women, who smoke at a rate essentially equivalent to that of the general female population in the US. The greater smoking rates among African-American men may largely account for the fact that African American men suffer the highest mortality rates of death due to lung cancer of any group in our society.15 African Americans overall have more than six times the incidence of lung cancer as Whites.16 Factors that account for greater smoking rates in the general population, such as lower socioeconomic status, less formal education, blue-collar occupation and unemployment, also predict differences in smoking rates among African Americans. Smoking is a major contributor to shorter life expectancy among Black men in inner city neighborhoods.17 What's to be done? According to experts from the National Cancer Institute, if anti-smoking campaigns are to achieve widespread success among African Americans, especially those of lower socioeconomic status, several barriers will need to be overcome.18
Smoking is more prevalent among African American men than White or Hispanic men in our society. In women, smoking prevalences are comparable between African Americans and Whites, but much lower among Hispanics. Hispanic Americans Hispanic men overall smoke at similar rates as (non-Hispanic) White men overall, while Hispanic women overall smoke at lower rates than (non-Hispanic) White women and Hispanic men.19 Smoking prevalences have declined among Hispanic groups overall, but have remained relatively stable among some Hispanic subgroups while actually increasing among others, such as among young Puerto Rican American men and women. These increases portend higher rates of lung cancer in the future for these groups. Acculturation has an important bearing on smoking patterns among Hispanics, especially Hispanic women. Acculturation is the process by which immigrant groups adopt the customs and behavior of the host culture.20 Researchers find that with increasing acculturation, smoking attitudes and patterns among Hispanics become more like those of the larger culture. Traditional Hispanic cultures discourage smoking among women but not among men, which may explain the traditional gender gap in smoking rates among Hispanics. Yet the mainstream US culture has less rigidly defined gender roles. Not surprisingly, smoking rates among more acculturated Hispanic women in the US tend to be higher than those among less acculturated Hispanic women. Smoking in more acculturated Hispanic women has also increased to the point that traditional gender differences have been largely erased, especially among young Puerto Rican Americans. Acculturation has less bearing on smoking patterns in Hispanic men, as men have had greater social license to smoke in their traditional cultures. Native Americans We lack reliable national estimates of smoking prevalences among Native Americans. Estimates suggest prevalence rates within the American Indian/Alaskan Native population overall of 28% among men and 35% among women.21 Much variability exists among tribes as survey evidence shows smoking prevalences to greatly exceed the norms for the general US population among some groups, such as Northern Plains Indians (42% to 70% across tribes) and Alaskan Natives (56%),22 but are lower among others, such as Southwestern Indians (13% to 28%). Use of smokeless tobacco is also higher among some American Indian groups, especially among the young. Native Americans also suffer from a high prevalence of alcohol abuse and dependence. Excessive drinking and cigarette smoking is an especially deadly combination for Native Americans, as it is for other groups. Asian Americans We also lack national survey data on smoking prevalences among Asian Americans. Local surveys of specific Asian groups show that smoking rates vary across subgroups. A 1986 survey in Hawaii showed smoking rates of 25% for Filipinos and 21% for Japanese, as compared to 29% for Whites and Native Hawaiians.23 Among the highest reported rates of any ethnic group in the US are men who recently emigrated from southeast Asia.24 Culturally-Sensitive Smoking Cessation Programs for Minority Smokers Given the diversity of smoking patterns that exist in the US in relation to such factors as ethnicity and socioeconomic level, health officials recognize that no one approach to smoking cessation is likely to be effective for all smokers.26 Health officials also point out that anti-smoking programs need to be tailored to the groups they are intended to reach and take into account the distinguishing cultural characteristics of these targeted groups. For example, since Hispanic smokers are more likely to connect smoking with socializing with their friends than are smokers from other groups, learning how to politely refuse a cigarette in a culturally appropriate manner takes on added importance in working with Hispanic smokers. Hispanics are also more likely to express concern about the social or interpersonal consequences of smoking, such as setting a bad example for their children, damaging their children's health, or provoking criticism from family members, and on the short-term consequences of smoking, such as bad breath and burning holes in clothing.27 Incorporating these concerns in anti-smoking messages may be more effective than a campaign that limits the focus to long-term health consequences. The central reference points in the Hispanic communities, such as the churches, bodegas (neighborhood grocery stores), community health clinics and community organizations, also need to be utilized in disseminating information and messages promoting more healthful behaviors. The development of culturally specific smoking cessation programs for minority smokers is now in a beginning stage of development and implementation. In one of the few reported studies thus far, G. Marin and his colleagues offered a community-wide media intervention within a predominantly Hispanic community.28 The media intervention increased awareness of the availability of a culturally-informed smoking cessation program in the neighborhood and also raised people's awareness of the dangers of smoking. However, the program failed to reduce community smoking prevalences after seven months. I was a principal investigator along with Dr. Rafael Javier on an externally funded research project supported by the National Heart, Lung and Blood Institute of NIH which involved the development of a culturally sensitive smoking cessation program for Hispanic smokers.29 Called the "SI, PUEDO" ("Yes, I Can") program, this eight-week-long stop-smoking program was offered in predominantly Hispanic communities in Queens, New York and incorporated, as part of a multicomponent behavior modification program, the use of videotaped vignettes of smoking-related situations enacted by Hispanic actors. Culturally laden values such as machismo (masculinity), familiarismo (responsibility to family) and respeto (respect for self and others) were used in these vignettes to convey anti-smoking messages and encourage smoking cessation. Participants were screened on the basis of the following study criteria: reported present smoking; 18+ years of age; minimal bilingual competence; Spanish surname status; and a history of at least one previous unsuccessful quit attempt. Despite an extended, multifaceted recruitment effort, we were able to recruit only 93 participants (48 men and 45 women), less than half the number we had hoped to recruit. The study sample averaged 44 years of age and reported a median family income level of $15,000 to $20,000 per year. More than nine of ten (93%) were born outside the mainland US, with two of three originating from South or Central America and about one in four from the Caribbean region. Eighty-four percent were high school graduates. Participants obtained an average (mean) acculturation score at a level corresponding to scores obtained with first generation immigrants. Participants smoked an average of 21 cigarettes daily, or slightly more than one pack a day. Men and women did not differ significantly in terms of reported smoking rates. Participants had smoked for nearly 25 years on the average and had started smoking at a median age of 16.0 years. The multicomponent behavioral program used a nicotine-fading protocol and incorporated behavioral techniques such as stimulus control, self-reward, coping skills training for handling smoking urges and temptations, and relapse prevention training. Group leaders were bilingual Hispanic professionals (psychologists and social workers) who worked from a structured treatment manual. The multicomponent program was compared with a minimal contact (self-help) control condition which involved distribution of the widely-used American Lung Association manual for smoking cessation, Freedom from Smoking in 20 Days, which was presented in both the original English version and a backward-translated Spanish version. This control program was enhanced by the addition of a Spanish language quitting manual, as well as by the use of an introductory group session which focused on building motivation and clarifying instructions for the proper use of the self-help manuals, and use of supportive phone calls placed by a bilingual Hispanic staff member on a twice monthly basis during the following eight-week period. Following the treatment phase, a low-intensity maintenance program was used in both treatment conditions, consisting of (1) distribution of a Spanish/English version of the American Lung Association self-help maintenance manual, A Lifetime of Freedom from Smoking, and (2) use of supportive phone calls on a twice monthly basis during the first six-month follow-up interval. Our analysis of results showed a significant difference in abstinence rates favoring the multicomponent treatment, but only at post-treatment. Abstinence was validated by analysis of saliva cotinine, a metabolite of nicotine. With missing data coded for non-abstinence, the percentages of validated abstainers in the multicomponent group treatment program declined from 21% at treatment termination (as compared to 6% among controls) to 13% at six-month follow-up and to 8% at 12-month follow-up. Percentages of validated abstainers in the enhanced self-help condition increased slightly from 6% at post-treatment to 9% at six month-follow-up, before declining to 7% at 12-month follow-up. Our findings indicate that participation in intensive, culturally-sensitive smoking cessation programs which provide support and training in cessation techniques may help boost initial cessation rates, but may not be sufficient to avert eventual relapse or promote long-term smoking cessation. Perhaps more intensive efforts or new techniques are needed to maintain abstinence following the treatment phase. Relapse rates of 50% in the minimal contact condition and 78% in the multicomponent group program suggest that a low intensity maintenance program may not be potent enough to prevent eventual relapse in the population we studied. Nor does the incorporation of relapse prevention techniques during the intervention phase appear to bolster resistance to eventual relapse. The study was plagued by difficulties in recruiting subjects, inconsistent attendance, and high rates of attrition. Difficulties encountered in recruiting ethnic minority group participants to a community-based health promotion program parallel those reported by other investigators in recent studies, even in culturally-informed programs.30 We did find evidence of a dose-response relationship with respect to attendance in multicomponent group sessions. That is, more frequent attendees were more likely to demonstrate initial cessation and six-month follow-up abstinence than were less frequent attendees. Perhaps it is less surprising that the multicomponent program failed to demonstrate superior results to a minimal contact control at follow-up intervals than it is that it produced initially higher cessation rates despite poor attendance. Perhaps more intensive treatments can yield greater benefits in smoking outcomes with ethnic minority participants if they are structured in a way that maximizes exposure and continued participation. Additional Culturally-Specific Anti-Smoking Interventions In another federally funded minority-oriented program, the American Indian Health Care Association offered a smoking cessation program directed at Native Americans through Indian health clinics in the upper Midwest and Northwest.31 At Ohio State University, the federal government has funded a program in which Asian Americans are trained to direct smoking cessation efforts targeted toward Southeast Asian men, a group composed largely of recent immigrants from Vietnam and Cambodia among whom smoking rates are especially high.32 One recent example of a successful community-wide anti-smoking effort involved a grassroots campaign waged in Philadelphia against the test marketing of "Uptown" cigarettes, a new brand that was targeted toward the African American community. Organizers were able to mobilize community residents and put enough pressure on the cigarette maker to force withdrawal of the brand.33 Cigarette advertising has been increasingly directed at African Americans, which has created something of a backlash effect, with many community organizations in African American communities taking action to prevent the displays of cigarette advertisements on community billboards. In New York City and elsewhere, leading clergy and other community leaders have become involved in efforts to prohibit billboard advertising of cigarettes (in some cases, even "whitewashing" billboards) and to ensure stricter enforcement of restrictions against selling cigarettes to minors. Other programs have recruited community residents from churches and community organizations to serve as volunteers in talking to their friends and neighbors about the dangers of cigarette smoking. Anti-smoking organizers have also made use of churches, recreational centers, and barber shops in African American communities as settings for holding stop-smoking programs and distributing anti-smoking materials. In East Baltimore, Maryland, the Heart, Body & Soul Project involved a collaboration between Black clergymen and the Johns Hopkins Center for Health Promotion in which the clergymen delivered smoking cessation messages as part of their sermons and sponsored health fairs and special programs for smoking cessation within their churches.34 Voluntary health organizations, including the American Lung Association, the American Heart Association and the American Cancer Society, have become involved in spearheading stop-smoking initiatives targeting minority smokers. For example, the American Lung Association has developed a pamphlet, Don't Let Your Dreams Go Up in Smoke, that addresses the problem of smoking in the African American community.35 Government health agencies have also begun to meet the need for smoking cessation programs targeted toward minority smokers. In the Bedford Stuyvesant area of Brooklyn, New York, a predominantly African American community, the New York State Healthy Heart Program sponsored a quit smoking contest in which people who quit smoking for a month were eligible to participate in a drawing for various prizes. In New York's Washington Heights community, an area with a predominantly Dominican population, the local Healthy Heart Program sponsored a "Burial of Joe Camel" day. Though the problem of promoting smoking cessation and preventing relapse is a vexing one, and certainly not limited to ethnic minority groups, the social and acculturative stresses faced by these groups present health behavior researchers with special challenges. Adapting smoking cessation interventions to settings that fall within the smoker's usual routines offers the promise of greater cost effectiveness, adaptability and affordability. We are now examining the utility of piggy-backing our smoking cessation program onto other health delivery systems, such as prenatal care for pregnant women. Such approaches may be capable of reaching a far greater number of smokers, especially minority smokers, than clinic-based programs that require regular attendance in community-based, group meetings. Moreover, integrating interventions and maintenance approaches within customary health, educational and social routines may promote long-term maintenance of smoking abstinence. It is still too early to tell whether culturally appropriate treatment interventions will prove more effective than conventional practices, such as physician encouragement of smoking cessation efforts. Let me close on a hopeful note. With increased attention focused on smoking cessation in all segments of our society, including socially disadvantaged groups, we can hope that "Joe Camel's" days may well be numbered. ENDNOTES 1. US Department of Health and Human Services (USDHHS), Public Health Service, National Institutes of Health, National Cancer Institute. Strategies to Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990s. (NIH Publication No. 92-3316) Washington D.C.: National Cancer Institute, 1991.return to paragraph 2. Bartecchi, C. E., MacKenzie, T. D., & Schrier, R. W. (1994). "The human costs of tobacco use" (First of two parts). New England Journal of Medicine, 330, 907-912.return to paragraph 3. USDHHS. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. (DHHS Pub. No. CDC 90-8416). Rockville, MD: Centers for Disease Control, Office on Smoking and Health, 1990; USDHHS. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. (DHHS Pub. No. PHS 91-50212). Washington, DC: Public Health Service, 1991b; Mayer, J. P., Hawkins, B., and Todd, R. "A randomized evaluation of smoking cessation intervention for pregnant women at a WIC clinic." American Journal of Public Health, 80 (1990), 76-79. return to paragraph 4. Sardella, S. "APA backs tobacco tax to fund health reform." APA Monitor, January 1994, p. 6.return to paragraph 5. Shenon, P. "Asia's having one huge nicotine fit." The New York Times, May 15, 1994, Section 4, pp. 1, 16. return to paragraph 6. Darnton, J. "Report says smoking causes a global epidemic of death." The New York Times, September 21, 1994 , p. B8.return to paragraph 7. Ibid. return to paragraph 8 "Smoking will be world's biggest killer." Newsday, September 17, 1996, p. A21.return to paragraph 9. USDHHS. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. (DHHS Publication No. [CDD] 89-8411). Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Washington, D.C., 1989; USDHHS, 1991a; "Smoking declines at a faster pace.". The New York Times, May 22, 1992, p. A17. return to paragraph 10. Hilts, P. J. "Long-term decline in smoking in U.S. is apparently over." The New York Times, May 20, 1994, p. A16.return to paragraph 11. Feder, B. J. "Increase in teen-age smoking sharpest among Black males." The New York Times, May 24, 1996, p. A20. return to paragraph 12. "Cigarettes: A constant pain in the budget." Newsweek, July 18, 1994, p. 65.; Hilts, P. J. "Sharp rise seen in smokers' health care costs." The New York Times, July 8, 1994, p.A12. return to paragraph 13. Source: Nevid, J.S., Rathus, S. A., and Rubenstein, H. Pathways to Health. Manuscript in preparation. All rights reserved. 15. USDHSS, 1991a return to paragraph 16. "Smoke Rises." The New York Times, December 27, 1993, p. A16. return to paragraph 17. McCord, C., and Freeman, H. P. "Excess mortality in Harlem." The New England Journal of Medicine, 322 (1990), 173-177. return to paragraph 18 USDHHS, 1991a return to paragraph 19. Escobedo, L.G. and Remington, P. L. "Birth cohort analysis of prevalence of cigarette smoking among Hispanics in the United States." Journal of the American Medical Association, 261 (1989), 66-69; Rogers, R. G., & Crank, J. "Ethnic differences in smoking patterns: Findings from NHIS." Public Health Reports, 103 (1988), 387-393. return to paragraph 20. Marin, G., et al. "The role of acculturation in the attitudes, norms, and expectancies of Hispanic smokers." Journal of Cross Cultural Psychology, 20 (1989), 399415. return to paragraph 21. Centers for Disease Control and Prevention. "Cigarette smoking among adults -- United States, 1991". Morbidity and Mortality Weekly Report, 42:12 (1993), 230-233. return to paragraph 22. USDHHS, 1989 return to paragraph 23. Chung, C. S. A Report on the Hawaii Behavioral Risk Factor Surveillance System for 1986. Unpublished Manuscript. School of Public Health, University of Hawaii, 1986. return to paragraph 24. Chen, M.S. Lay-led smoking cessation approach for southeast Asian men. Paper presented at the program on smoking cessation strategies for minorities, National Heart, Lung & Blood Institute, National Institutes of Health, Bethseda, MD, February 1991. return to paragraph 25. Adapted from Nevid, Rathus, and Rubenstein, manuscript in preparation. All rights reserved. 26. USDHHS, 1991a return to paragraph 27. Marín, G., Marín, B. V., Pérez-Stable, E. J., Sabogal, F., and Otero-Sabogal, R. "Cultural differ ences in attitudes and expectancies between Hispanic and nonHispanic White smokers." Hispanic Journal of Behavioral Sciences, 12 (1990), 422436. return to paragraph 28. Marín, G., Marín, B. V., Pérez-Stable, E. J., Sabogal, F., and Otero-Sabogal, R. Changes in infor mation as a function of a culturally appropriate smoking cessation community intervention for Hispanics. American Journal of Community Psychology, 18 (1990), 847864. return to paragraph 29. Nevid, J.S., and Javier, R.A. "SI, PUEDO" smoking cessation program for Hispanic Smokers. Fourth National Forum on Cardiovascular Health, Pulmonary Disorders, and Blood Resources, Minority Health Issues for an Emerging Majority, National Heart, Lung, and Blood Institute, National Institutes of Health, June 1992. Nevid, J. S. (1996). "Smoking cessation with ethnic minorities: Themes and approaches." Journal of Social Distress and the Homeless, 5 (1996), 1-16; Nevid, J. S., and Javier, R. A. "Preliminary investigation of a culturally-specific smoking cessation intervention for Hispanic Smokers." American Journal of Health Promotion, 1996; Nevid, J. S., Javier, R. A., and Moulton, J. (1996). "Factors predicting participant attrition in a community-based culturally-specific smoking cessation program for Hispanic smokers." Health Psychology, 15 (1996), 226-229. return to paragraph 30. Marín, G., Marín, B. V., Pérez-Stable, E. J., Sabogal, F., and Otero-Sabogal, R, 1990; Baranowski, T., Simons-Morton, B., Hooks, P., Henske, J., Tiernan, K., Dunn, J. K., Burkhalter, H., Harper, J., & Palmer, J. A center-based program for exercise change among Black-American families. Health Education Quarterly, 17 (1990), 179-196. return to paragraph 31. The G.A.I.N.S. Project. American Indian Health Care Association. 2345 E. Sixth Street, St. Paul, Minnesota; Johnson, K. M. and Lando, H. "Smoking cessation strategies for minorities." Paper presented at the program on Smoking Cessation Strategies for Minorities. National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, February 1991. return to paragraph 32. Chen, M. S. Lay-led smoking cessation approach for Southeast Asian men, February 1991. return to paragraph 33. LePera, P. "ACS runs Uptown out of town." Cancer News, 44: 2 (1990), 20. return to paragraph 34. The Heart, Body & Soul Project. A collaborative program between the Clergy United for Renewal of East Baltimore (CURE) and the Johns Hopkins Medical Institutions, Center for Health Promotion; Levine, D., et al. "Church-based smoking cessation strategies in urban blacks." Paper presented at the program on Smoking Cessation Strategies for Minorities. National Heart, Lung & Blood Institute, National Institutes of Health, Bethseda, MD, February 1991. return to paragraph 35. American Lung Association. Don't let your dreams go up in smoke. . . , April 1990. return to paragraph
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Introduction
