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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Health Promot Pract. Author manuscript; available in PMC 2013 September 1.
Published in final edited form as:
PMCID: PMC3751998
NIHMSID: NIHMS497431

Eliminating Tobacco Disparities Among Native Hawaiian Pacific Islanders Through Policy Change: The Role of Community-Based Organizations

Abstract

Although cigarette smoking in the general U.S. population has decreased considerably over the past several decades, prevalence rates among Native Hawaiian Pacific Islanders (NHPI) have remained elevated by comparison with other groups. The aggregation of NHPI smoking data with that of Asians has drawn attention away from the serious smoking problems that NHPIs experience, thus, limiting funding, programs, and policies to reduce tobacco-related health disparities in their communities. In California, community-based organizations (CBOs) have played a major role in supporting the state's comprehensive tobacco control program, which is arguably one of the most successful in the nation. In this commentary, we describe the tobacco control activities of five NHPI-serving CBOs in Southern California and how they have provided anti-tobacco education for thousands of Native Hawaiians, Chamorros, Marshallese, Samoans, Tongans, and other Pacific Islander subgroups, and used advocacy and coalition building to promote smoke-free environment policies in their communities. The concerted efforts of the CBOs and their community members have made vital contributions to the reduction of tobacco-related disparities for NHPI populations in California.

Keywords: tobacco prevention and control, Native Hawaiian, minority health, Pacific Islander, minority health, health disparities, community organization, advocacy, public health laws/policies

Native Hawaiian Pacific Islanders (NHPI) account for only 0.4% or 1.2 million of the U.S. population (U.S. Census Bureau, 2010), yet they suffer from higher rates of leading health disparity indicators, such as hypertension, obesity, diabetes, tuberculosis, hepatitis B, and asthma compared with most other racial/ethnic group (Centers for Disease Control and Prevention, 2002). These disparities extend to cigarette smoking as well, where despite a dramatic nationwide decline, tobacco use prevalence among NHPIs remains disproportionately high. Between 2002 and 2005, past-month NHPI smoking prevalence among adult males and females was 35.9% and 26.6%, respectively, compared with the national average of 30.0% for males and 23.9% for females (Caraballo, Yee, Gfroerer, & Mirza, 2008). The aggregation of NHPI data with that of Asians (Asian Pacific Islanders) in most epidemiological studies has veiled their high rates of smoking, strong preference for menthol cigarettes, and tobacco-related disease data (lung cancer, cardiovascular disease, etc.).

Tobacco control challenges affecting NHPIs include their relatively small population size, multiethnic/multilingual composition, and dispersed population density, all of which have drastically curtailed knowledge of their needs, delivery of services and programs, and progress generally toward reducing tobacco use. California, with the nation's second largest NHPI population after Hawaii, provides an example of how NHPI-led community-based organizations (CBOs) have contributed to tobacco control policies and discouraged tobacco use in Southern California's Chamorro, Marshallese, and Native Hawaiian, Samoan, Tongan, and other Pacific Islander communities.

TOBACCO CONTROL IN CALIFORNIA

California has been the vanguard of tobacco control efforts since 1989 when the California Tobacco Control Program (CTCP) was established. The California Health and Protection Act of 1988 (Proposition 99), added a 25% tax on cigarette packs and comparable tax on other tobacco products, thus providing approximately $95 million to the CTCP to aid counties, schools, and communities in anti-tobacco activities (Bal, Kizer, Felten, Mozar, & Niemeyer, 1990). The hallmark of the CTCP approach has focused on changing the social and legal environment around tobacco use through anti-tobacco mass media campaigns and the promotion of smoke-free environments by means of public policy change through local policy adoption (Weber et al., 2012). As smoking prevalence decreased in California (Gilpin, Messer, White, & Pierce, 2006), smoking-attributable cancer mortality followed, declining between 1979 and 2005 by 25.7% compared with 8.9% nationwide (Cowling & Yang, 2010). Although the CTCP is regarded as a paragon for comprehensive, successful anti-tobacco programs, steep budget cuts over the past decade threaten the continuing success of tobacco control efforts in the state.

EDUCATION, COALITION BUILDING, AND POLICY ADOPTION IN NHPI COMMUNITIES

While NHPI adults in California have lower 30-day smoking rates than the NHPI national average, they have among the highest rates in the state at 31% for males and 16% for females compared with overall male and female averages of 19% and 12%, respectively (California Health Interview Survey, 2005, 2007). Similarly, the 30-day smoking prevalence rate for NHPI high school students nationally is 24.8% compared with the general high school population at 19.5% (Centers for Disease Control and Prevention, 2010), whereas in California the NHPI smoking rate among 11th graders is 15.0% compared with all 11th graders at 13.0% (California Health Kids Survey, 2010). Aware of the smoking problem in their communities, five NHPI-led CBOs in Southern California: the Guam Communications Network (GCN), Pacific Islander Health Partnership (PIHP), Samoan National Nurses Association (SNNA), Tongan Community Service Center (TCSC), and Union of Pan Asian Communities (UPAC) have acted as stalwarts against tobacco use. Given the dearth of published NHPI data to substantiate what they observed on a daily basis, the CBOs sought out opportunities to combat cigarette smoking in their communities.

As anti-tobacco advocates and educators, the CBOs have used outreach strategies to provide community members with culturally tailored, multilingual anti-smoking materials through printed items, public service announcements and videos, and presentations at various venues, including churches, festivals, health fairs, civic clubs, social gatherings, and youth groups. They have also engaged in anti-tobacco coalition building and participation with municipal and state governments, state and national organizations, and businesses. To counter the Marlboro-sponsored Long Beach Grand Prix, NHPI CBOs participated in a coalition that created a tobacco-free grand prix for youth. Another example is Project RIDE, a state-wide effort to promote the adoption of tobacco-free sponsorship policies and events associated with car shows, racing teams, and other automotive-related areas of influence, including car magazines and automotive shops. In 2010, GCN was awarded a Project RIDE grant for Southern California that focused on the inclusion of NHPIs. These activities serve as models of how communities can come together in innovative ways to oppose key health threats, such as tobacco advertising.

The NHPI-led CBOs have been staunch supporters of policy adoption and enforcement, including the creation of smoke-free indoor and outdoor environments, bans on tobacco use at entertainment and community events, and enforcement of retail restrictions on tobacco sales to minors. UPAC in conjunction with the Pacific Islander Festival Association (PIFA) and other local NHPI organizations collaborated with the City of San Diego tobacco coalition to pass End Tobacco Advertisement and Sales to Kids (ETASK), a city ordinance that became the impetus for a no-smoking ban at public playgrounds in the city. Working with San Diego County, they also participated in smoke-free bar compliance checks. PIFA's smoke-free policy, which prohibits the sale or use of tobacco products on festival grounds, preceded San Diego's smoke-free parks and beach ordinance of 2006. In the greater Long Beach area, GCN worked with the Coalition for a Smoke-Free Long Beach, which succeeded in passing smoke-free ordinances for parks, beaches, apartments, indoor events, and indoor/outdoor dining spots. Most recently with funding from Los Angeles County, TCSC was instrumental in the passage of an ordinance for the City of Carson that bans smoking at ATMs and bus stops. Importantly, the CBOs have played a vital role in educating local and national level policy makers, many of whom had little knowledge of priority health-related issues in NHPI communities, such as the importance of smoke-free environments.

The NHPI-led CBOs are diverse in their skill sets and scope. They have benefited from technical assistance ranging from advocacy training to policy development provided by organizations, such as Asian Pacific Partners for Empowerment, Advocacy, and Leadership (APPEAL; Lew, 2004). To support their tobacco-related activities, the CBOs have received numerous grants from state and federal sources and foundations. For example, they are currently co-investigators on a community–academic project to develop a mobile phone–based cessation program for NHPI young adults through the NCI-funded Weaving an Islander Network for Cancer Awareness, Research, and Training (WINCART; Tanjasiri et al., 2007).

LESSONS LEARNED: THE POWER OF COMMUNITY MOBILIZATION FOR POLICY AND SOCIAL NORM CHANGE

The NHPI-led CBOs have been involved in the promotion of tobacco-free policies for more than a decade, and their experiences are instructive in several ways:

  • Investments in community-driven tobacco control complement local and state policy efforts: Given California's shrinking tobacco control budget, the work of grassroots organizations is essential to develop and sustain policies. The CBOs have been instrumental in passing local anti-smoking ordinances and enforcing existing bans in their communities, which, in all likelihood, could not be achieved without their efforts.
  • Community-led tobacco control activities benefit from insider knowledge: The ability of the CBOs to garner support for tobacco education, coalition building, and policy change within their communities is strengthened considerably by their expertise in Pacific Islander cultures, languages, communication styles, and social networks. The CBOs have reached thousands of NHPIs through multiple forms of culturally competent community outreach strategies.
  • Community social norm change piggybacks on policy change: Along with the CBOs' accomplishments in city and county anti-tobacco policy activities, social norm changes are occurring. For example, most NHPI faith-based organizations now prohibit smoking on church property and reject offers of monetary support from tobacco companies. Bans exist on smoking at NHPI festivals and other cultural events. Moreover, NHPI smoking prevalence is decreasing in California. These are real changes that come with policy adoption and improved community awareness of the inherent dangers of tobacco use.

Despite these successes, there is concern that funding for NHPI community tobacco control activities will dwindle, progress to date will be unsustainable, and tobacco use will increase. Deep financial cuts to the CTCP continue with the per capita budget for tobacco control in California hovering at only 18% of what the Centers for Disease Control and Prevention's (2007) best practices for tobacco control recommended. Many NHPIs live in lower socioeconomic neighborhoods, which suffer the most when programs lose funding. Another threat is a shift of funding for competing health priorities, such as obesity prevention. The full range of health disparities experienced by NHPIs demands attention, however, it is vital not to backslide on what has been accomplished in community tobacco control.

The NHPI population increased by 40.1% between 2000 and 2010, making it one of the fastest growing groups. This portends the necessity of continuing support of grassroots efforts, such as the work carried out by the NHPI-led CBOs. Clearly, the mobilization of NHPI communities to combat tobacco use through policy change has made important inroads to California's efforts to provide smoke-free environments and positive permanent change to what once was a robust smoking social norm.

Acknowledgments

This project was supported by Grant Number 1U54CA153458 from the National Cancer Institute (NCI), Center to Reduce Cancer Health Disparities (CRCHD). The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCI CRCHD.

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