COVID-19 pandemic impacting smoking prevalence in minority populations

A media briefing hosted by the University of California, San Francisco, Smoking Cessation Leadership Center and Robert Wood Johnson Foundation highlighted the impact of the COVID-19 pandemic on smoking disparities in minority populations.

A panel of experts in December highlighted new information on the association between COVID-19 and the deceleration in progress to reduce smoking in minority populations.

In the United States, smoking rates have declined by more than 50% over the past 5 decades; yet, tobacco use remains the No. 1 cause of preventable death, particularly in minority populations. Disparities persist in tobacco use cessation rates and depend in part on where and how people live and income, according to the briefing.

“Although we have made progress in some communities, smoking is and has been for some time now a social justice issue where someone is born, lives, plays and works, and access — or lack thereof — to quality education and health care are key factors that play a part in smoking rates in communities and lead to a high burden of mortality and morbidityCatherine Saucedo, deputy director of the Smoking Cessation Leadership Center, said during the briefing. “Compounding these disparities, targeted marketing [and] vile tactics of the tobacco industry have taken advantage of historically marginalized individuals.”

‘A double whammy’

Delmonte Jefferson, executive director at the Center for Black Health & Equity, discussed disproportionate effects of COVID-19 in Black smokers.

“African Americans have more of the circumstances that make it harder survive this COVID-19 pandemic — deep-rooted poverty, preexisting medical conditions and issues, less access to health care, less stable employment,” Jefferson said during the briefing.

"COVID-19 did not cause these racial disparities ... [but it is] exposing existing inequities in our health care, education, traditional employment and our social systems,” Jefferson said.

Beyond the pandemic’s great impacts on mental health, physical health and economic well-being in the Black communities, high smoking rates further contribute to disparities, according to the briefing.

According to Jefferson, 85% of Black smokers consume menthol products. High use of menthol products is likely caused by “predatory marketing,” Jefferson said, utilizing community athletes, entertainers, donations to community events and festivals. Menthol products have been targeted to Black communities due to them being an “easy” product to smoke, which aids in creating an addiction and making it more difficult to quit, Jefferson said.

“So, here you've got COVID-19, which is a respiratory illness — it's in your lungs, is hard to breathe — and then you've got menthol cigarettes being aggressively targeted and marketed to our communities. At the same time, African American communities, other minority populations, all of those are being predatory marketed to by the tobacco industry,” Jefferson said. “This is a double whammy in our communities — something that we have to address, something that we're trying to address and something that we need to be aware of.”

Smoking disparities in Asian Americans

Recent data from the National Health Interview Survey showed that the current smoking rate among Asian Americans is 7%, Janice Tsoh, PhD, practicing clinical psychologist and professor of psychiatry and behavioral sciences at UCSF, said during the briefing. However, Tsoh noted that this number may be misleading due to aggregation to all Asian groups and sexes. In addition, the highest smoking rates were observed among Asian Americans with limited English vocabulary, Tsoh said.

In the context of the COVID-19 pandemic, Tsoh said many changes in smoking behaviors have been observed, including some individuals reporting smoking more, some reporting smoking cessation, some reporting decreasing intake of packs per day and some former smokers reporting relapse.

Tsoh discussed the National Asian American and Native Hawaiian/Pacific Islander Health Response Assessment ran by the Asian and Pacific Islander American Health Forum in partnership with the CDC, which asked individuals about coping strategies for stress related to COVID-19; characteristics and factors that affect their choice of smoking or vaping to cope with stress; and preexisting conditions.

According to Tsoh, elevated levels of depression and anxiety during the past 7 days were the primary factors cited for smoking among Asian American and Native Hawaiian/Pacific Islander respondents. Asian Americans and Native Hawaiian/Pacific Islanders with depression and anxiety were twice as likely to report choosing smoking or vaping to cope with stressors related to the pandemic. Individuals who reported having at least one mental health condition were almost six times more likely to report choosing smoking or vaping, Tsoh said.

“For those who reported facing discrimination during this time, among our Asian American participants, they were nearly 1.5 to two times more likely to have reported using smoking and vaping to cope with stress,” Tsoh said.

Currently, Tsoh and her team are conducting an educational project that utilizes text messaging to provide updated COVID-19 information on risks and why tobacco smokers are at higher risk for severe COVID-19. This project also provides individuals with information, links and the phone number to a quitline. Tsoh hypothesized that providing this engagement in the appropriate languages to cater to language barriers may aid in lowering the percentage of Asian Americans who smoke and are, therefore, at higher risk for COVID-19.

Smoking disparities in Latinos/Hispanics

While the overall prevalence of smoking in Latinos is lower than the non-Latino white population, it is much higher in certain subgroups, Marcel A. de Dios, PhD, assistant professor in the department of psychological, health and learning sciences at the University of Houston, said during the briefing. For example, the rate of smoking is 35% among Puerto Rican American men and 32.6% among Puerto Rican American women.

The 2019 National Youth Tobacco Survey found e-cigarettes were the most used tobacco product (23%) among Latino/Hispanic high school students, and Latino/Hispanic youth used e-cigarettes at higher rates than other racial/ethnic groups. According to de Dios, despite the availability of low-cost pharmacotherapies, like nicotine replacement patches, Latino/Hispanic individuals were less likely to utilize them.

Reasons for nonuse or underuse, according to de Dios, include cultural inclination, quitting without chemical aid, a lack of knowledge of the effectiveness and the use of medications, and misconceptions about the risks of smoking while on the patch.

“When they do utilize pharmacotherapies, Latinos tend not to adhere to the product,” de Dios said. “... So, the challenge of medication adherence for Latinos is not exclusive to just nicotine replacement therapy or Chantix or Wellbutrin or other pharmacotherapies that are out there. Compared to other ethnic/racial groups, Latinos have a lower adherence rate to medications for chronic illnesses like diabetes, hypertension, HIV, psychiatric conditions. Adherence poses a significant barrier to health and well-being in the Latino population.”

de Dios said smoking cessation interventions, and other health-related interventions, should account for cultural hesitance.

Early data from the CDC’s National Health Interview Survey 2019 to 2021 show a slight decline in current cigarette smoking, across all populations, during the COVID-19 pandemic in 2021. Use of electronic nicotine delivery systems dipped in 2020 but returned to higher rates in 2021, de Dios said.

In 2012, the CDC started 1-800-QUIT-NOW, a national media campaign targeting tobacco users. According to de Dios, the campaign was highly effective in increasing calls to the quitlines, ranging from 700,000 to 900,000 calls each year. However, in 2020, calls to the state quitlines declined by 27% compared with 2019.

“What we’re seeing is less people are making quit attempts” during the pandemic, de Dios said.

The impact of the pandemic on the Latino population extends beyond smoking. de Dios highlighted a high rate of Latinos indicated that a family member or close friend was hospitalized or died from COVID-19; many experienced job or wage loss; and lower rates of vaccine uptake compared with their white counterparts. As of Nov. 30, 2021, the CDC reported that race/ethnicity was known for 70% of people in the U.S. who received at least one dose of the vaccine; among those, 58% were white, 19% were Hispanic, 10% were Black and 6% were Asian.

“There are parallels to draw related to vaccine uptake — those same concerns related to hesitancy, fears, side effects, like you see with [smoking] pharmacotherapies among Latinos I believe are also driving some of the differences and disparities we’re seeing with COVID-19 vaccination,” de Dios said.

Smoking disparities in American Indians

American Indians and Alaska Natives have one of the highest rates of smoking in the country, according to Patricia Nez Henderson, MD, MPH, member of the Dine Navajo tribe and leading authority on tobacco control in American Indian communities. American Indian and Alaskan Native women, for example, are the only group wherein smoking prevalence has increased from 34% to 49.9% in the past two decades. This group also has more difficulty with smoking cessation, but 70% report wanting to quit, 41% have made quit attempts and only 5% succeeded in quitting, Nez Henderson said.

“Even before COVID-19, Indigenous peoples who have experienced colonization have been affected by commercial tobacco-related harms [moreso] than the general population,” Nez Henderson said.

Smoking rates vary by region, with higher rates in the Northern Plains tribes and Alaska Natives, and lower rates in the Southwest tribes, Henderson said. However, smoking rates are increasing lately among young adults and youth in the Southwest, according to Nez Henderson.

“The pandemic brought to light the health and social inequities in our Indigenous communities,” Nez Henderson said. “These include underfunded health systems, limited access to health care services, lack of water, lack of electricity. These issues directly impact providing culturally relevant smoking cessation services to these communities. We know what works and [what helps] other populations quit; [for example] quitlines have been successful. However, if more than 30% of a tribal nation does not have electricity, how does a community promote a service that requires electricity?”

According to Nez Henderson, widespread advocacy efforts are needed to bring to light the need for smoking cessation services in Indigenous communities at the federal, state, tribal and local levels.

“The interesting thing that has happened with COVID-19, though, is that it has provided a unique opportunity for tribal nations to address the high rates of smoking through commercial tobacco policy and control,” Nez Henderson said.

Before the COVID-19 pandemic, there were fewer than 10 tribally operated casinos that provided a smoke-free environment. When most casinos shut down during the pandemic, this led to more discussion with tribal health advocates regarding the importance of reopening casinos with smoke-free policies. Currently, more than 144 tribal casinos reopened smoke free, Nez Hernandez said.

On Nov. 6, 2021, Jonathan Nez, the National President of the Navajo Nation, signed into law a comprehensive commercial tobacco-free policy that will prohibit use of commercial tobacco products in all public places and workplaces, including casinos, parks, rodeos and powwow grounds, according to Nez Hernandez.

“Addressing this completely preventable cause of disease is essential. It will bring attention — and by bringing attention to this, it is expected to lead to significant health benefits for our communities and better informing policies and programs aimed at eliminating the harms of commercial tobacco,” Nez Henderson said. “While these efforts are a positive step in decolonizing ... they must work carefully in a way that does not continue to disenfranchise our people or Indigenous people or restrict the use of an understanding ceremonial tobacco in our communities.”

Future directions

The panel discussed strategies and solutions to increase support and access to smoking cessation treatments and aid in the mental and physical health of smokers, emphasizing the following:

• improved education;
• culturally informed and relevant informed smoking cessation interventions for all races and ethnicities; and
• continued research efforts.