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Respiratory Medicine
Series Editor: Sharon I.S. Rounds

Lynn B. Gerald
Cristine E. Berry Editors

Health
Disparities in
Respiratory
Medicine
Respiratory Medicine
Series Editor:
Sharon I.S. Rounds

More information about this series at http://www.springer.com/series/7665

Lynn B. Gerald • Cristine E. Berry
Editors

Health Disparities
in Respiratory Medicine
Editors
Lynn B. Gerald, PhD, MSPH Cristine E. Berry, MD, MHS
Arizona Respiratory Center and Department Arizona Respiratory Center and
of Health Promotion Sciences Department of Medicine,
Mel and Enid Zuckerman College Division of Pulmonary
of Public Health Allergy, Critical Care and Sleep Medicine
University of Arizona College of Medicine
Tucson, AZ, USA University of Arizona
Tucson, AZ, USA

ISSN 2197-7372 ISSN 2197-7380 (electronic)

Respiratory Medicine
ISBN 978-3-319-23674-2 ISBN 978-3-319-23675-9 (eBook)
DOI 10.1007/978-3-319-23675-9

Library of Congress Control Number: 2015947791

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

Humana Press is a brand of Springer

Springer International Publishing AG Switzerland is part of Springer Science+Business Media
(www.springer.com)
Contents

1 Introduction to Health Disparities and Respiratory Health ............... 1

Andrew Pleasant, Jennifer Cabe, and Richard H. Carmona
2 Health Disparities in Tobacco Smoking and Smoke Exposure ........... 9
Pebbles Fagan
3 Health Disparities Related to Environmental Air Quality .................. 41
Sonali Bose and Gregory B. Diette
4 Health Disparities in Occupational Exposures..................................... 59
Kenneth D. Rosenman
5 Health Disparities and Pulmonary Function Testing .......................... 79
Joseph H. Skalski, Rachele A. Gibson, Sarah A. Narotzky,
Hemang Yadav, and Paul D. Scanlon
6 Health Disparities as They Relate to Medication Adherence ............. 105
Sandra R. Wilson, Meghan Halley, and Sarah Knowles
7 Health Disparities in ARDS ................................................................... 135
Nancy Gonzalez Casanova, Jorge R. Navarrete, Hector Quijada,
Louise Hecker, and Joe G.N. Garcia
8 Social Disparities in Lung Growth and Respiratory Health ............... 147
Kelly J. Brunst and Rosalind J. Wright
9 Health Disparities in Asthma ................................................................. 173
Christian Bime
10 Health Disparities in Chronic Obstructive Pulmonary Disease ......... 189
Miriam Siegel, Jerry A. Krishnan, Jamie Lamson-Sullivan,
Scott Cerreta, and David M. Mannino
11 Health Disparities and Tuberculosis...................................................... 207
Eyal Oren

v
vi Contents

12 Disparities in Lung Cancer Outcomes .................................................. 237

Ching-Fei Chang, Gary S. Feigenbaum, and Michael K. Gould
13 Health Disparities in Critical Illness ..................................................... 265
Daniel Monroy Chaves and John Daryl Thornton
14 Health Disparities in Sleep-Related Breathing Disorders ................... 295
Jose S. Loredo
15 Health Disparities in End-of-Life Care ................................................. 325
Ann C. Long and J. Randall Curtis
16 Where Do We Go from Here? Improving Disparities
in Respiratory Health ............................................................................. 341
Juan C. Celedón, Gary Ewart, and Patricia W. Finn

Index ................................................................................................................. 355

Contributors

Christian Bime, M.D., M.Sc. Department of Medicine, Division of Pulmonary,

Allergy, Critical Care, and Sleep Medicine, College of Medicine, University of
Arizona, Tucson, AZ, USA
Sonali Bose, M.D., M.P.H. Division of Pulmonary and Critical Care Medicine,
Johns Hopkins Hospital, Baltimore, MD, USA
Kelly J. Brunst, Ph.D. Department of Pediatrics, Kravis Children’s Hospital at
Mount Sinai, New York, NY, USA
Jennifer Cabe, M.A. Canyon Ranch Institute, Tucson, AZ, USA
Richard H. Carmona, M.D., M.P.H., F.A.C.S. Canyon Ranch Institute, Tucson,
AZ, USA
Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson,
AZ, USA
Nancy Gonzalez Casanova, M.D., M.P.H. Department of Medicine, Division of
Pulmonary, Allergy, Critical Care and Sleep Medicine, College of Medicine,
University of Arizona, Tucson, AZ, USA
Juan C. Celedón Division of Pulmonary, Allergy and Immunology, Department of
Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh,
Pittsburgh, PA, USA
Scott Cerreta The COPD Foundation, Washington, DC, USA
Ching-Fei Chang, M.D. Division of Pulmonary, Critical Care, and Sleep Medicine,
University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
Daniel Monroy Chaves, M.D. Division of Pulmonary, Critical Care, and Sleep
Medicine, The MetroHealth Campus of Case Western Reserve University,
Cleveland, OH, USA

vii
viii Contributors

J. Randall Curtis, M.D., M.P.H. Division of Pulmonary and Critical Care

Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
Gregory B. Diette, M.D., M.H.S. Division of Pulmonary and Critical Care Medicine,
Johns Hopkins Hospital, Baltimore, MD, USA
Gary Ewart American Thoracic Society, Washington, DC, USA
Pebbles Fagan, Ph.D., M.P.H. Cancer Prevention and Control Program, University
of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA
Gary S. Feigenbaum, M.D. Department of Internal Medicine, University of
Southern California, Keck School of Medicine, Los Angeles, CA, USA
Patricia W. Finn Department of Medicine, University of Illinois at Chicago,
Chicago, IL, USA
Joe G.N. Garcia, M.D. Senior Vice President for Health Sciences, Department of
Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine,
College of Medicine, University of Arizona, Drachman Hall, Tucson, AZ, USA
Rachele A. Gibson, M.D. Division of Pulmonary and Critical Care Medicine,
Mayo Clinic, Rochester, MN, USA
Michael K. Gould, M.D., M.S. Department of Research and Evaluation, Kaiser
Permanente Southern California, Pasadena, CA, USA
Meghan Halley, Ph.D., M.P.H. Palo Alto Medical Foundation Research Institute,
Palo Alto, CA, USA
Louise Hecker, Ph.D. Department of Medicine, Division of Pulmonary, Allergy,
Critical Care and Sleep Medicine, College of Medicine, University of Arizona,
Tucson, AZ, USA
Sarah Knowles, Ph.D., M.P.H. Palo Alto Medical Foundation Research Institute,
Palo Alto, CA, USA
Jerry A. Krishnan Breathe Chicago Center, Division of Pulmonary, Critical Care,
Sleep and Allergy, University of Illinois in Chicago, Chicago, IL, USA
Jamie Lamson-Sullivan The COPD Foundation, Washington, DC, USA
Ann C. Long, M.D., M.S. Division of Pulmonary and Critical Care Medicine,
Harborview Medical Center, University of Washington, Seattle, WA, USA
Jose S. Loredo, M.D., M.S., M.P.H. Department of Medicine, University of
California San Diego School of Medicine, San Diego, CA, USA
David M. Mannino, M.D. Department of Preventive Medicine and Environmental
Health, University of Kentucky College of Public Health, Lexington, KY, USA
Sarah A. Narotzky, M.D. Division of Pulmonary and Critical Care Medicine,
Mayo Clinic, Rochester, MN, USA
Contributors ix

Jorge R. Navarrete, M.D. Department of Medicine, Division of Pulmonary,

Allergy, Critical Care and Sleep Medicine, College of Medicine, University of
Arizona, Tucson, AZ, USA
Eyal Oren, Ph.D., M.S. Department of Epidemiology and Biostatistics, Mel and
Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
Andrew Pleasant, Ph.D. Canyon Ranch Institute, Tucson, AZ, USA
Hector Quijada, B.S. Department of Medicine, Division of Pulmonary, Allergy,
Critical Care and Sleep Medicine, College of Medicine, University of Arizona,
Tucson, AZ, USA
Kenneth D. Rosenman, M.D. Department of Medicine, Michigan State University,
East Lansing, MI, USA
Paul D. Scanlon, M.D. Division of Pulmonary and Critical Care Medicine, Mayo
Clinic, Rochester, MN, USA
Miriam Siegel Department of Preventive Medicine and Environmental Health,
University of Kentucky College of Public Health, Lexington, KY, USA
Joseph H. Skalski, M.D. Division of Pulmonary and Critical Care Medicine,
Mayo Clinic, Rochester, MN, USA
John Daryl Thornton, M.D., M.P.H. Division of Pulmonary, Critical Care, and
Sleep Medicine and Center for Reducing Health Disparities, The MetroHealth
Campus of Case Western Reserve University, Cleveland, OH, USA
Sandra R. Wilson, Ph.D. Palo Alto Medical Foundation Research Institute, Palo
Alto, CA, USA
Rosalind J. Wright, M.D., M.P.H. Department of Pediatrics, Kravis Children’s
Hospital at Mount Sinai, New York, NY, USA
Mindich Child Health and Development Institute, Icahn School of Medicine at
Mount Sinai, New York, NY, USA
Hemang Yadav, M.B.B.S. Division of Pulmonary and Critical Care Medicine,
Mayo Clinic, Rochester, MN, USA
Chapter 1
Introduction to Health Disparities
and Respiratory Health

Andrew Pleasant, Jennifer Cabe, and Richard H. Carmona

A review of a 2014 report released by the Forum of International Respiratory

Societies makes the case for an increased focus on respiratory health crystal clear,
“the morbidity and mortality related to lung diseases is staggering. Hundreds of
millions of people are burdened with chronic respiratory conditions; four million
people die prematurely from chronic respiratory diseases each year. Respiratory
infections are the leading cause of death in developing countries [1].”
Most respiratory illnesses are avoidable. The cost of prevention—as is the case
with most chronic disease—is only a fraction of the cost of treatment. While
research is always important, we very often already know how to prevent the
millions of cases of chronic respiratory illness occurring around the world [2].
We hold a high value for basic research, but perhaps nowhere more than in
this arena is there a critically important need for applied research and informed
advocacy.
The leading respiratory diseases—where the most gain is likely—are chronic
obstructive pulmonary disease (COPD), asthma, acute respiratory infections,
tuberculosis, and lung cancer. The most fruitful areas for solutions are also very
well known and researched: the use of tobacco, indoor and outdoor air quality,
childhood immunizations, nutrition, and physical activity/exercise.
As is well demonstrated throughout this volume, access to better living conditions,
escape from poverty and unhealthy environments, and having hope for tomorrow

A. Pleasant, Ph.D. (*) • J. Cabe, M.A.

Canyon Ranch Institute, Tucson, AZ, USA
e-mail: [email protected]
R.H. Carmona, M.D., M.P.H., F.A.C.S.
Canyon Ranch Institute, Tucson, AZ, USA
Mel and Enid Zuckerman College of Public Health,
University of Arizona, Tucson, AZ, USA
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 1

L.B. Gerald, C.E. Berry (eds.), Health Disparities in Respiratory Medicine,
Respiratory Medicine, DOI 10.1007/978-3-319-23675-9_1
2 A. Pleasant et al.

are often least available to those who would benefit the most. These structural deter-
minants of health are not a mystery—we currently have the knowledge of how to
improve those. What the world lacks is the will. Our hope, and thus we are collabo-
rating on this introduction, is that collections of evidence and understanding such as
this volume will help create that will.
In this volume, you will explore complex connections between poor respiratory
health, the proximal causes, the social and environmental determinants that under-
pin those causes, and suggested solutions.
Following this introduction, in the remainder of this volume you can explore the
creation and possible responses to health disparities in regard to tobacco smoke
exposure, environmental air quality, occupational exposures, pulmonary function
testing, medication adherence, acute respiratory distress syndrome (ARDS), asthma,
COPD, tuberculosis, lung cancer, critical illness, sleep-related breathing disorders,
and end-of-life care.
First, Fagan offers insight into disparities associated with exposure to tobacco
smoke. Fagan writes, “Tobacco affects nearly every organ in the body [3] … Annual
indirect costs due to productivity losses are $150 billion [4] and medical expenses
range from $130 billion to $176 billion [4].”
Fagan accurately points out and relies on the history of reports on tobacco from
the U.S. Surgeons General—beginning with the first report now over 50 years ago
by Surgeon General Dr. Luther Terry. These reports have driven not only more sci-
entific research and significant changes in policy around the world but also helped
improve health literacy so people are better equipped to find, understand, evaluate,
communicate, and use information to make informed choices and change behaviors
in relation to their health and well-being [5, 6].
In Chap. 3, Bose and Diette take on issues of health disparities related to envi-
ronmental air quality. The pair explores disparities related to socioeconomic status,
race, gender, age, and place. While maintaining awareness that certain groups—
people in poverty, racial minorities, women, children, the elderly, those living in
developing rural areas, and inner-city residents—face an unfair burden of the
adverse effects, they also remain aware that “no one group can be ‘safe’ or immune
to the far-reaching nature of outdoor pollution as it sweeps across continents, nor to
the toxins emerging from the indoor environments that we create in our own homes
in which we purposefully seal ourselves.”
Chapter 4 takes a look at occupational exposures with a series of brief case stud-
ies on issues such as chromates, coke oven emissions, cotton dust in textile mills,
Navajo miners in uranium mines, rubber workers, exposure to silica in drilling and
mining, and work-related asthma. The chapter’s author, Rosenman, calls for
improvements in monitoring systems, including, “requiring the reporting of race in
the annual Bureau of Labor Statistics employer based survey on injuries and ill-
nesses; adding race as a core variable in worker compensation state data systems;
adding industry and occupation to the core module of the annual BRFSS survey
administered in the 50 states; and routinely collecting information about occupa-
tion/employer in medical records and making collection of such information a
1 Introduction to Health Disparities and Respiratory Health 3

requirement for future meaningful use incentives as part of the transition to elec-
tronic medical health records.”
In Chap. 5, readers will explore health disparities in the context of pulmonary
function testing. Skalski, Gibson, Narotzky, Yadav, and Scanlon explore disparities
related to access, language barriers, cultural variations among English speakers,
reference values for pulmonary function testing based on gender, age, height, and
ethnicity, and corrections based on self-reported race.
The authors of this chapter explore, in part, the two-sided nature of many
underpinning causes of health disparities—the failure of health care professionals
and systems to effectively communicate as well as the level of skills and abilities
in many of the populations they serve. In this context, the authors argue that “an
important aspect of lung function testing is that accurate testing is highly depen-
dent on patient performance.” While avoiding blaming the victims, the authors
conclude that “all of this makes PFTs more sensitive than many other medical
diagnostic tests to linguistic and cultural barriers that may exist between testing
personnel and the patient. Furthermore, for a patient to have access to accurate
PFTs, they must not only have access to a medical facility with equipment and
willingness to perform the PFTs but they must also have appropriately trained
technicians at that facility, assisted by translators when necessary, to perform max-
imal and error-free tests.”
In Chap. 6, Wilson, Halley, and Knowles explore health disparities as they relate
to medication adherence. They begin their focus by discussing disparities related to
characteristics of the health care delivery system, the physician/patient relationship,
disease and treatment regimen, and characteristics of the patient—such as age, gen-
der, health literacy, income, insurance, socioeconomic status, comorbidities, and
race and ethnicity.
As is true of discussions of disparities in general, medication adherence studies
often blame, or verge on blaming, the patients and even more frequently focus on
whether, not how, the medications were taken, while neglecting the demand side of
the equation coming from the health care system. That history is reflected in this
review of the literature to date in Chap. 6. Reflecting the state of disparities research
overall—which is the driver of the content of this book—the authors of this chapter
call for better measurement, better theory, and more equitable and practical research
and practice. We couldn’t agree more, but do suggest the argument can be taken
further in terms of the causative factors related to social determinants of health such
as health literacy, a focus on prevention versus documenting effects, and an even
stronger emphasis on identifying causes within the sick care system—the demand
side—versus placing such an emphasis on patients.
The next chapter shifts the focus to health care disparities in ARDS. Briefly
stated, ARDS is a life-threatening lung condition that prevents enough oxygen from
getting to the lungs and the blood. Casanova, Navarrete, Quijada, Hecker, and
Garcia highlight that further ARDS research studies focused on Latinos, African
Americans, Native Americans, and other minorities are needed to understand the
multifactorial causes associated with disparities. They conclude by pointing out the
4 A. Pleasant et al.

potential benefits from increased and continued studies focused on genomic and
epigenetic analysis of the risk factors underlying ARDS.
Chapter 8, written by Brunst and Wright, takes a look at the role of social stress
in asthma disparities. They suggest, “Social toxicity experienced as increased psy-
chological stress is likely a major driver of observed disparities in lung growth and
development and asthma, as well as a range of other respiratory conditions. Most
respiratory conditions likely share overlapping etiology; therefore, multiple mecha-
nistic pathways with complex interdependencies must be considered when examin-
ing the integrative influence of stress independently as well as the interaction of
social and physical environmental toxins in explaining the social patterning of
respiratory diseases. Because these factors tend to cluster in the most socially disad-
vantaged, this line of research may better inform the etiology of growing health
disparities increasingly documented for respiratory disorders.”
While we don’t disagree, we wonder if solutions to disparities might also be
discovered by looking at where they don’t exist, as well as where they do.
Communities and individuals suffering greater prevalence of disease are certainly
where researchers will identify disparities and their associations, but observing
where disease is not prevalent may be a better way to understand what changes need
to be put in place to prevent disparities from occurring at all.
Bime continues the focus on asthma by looking at disparities related to patient
factors, social and environmental factors, and factors related to health care systems
and health care professionals. Asthma is perhaps the quintessential example of
health disparities. Bime describes that situation very well and concludes with a call
for greater emphasis on “adequate representation of members of high-risk popula-
tions and minority investigators that should be involved in the research.”
The next chapter by Siegel, Krishnan, Lamson-Sullivan, Cerreta, and Mannino
focuses on health disparities in chronic obstructive pulmonary disease (COPD). The
authors point out the multitude of types of disparities in COPD that currently exist—
from death rates and frequency in various populations to perception of the disease.
They discuss disparities related to race and ethnicity, gender, age, genetic predispo-
sition, geographic residence and location of care, type of chronic illness, un- and
under-insured, work trajectory and unemployment, income inequality, and the
nature of critical care settings.
In Chap. 11, health disparities and tuberculosis (TB) become the central point of
interest. Oren argues that “as with many other diseases, the TB burden follows a
clear socioeconomic gradient, with the poorest at the most elevated risk.” For exam-
ple, Oren reports that “worldwide, one out of three persons is infected with M.
tuberculosis, with 1.5 million deaths due to TB… In the U.S.A., foreign-born per-
sons have case rates 11.5 times higher than U.S. -born persons, and among the U.S.
-born, the largest disparities are between blacks and whites; where TB rates in
blacks are 5.8 times greater than among whites, and distribution is geographically
heterogeneous, with California, Texas, New York, and Florida reporting half of all
TB cases in 2012.”
A true highlight of this volume is Chap. 12 by Chang, Feigenbaum, and Gould
that takes a definitive look at disparities in lung cancer outcomes. Taking a proactive
1 Introduction to Health Disparities and Respiratory Health 5

view and offering a series of practical and tangible recommendations to address the
issue, the authors set up the problem by arguing that “despite good intentions and
the passage of major legislation, significant social, economic, and cultural barriers
still persist that undermine access to appropriate health care for those at greatest risk
for lung cancer. Thus social revolution, rather than technological innovation, may
be the true answer to improving lung cancer mortality in America on a large scale.”
Taking a broad and holistic approach, Chang, Feigenbaum, and Gould assert that
“no matter what kind of modern miracles medicine may offer, the social paradigms
in America will ultimately define what kind of impact they achieve in regard to lung
cancer outcomes.” They suggest aggressive action to address tobacco prevention,
improvement of infrastructure and environments within poverty-stricken communi-
ties, universal health care, standardization of practices within health care, health
care professionals receiving training in cultural sensitivity, increased enrollment of
underrepresented populations in clinical trials, and a new appreciation of “the com-
plexity of lung cancer biology, including gender differences and genetic mutations,
leading to more targeted, effective, and personalized therapy.”
Health disparities in critical illness are the focus of the Chap. 13, offered by
Chaves and Thornton. As is true for much of this volume, this chapter paints a
detailed picture of the issue. The authors sum up the issue, accurately, by stating,
Race and ethnicity also continue to be used as poor substitutes for the true factors
that need to be identified including income, insurance status, location where health-
care was delivered, neighborhood of residence, and work trajectory. This not only
leads to false declarations, but it prevents the field from moving forward as it implies
that such factors and their associated outcomes are not modifiable.
Loredo offers in Chap. 14 a focus on health disparities in sleep-related breathing
disorders. For those looking for an in-depth introduction to the existing science of
sleep and sleep-related breathing issues, go no further. The case is made that while
the importance of sleep to health has only been recently recognized, the nature,
causes, and extent of disparities in sleep and sleep-related breathing disorders are
areas where more research is needed.
Health disparities in end-of-life care are the focus of Long and Curtis in Chap. 15.
The authors explore differences in end-of-life care across patient characteristics,
including gender; race and ethnicity; socioeconomic status; health literacy; and
members of the lesbian, gay, bisexual, and transgender community. It seems more
work may be needed to fully explore the extent of causes of disparities in this area
that may reflect the health care system and/or the patient and their family’s responses
to end-of-life issues. The authors conclude, “Cultural competence in end-of-life
care must be a priority for health care providers in order to improve communication
for nonwhite patients and their family members and ensure respect for informed
decisions that reflect patient and family preferences.”
Wrapping up this volume focusing on health disparities and respiratory health
issues, Celedón, Ewart, and Finn offer a chapter titled, “Where do we go from here?
Improving disparities in respiratory health.” The authors base their argument on the
all-too-well-known but under-addressed reality that “current health disparities are
not only morally unacceptable but financially unsound.”
6 A. Pleasant et al.

Causing that unwise and unsound approach is a lack of prevention of respiratory

health issues. The authors acknowledge that the modifiable risk factors for most
respiratory health issues are environmental and lifestyle risk factors—tobacco use,
air pollution, and occupation—and that those determinants are unevenly distributed
in society. To conclude, the authors call for true universal health care, more research,
a more diverse health care workforce, environmental justice, healthier lifestyles,
and advocacy.
There are two important issues, in our view however, that deserve further atten-
tion than they receive in the volume that follows. One is the importance of health
literacy as a solution. The second is a need for the scientific enterprise to begin not
only to embrace calls for more research but also to propose functional solutions and
responses to the social determinants of health.
Health literacy is being shown to be one of the strongest social determinants.
While the concept is mentioned in some—but far from all—of the chapters in this
volume, the idea is worthy of greater consideration in the realm of health disparities.
Respiratory illnesses may prove a key context in which to fully deploy the ability of
health literacy not as a diagnosis, but as a powerful tool of prevention. One issue this
volume, in its totality, makes perfectly clear is that in order to prevent and treat
respiratory illnesses, true partnerships must occur between health care professionals
and the individuals and communities they are striving to serve.
In this age, when we face shortages in qualified health care professionals, the
burden of addressing chronic diseases of all types will only succeed through forging
new partnerships between the public and the health care systems based on the best
practices of health literacy. Only then we can successfully transform our current
sick care systems into true health care systems focusing on prevention. The benefits
of that transition will be significant to all of the global community.
Finally, we close with a plea to all readers. Research is incredibly valuable—but
not when it sits on a dusty shelf for years before it is utilized. We fully embrace the
need for verification and building a body of evidence, but such a vast majority of
book chapters and journal articles simply conclude with a call for further research
that it is no wonder society does not give due heed to the lessons learned through
vigorous and reliable research. We hope that researchers will conclude with a call to
action and advocate for application of their findings. Furthermore, we hope that
readers will be inspired to implement evidence-based solutions derived from such
research.
Certainly, part of the know-do gap—the gap between what people know and
what they actually do to improve or maintain their health—has many explanations
and causes. We hope that the exceptional discussions in this text of the complex
scientific and social issues around pulmonary disease will inspire all of us to aggres-
sively translate what we know into effective and sustainable public health programs
that reduce morbidity, mortality, and cost while improving the quality of life for our
fellow citizens.
1 Introduction to Health Disparities and Respiratory Health 7

References

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2. Respiratory diseases in the world: realities of today—opportunities for tomorrow: Forum of
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Promot Int. 2005;20:195–203.
Chapter 2
Health Disparities in Tobacco Smoking
and Smoke Exposure

Pebbles Fagan

Key Points
• While overall smoking rates have decreased in the USA, disparities related to
tobacco smoking by race/ethnicity and socioeconomic status persist.
• Secondhand smoke exposure also differs by race/ethnicity and socioeconomic
status, but objective measurement using cotinine levels is complex because
nicotine metabolism differs by gender, race/ethnicity, and type of cigarette
consumed.
• Reporting aggregate data on racial/ethnic groups, sampling strategies that capture
small numbers of disparate groups, and low response rates to national surveys
are examples of some of the methodological challenges that influence the study
of tobacco-related health disparities.
• Comprehensive tobacco control programs are essential in developing strategies
to reduce health disparities in tobacco-related respiratory diseases.

Introduction

Cigarette smoking rates in the USA have dramatically declined in the past 50
years, and the reduction in cigarette smoking is one of the top public health
achievements in the 20th and 21st centuries [1, 2]. Per capita cigarette consumption
has declined from 4345 cigarettes in 1963 to 1196 cigarettes in 2012 [2]. However,
in the past 10 years, declines in cigarette smoking have slowed among adults [3].

P. Fagan, Ph.D., M.P.H. (*)

Cancer Prevention and Control Program, University of Hawaii
Cancer Center, University of Hawaii at Manoa, 701 Ilalo Street,
Honolulu, HI 96813, USA
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 9

L.B. Gerald, C.E. Berry (eds.), Health Disparities in Respiratory Medicine,
Respiratory Medicine, DOI 10.1007/978-3-319-23675-9_2
10 P. Fagan

Approximately 42 million Americans smoke, putting many smokers at risk for

tobacco-related and -caused diseases and conditions [4].
Tobacco exposure, including cigarette smoking and secondhand smoke exposure
(SHS), is the leading cause of preventable death in the USA [5] and globally [6].
Worldwide, tobacco kills more than six million people annually and in the USA, an
estimated 480,000 Americans die each year from tobacco exposure [2]. Cigarette
smoking is responsible for one in five deaths in the USA annually [2]. Since 1964, 20
million Americans have died from smoking-attributable diseases [2]. Tobacco affects
nearly every organ in the body [7]. Tobacco exposure in utero and among children,
adolescents, and adults can increase the risk for adverse reproductive health out-
comes, cancer, cardiovascular disease, respiratory disease, hip fractures, sudden
infant death syndrome, cataracts, and other conditions [7] (see Table 2.1). There are
economic costs as well. Annual indirect costs due to productivity losses are $150
billion [2] and medical expenses range from $130 billion to $176 billion [2].
There are 16 million people in the USA who have at least one tobacco-related
serious illness [2], and tobacco is associated with the top three leading causes of
death in the USA. Among adults age 35 years and older, 41 % of all smoking attrib-
utable deaths are due to cancer [7], 32.7 % are due to cardiovascular disease, and
26.3 % are due to respiratory disease [8]. The three major categories of tobacco-
caused deaths are lung cancer (n = 128,922), ischemic heart disease (n = 126,005),
and chronic obstructive pulmonary disease (COPD) (n = 92,915). In addition,
49,400 lung- and heart disease-related deaths are due to SHS annually [8].
About 90 % of all lung cancers in the USA are due to tobacco [8], and lung can-
cer is the leading cause of cancer mortality in the USA. From 2005 to 2011, 5-year
survival rates have increased from 11.4 to 17.4 %, but survival rates remain quite
low [9]. Lung cancer comprises an estimated 13.3 % of all new cancers and 26.8 %
of cancer deaths [9]. Most importantly, lung cancer can nearly be eliminated if
tobacco were eliminated. Therefore, the prevention of lung cancer by targeting
tobacco exposure has been a primary goal for the U.S. Department of Health and
Human Services, Office of Disease Prevention and Health Promotion [10].
Unfortunately, tobacco-caused respiratory diseases and conditions other than lung
cancer have received less attention. Tobacco exposure affects the trachea, bronchi,
and the lungs. The primary nonmalignant respiratory diseases caused by tobacco
exposure are asthma and COPD, which includes emphysema and chronic
bronchitis.
The 1964 Surgeon General’s report, Smoking and Health: Report of the Advisory
Committee to the Surgeon General of the Public Health Service, was the first docu-
ment to conclusively state that smoking causes chronic bronchitis [11].
“Cigarette smoking is the most important cause of chronic bronchitis in the USA
and increases the risk of dying from chronic bronchitis [11].”
The casual relationship between smoking and COPD was later confirmed in the
1984 Surgeon General’s report, The Health Consequences of Smoking: Smoking
and Chronic Obstructive LungDisease [12]. Subsequent reports further supported
this finding, and additional diseases and conditions have been causally linked to
Table 2.1 Diseases and conditions causally linked to tobacco exposure
Cancer Cardiovascular Respiratory Other
• Oropharynx • Stroke • Chronic obstructive pulmonary • Oral cleftsa
• Larynx • Coronary heart • α1-antitrypsin deficiency and cutis • Reduced fertility in women
disease laxa are genetic causes of COPDa
• Esophagus • Atherosclerotic • Childhood asthma incidencea, poor asthma control, • Erectile dysfunctiona
peripheral vascular exacerbations of asthma in adults, asthma symptoms,
disease wheezing severe enough to be diagnosed as asthma in
susceptible children and adolescents
• Trachea • Abdominal aortic • Chronic respiratory symptoms • Low birth weight and fetal growth
• Acute myeloid leukemia aneurysm • Acute respiratory illness • Ectopic pregnancya
• Stomach • Pneumonia • Preterm delivery, still birthsa, and other pregnancy
complications
• Pancreas • Mycobacterium tuberculosis diseasea and mortalitya • Sudden infant death syndrome
• Kidney and ureter • Reduced lung function • Periodontitis
• Cervix • Impaired lung growth • Diabetes mellitusa
• Bladder • Early onset of lung function decline • Diminished health statusa
• Lung and bronchus • Lower respiratory illnesses • Hip fractures
• Livera • Middle ear disease • Nuclear cataracts
• Colorectala • Nasal irritation • Macular degenerationa
• All-cause mortality and cancer- • Low bone density in postmenopausal women
specific mortality in cancer patients
and survivorsa
• Second primary cancersa • Peptic ulcer disease in persons with Helicobacter pylori
• Odor annoyance
• Rheumatoid arthritisa
• Inflammation and impair immune functiona
• Nicotine activates biological pathways through
which smoking increases the risk for diseasea
a
Causal link reported for the first time in Surgeon General’s Report in 2014
Source: The Health Consequences of Smoking—50 years of Progress: A report of the Surgeon General, 2014
12 P. Fagan

Table 2.2 Causal relationships between tobacco use and exposure and respiratory diseases and
conditions
Active smoking Secondhand smoke exposure
• Lung cancer • Lung cancer in nonsmokers
• Poor asthma control • Stroke
• Asthma-related symptoms (i.e., wheezing) • Coronary heart disease morbidity and
in childhood and adolescence mortality
• Acute respiratory illnesses, including • Ever having asthma among children of
pneumonia, in persons without underlying school age
smoking-related chronic obstructive lung
disease
• Exacerbations of asthma in adults • Lower respiratory illnesses in infants
and children
• Chronic obstructive pulmonary disease • Middle ear disease in children,
morbidity and mortality including acute and recurrent otitis
media and chronic middle ear effusion
• All major respiratory symptoms among • Ever having asthma in school age
adults, including coughing, phlegm, children
wheezing, and dyspnea
• Mycobacterium tuberculosis disease • Exposure after birth and lower level of
and mortality lung function during childhood
• Premature onset of accelerated age-related • Cough, phlegm, wheeze, and
decline in lung function among adults breathlessness among children of
school age
• Reduced lung function and impaired lung • Onset of wheeze illnesses in early
growth during childhood and adolescence childhood
• Early onset of decline in lung function • Maternal smoking and persistent
during late adolescence and early adulthood adverse effects on lung function across
• Respiratory symptoms in children and childhood
adolescents including coughing, phlegm,
wheezing, and dyspnea
• Asthma-related symptoms (i.e., wheezing)
in childhood and adolescence
• A reduction of lung function in infants of
mothers who smoked during pregnancy
• Odor annoyance
• Nasal irritation
Source: The Health Consequences of Smoking—50 years of Progress: A report of the Surgeon
General, 2014

tobacco exposure. The 2004 Surgeon General’s report on Smoking and Health [7]
confirmed that active smoking and involuntary exposure to tobacco smoke cause
multiple preventable respiratory diseases and conditions that affect the trachea,
bronchi, and lungs of the respiratory tract (see Table 2.2). Tobacco exposure
increases the risk for acute respiratory illnesses, respiratory symptoms, and reduced
lung function among children and adults. Data also suggest that tobacco use is
2 Health Disparities in Tobacco Smoking and Smoke Exposure 13

associated with asthma, idiopathic pulmonary fibrosis, bronchiolitis, influenza,

Legionnaires’ disease [7], and pulmonary hypertension [13]. There is growing
evidence to support that respiratory bronchiolitis-interstitial lung disease [14],
histiocytosis X [14], smell dysfunction [15, 16], and snoring [17] are related to
tobacco exposure, but causal relationships have not yet been confirmed. The
Surgeon General’s report, The Health Consequences of Smoking—50 Years of
Progress, is the first to address tuberculosis related to tobacco exposure [2]. Tobacco
use and exposure are associated with about 53,795 respiratory disease-related
deaths annually [8].
The mechanisms by which tobacco exposure causes and is linked to respiratory
diseases and conditions are described in detail in the Surgeon General’s report, How
Tobacco Smoke Causes Disease [13]. In brief, tobacco smoke exposure moves
through the mouth to the upper airways and eventually reaches the alveoli [13].
Both harmful soluble gases and particles are deposited in the airways and alveoli
[13]. Tobacco use and exposure increase the exposure of the airways and lungs to
toxic constituents, and over time, tobacco smoke can reduce the lung defenses to
these toxins. Tobacco smoke reduces the clearance rate of particles from the lung,
and 60 % of the particles from cigarette smoke are deposited in the lung [13].
Reduced particle clearance is due to the shortening, loss, or discoordination of cilia
[12, 18, 19] and possibly changes in airway surface liquid including mucus visco-
elasticity [12, 19, 20]. Furthermore, these particles are difficult to clear due to their
high numbers, and smokers remove these particles at a slower rate [12]. The amount
of particles and gases received from tobacco smoke depends on the nature of the
tobacco, puff volume, air drawn in through ventilation holes of cigarettes, and local
characteristics within the lung that determine the diffusion of toxic gases and the
deposition of particles. The repeated exposure to these gases and particle damage to
the mucociliary system increase the risk for bacterial or viral infections [13].
Tobacco-caused and tobacco-related respiratory diseases and conditions affect
all smokers, but studies suggest that some racial/ethnic groups and individuals of
low socioeconomic status (SES), and the intersection of these groups, suffer dispro-
portionately from respiratory diseases and conditions. Tobacco use has also been
linked to disparities in lung and other cancers and cardiovascular disease. There is
adequate evidence to say that tobacco causes disparities in cancer among minority
racial/ethnic groups [10, 21] and low SES groups [22]. However, it remains unclear
if tobacco exposure is a cause of health disparities related to nonmalignant respira-
tory diseases among minority racial/ethnic groups and low SES groups in the USA.
For example, cigarette smoking is the primary cause of chronic obstructive pul-
monary disease (COPD) [2]. Approximately 80–90 % of all COPD deaths are
caused by smoking [23]. COPD is associated with an elevated risk of lung cancer
and although African Americans have similar COPD prevalence rates as Whites
[24], African American men with COPD have a sixfold increased risk for lung can-
cer compared to Whites [25]. African American men have the highest incidence and
death rates of lung cancer in the USA [9]. Disparities in lung cancer between African
American and White men and women are largely unexplained by the duration, fre-
quency, and intensity of cigarette smoking [21, 25, 26]. In one study, 94 % of
14 P. Fagan

African American men and 78 % of African American women with lung cancer also
had a diagnosis of COPD [27]. These data suggest that it is possible that a respiratory
diagnosis can contribute to tobacco-caused disparities in another disease category
since African Americans disproportionately suffer from lung cancer incidence and
mortality.
COPD can also contribute to deaths from pneumonia, ischemic heart diseases,
and heart failure [20, 28–31], and heart disease disproportionately affects minority
racial/ethnic groups. Deaths from heart disease, stroke, and hypertension combined
are higher among African Americans compared to all other ethnic groups and
almost twice that of White adults [32]. Furthermore, SHS increases adverse health
outcomes among COPD patients and could adversely affect minority groups who
are more likely to be exposed to SHS [33, 34]. Thus, although Whites suffer more
adverse health outcomes from COPD [23], COPD increases the risk for other
tobacco-caused illnesses that minority groups suffer from disproportionately.
The purpose of this chapter is to (1) provide an overview of populations in the
USA who disproportionately experience disparities; (2) review current data
on tobacco exposure among these groups; (3) present a framework for examining
the problem; (4) discuss gaps in research and methodological challenges; and (5)
provide suggestions for future research and practice.
This chapter specifically focuses on disparities in tobacco use and exposure
among racial/ethnic minority and low socioeconomic groups for which there have
been long-standing disparities. We report on the intersection between gender and
race/ethnicity and gender and socioeconomic status (SES) when possible. There is
insufficient evidence on tobacco-related health disparities in lesbian, gay, bisexual,
and transgender (LGBT) individuals and populations that suffer from mental ill-
nesses, but we report the available data. Recommendations for research and practice
are made for all of these populations in the chapter summary.

Populations in the USA Who Disproportionately Experience

Tobacco-Related Health Disparities

There are differences in health and indicators of health, but not all differences are
health disparities and not all similarities suggest an achievement of equity. For
example, smoking prevalence has declined among racial/ethnic groups, and
African Americans and Whites have similar smoking rates. In 2013, current smok-
ing was 18.3 % among African American and 19.4 % among White adults [4].
African Americans smoke fewer cigarettes per day on average, have a higher per-
centage of non-daily smokers, and have later age of onset of smoking compared to
Whites [21, 35]. If one were to only examine these indicators, one might assume
that there is equity and possibly a slight health advantage to African Americans as
compared to Whites.
2 Health Disparities in Tobacco Smoking and Smoke Exposure 15

However, African Americans have disproportionately higher tobacco-caused

cancer morbidity and mortality rates and lower survival rates. One might suggest
that the lag in lung cancer rates may be due to lag in time related to smoking
declines. Yet, historically, cigarettes smoking rates among African American males
were not much higher than White males in 1965 and began to decline at the same
time. In addition, smoking rates among African American women since 1965 have
been similar to rates among White women [36], but African American women have
historically had higher lung cancer incidence rates and lower 5-year survival rates
than White women. These disparities are largely unexplained using the dose–
response model of lung cancer. In this chapter, disparities are examined from a
broad perspective, since not one indicator tells the entire story and there are multiple
factors that influence the respiratory disease continuum in minority racial/ethnic
and low SES groups.

Definition of Tobacco-Related Disparities

The definition of tobacco-related disparities was derived from the 2002 National
Conference on Tobacco and Health Disparities: Forging a National Research
Agenda to Reduce Tobacco Related Health Disparities, which was a meeting of
national stakeholders co-sponsored by the National Cancer Institute, Centers for
Disease Control and Prevention, the American Legacy Foundation, the Robert
Wood Johnson Foundation, the American Cancer Society, the Campaign for
Tobacco-Free Kids, the National African American Tobacco Prevention Network,
and the National Latino Council on Alcohol and Tobacco. The definition was cre-
ated at a time when stakeholders at local, state, and national levels were defining
health disparities and seeking to increase the visibility of the need to address dis-
parities within the USA. The consensus statement developed by this group defined
tobacco-related disparities as, “differences in patterns, prevention, and treatment of
tobacco use; the risk, incidence, morbidity, mortality, and burden of tobacco-related
illness that exist among specific population groups in the USA; and related differ-
ences in capacity and infrastructure, access to resources, and environmental tobacco
or SHS” [37].
This definition was later modified slightly by Fagan and colleagues [38] to cap-
ture more details embedded in the patterns of use that impact prevention and treat-
ment: “tobacco-related health disparities are differences in exposure to tobacco,
tobacco use initiation, current use, number of cigarettes smoked per day (cpd), quit-
ting/treatment, relapse, and the subsequent consequences among specific groups,
and include differences in capacity and infrastructure as well as access to resources”.
In this expanded definition, differences in capacity, infrastructure, and access to
resources are inclusive of access to care, quality of health care, socioeconomic
indicators that impact health care, and psychosocial and environmental resources
[38]. These definitions were intended to provide a framework for the scope of
research that is needed to understand tobacco-related disparities at different points
16 P. Fagan

along the tobacco-disease continuum, different trajectories that lead to health con-
sequences, and how various social, community, and societal level factors that inter-
act with tobacco use/exposure contribute to the development of or amelioration of
tobacco-related disparities.

Populations Who Experience Tobacco-Related Disparities

In 2018, the nation will celebrate the 20-year anniversary of the publication of the
1998 Surgeon General’s Report, Tobacco Use Behaviors Among U.S. Racial/Ethnic
Minority Groups [21]. This was the first major government report to bring attention
to the need to examine tobacco use and disease outcomes in minority racial/ethnic
groups in the USA. This report focused on Blacks/African-Americans, Hispanic/
Latino Americans (Hispanics/Latinos), American Indians and Alaska Natives
(American Indian/Alaska Natives), and Asian, Native Hawaiian, and other Pacific
Islander Americans. This chapter defines these groups more inclusively since data
are often reported using aggregate racial/ethnic categories. This chapter also recog-
nizes the heterogeneity within each aggregate racial/ethnic group where possible.
The aggregate categories include people who come from diverse cultures, nationali-
ties, religions, heritages, and lifestyles.
American Indians and Alaska Natives are people whose ancestors include any of
the original peoples of North and South America (including Central America) and
who maintain tribal affiliation or community affiliation or attachment with their
indigenous group [39]. There are approximately 566 federally recognized tribes
[40] and non-federally recognized tribes that have their own culture, beliefs, and
practices. We use Blacks/African-Americans to be inclusive of the diverse people
who self-identify as Black or African American. This category may include people
of US born descent, Caribbean descent, or immigrants from other countries.
Hispanic/Latino/Spanish American is an aggregate ethnic category that includes
people who self-identify with at least one of these terms, and this identification is
consistent with the census terminology as well. Persons who self-identify as
Hispanic/Latino/Spanish American often are people from Latin American, South
America, or Spain. Asian, Native Hawaiian, or other Pacific Islander Americans is
an aggregate category that comprises persons of Asiatic descent and persons of
Polynesian, Melanesian, or Micronesian descent. The aggregate grouping is largely
based on sample size rather than similarities in origin. Furthermore, the category is
somewhat misleading since these social groups convey different disease risks
related to tobacco. Some studies have used Asian Americans alone or Native
Hawaiian/Pacific Islander alone. Although important to report, because of the popu-
lation sizes at the national levels, there are often too few data to report out specific
Asian groups including Japanese, Chinese, Korean, Vietnamese, Hmong, Filipinos
(many of whom will state they are of Hispanic origin), and many other Asian ethnic
groups. The Native Hawaiians and Pacific Islanders category includes Native
Hawaiians, Samoans, Guamanians, Chamorros, Tahitians, Tongans, Tokelauans,
2 Health Disparities in Tobacco Smoking and Smoke Exposure 17

Chuukese, Palauans, Yapese, Marshallese, Carolinians, Pohnpeians, Kosraeans,

Nauruans, Fijians, Guineans, or Solomon Islanders, or other Pacific Islander ethnic
groups [41]. Although important to report if available, Native Hawaiians and Pacific
Islanders are often not reported in national data due to sample sizes, but these groups
also experience disparities. In 2015, the first national survey on Native Hawaiians
and Pacific Islanders was released as public data [42].
Thus, the four major minority racial/ethnic groups in the USA (American Indian/
Alaska Native, Black/African American, Hispanic/Latino/Spanish American,
Asian/Native Hawaiian/Pacific Islander Americans) are aggregate categories with
unique ethnolinguistic characteristics; multiple ancestries; different histories of
entry to the USA; diverse settlement in the USA; and different evolutions as racial,
ethnic, and minority groups. None of these racial/ethnic groups represent biological
groups or are necessarily used to describe one’s skin color. Common factors shared
by some of these racial/ethnic groups include that they have often suffered from
disparities and estimates suggest that these groups will experience population
growth in the next 50 years.
Overall, the USA will experience population growth and the total population will
increase by 98.1 million between the years 2014 and 2060 [43] (see Table 2.3).
Changes in population size are driven by births, deaths, and net international migra-
tions [43]. The U.S. Census Bureau estimates that as the number and proportion of
non-Hispanic Whites declines, the number and proportion of minority populations
will increase. For example, the White population will decrease from 198 million in
2014 to 182 million in 2060, and the number and proportion of all other racial/eth-
nic categories will increase [43] (see Table 2.3). In 2014, minority comprised 37.8
% of the US population and in 2060 will comprise 56.4 % of the US population
[43]. The actual growth of minority populations will more than double and increase
from 116.2 million people in 2012 to 241.3 million by 2060 [44]. The number of

Table 2.3 Population growth estimates for racial/ethnic aggregate groups in the USA
2014 2060
Race/ethnicity % or number % or number
Total population (in millions) 318,748 416,795
White alonea 77.7 68.5
White alone, not Hispanic or Latino 62.6 43.6
Black or African American alonea 13.2 14.3
American Indian and Alaska Native alonea 1.2 1.3
Asian alonea 5.4 9.3
Native Hawaiian and Other Pacific Islandera 0.2 0.3
Two or more races 2.5 6.2
Hispanic or Latinob 17.4 28.6
Source: Colby S and Ortman JM. Projections of the size and composition of the US population:
2014 to 2060, Current Population Reports, P25-1143, U.S. Census Bureau, Washington, DC 2014
a
Includes persons reporting only one race
b
Hispanics may be of any race, so also are included in applicable race categories
18 P. Fagan

Americans of Hispanic ethnicity will more than double by 2060 and Hispanics will
experience the largest increase of all racial/ethnic groups (see Table 2.3). In 2014,
48 % of children under age 18 were minority and by 2060, 64.4 % of children in the
USA will be minority [43].
As minority racial/ethnic populations grow in the USA, our nation’s health is not
likely to improve. Minority racial/ethnic groups are over-represented at the bottom
end of the socioeconomic ladder. Since 1967, median household income has both
increased and decreased among racial/ethnic groups. For example, among all racial/
ethnic groups, in 1967 the median household income was $43,558 and in 2013 was
$51,939. Among Asians and Pacific Islanders, the median income was $63,214 in
1987 (year data were first collected) and was $70,571 in 2001 [45]. The racial/eth-
nic categories were then changed to separate Asians from Pacific Islanders. Among
Asians, the median income was $68,143 in 2002 and $67,065 in 2013. Data are not
reported for Pacific Islanders or Native Americans and Alaska Natives. Among non-
Hispanic Whites, the median income was $51,380 in 1972 and $58,270 in 2013.
Among Hispanics, the median income was $38,229 in 1972 (year data were first
collected) and $40,963 in 2013. Among African Americans, the median income was
$29,569 in 1972 and $34,598 in 2013. In 2013, the median household income
among Asian Americans was more than double that in African Americans [45].
The poverty rate for all Americans was 14.7 % in 1966 and 14.5 % in 2013 [45].
For the first time since 2006, poverty rates declined from 15 % in 2012 to 14.5 % in
2013, but the number of people in poverty did not significantly change [45].
Furthermore, there have been very small fluctuations in the percent of people in
poverty. In 2013, 9.6 % of Whites, 10.5 % of Asians, 10 % of Asian and Pacific
Islanders, 27.2 % of African Americans, and 23 % of Hispanics lived in poverty
[45]. Aggregate data, like Asian and Pacific Islander, mask some of the differences
in poverty among racial/ethnic groups. For example, prior data show that American
Indians, Alaska Natives, and Native Hawaiians have higher levels of poverty than
Whites. If the data were aggregated with Asians, who have lower levels of poverty,
then the data would be misleading. Data from the U.S. National Center for Education
Statistics also show that individuals with greater educational attainment were fur-
ther away from poverty than those with less education, and overall, Asians and
Whites have higher educational attainment compared to the other racial/ethnic
groups [46].
According to the 2014 National Healthcare Quality and Disparities Report, few
disparities were eliminated. For example, advice for cessation services for African
Americans decreased. Poor people generally experienced less access and worse
quality health care compared to more advantaged people. Disparities in health care
quality and outcomes by income and race/ethnicity are large, remained the same,
and did not improve substantially through 2012 [47]. Through 2012, most dispari-
ties in access to care related to income and race/ethnicity also showed no significant
change, neither getting smaller nor larger.
Improvements have been observed in health insurance coverage among adults.
From 2000 to 2010, the percentage of adults aged 18–64 who were uninsured
increased from 18.7 to 22.3 % [47], whereas from 2010 to 2013, the percentage
2 Health Disparities in Tobacco Smoking and Smoke Exposure 19

without health insurance decreased to 20.4 %. During the first half of 2014, the
percentage without health insurance decreased even further to 15.6 %. Although
disparities still exist in insurance coverage and African Americans and Hispanics
are less likely to be insured than Whites, uninsured adults decreased from 2013 to
2014 among three racial/ethnic aggregate groups reported. In 2013, 14.5 % of
Whites, 24.9 % of African Americans, 40 % of Hispanics reported being insured. In
2014, 11.1 % of Whites, 15.9 % of African Americans, and 33.2 % of Hispanics
reported being uninsured. Improvement in insurance coverage is likely due to the
2010 Affordable Care Act, which as part of its implementation established market-
place enrollment in health insurance in 2013. No such declines in the uninsured
population were observed among racial/ethnic groups prior the implementation of
the Affordable Care Act [47]. It is important to determine whether improvements in
health insurance will lead to improvements in preventive care, access to care, and
quality care among the poor and minority racial/ethnic groups. As the US popula-
tion becomes more diverse, it becomes more important to monitor changes in access
to care and quality care among racial/ethnic and socioeconomic groups.

Tobacco Use Disparities

Racial/ethnic and SES disparities exist in tobacco use and SHS exposure. Differences
in smoking prevalence rates exist by employment status, occupation, income, pov-
erty, and education. SES, race/ethnicity, and gender often interact to increase
tobacco-related disparities among these groups. We briefly review tobacco use
prevalence rates among racial/ethnic and low SES groups as well as SHS exposure
in these groups using the available data.

Tobacco Use Rates Among Young People

Healthy People 2020 seeks to reduce cigarette smoking among adolescents to 21 %

overall and less than 16 % in the past 30 days as a strategy to help reduce tobacco-
related and tobacco-caused diseases and conditions in the USA [10]. Significant
progress was made in reducing cigarette smoking as a result of the 1998 Master
Settlement Agreement (MSA) [48]. The MSA resulted after Attorney Generals
from 46 states, five US territories, and the District of Columbia filed a lawsuit
against tobacco industry to recover health care-related costs of tobacco use. Five of
the largest tobacco industries paid states approximately $10 billion per year, and the
MSA sets standards for the sales and marketing of cigarettes, particularly to young
people. Cigarette smoking rates declined among young people after the 1998 Master
Settlement Agreement from 2000 to 2009 [31] and then reached a plateau. Recent
data show dramatic changes in the use of combustible versus noncombustible
tobacco among middle school and high school students [49, 50].
20 P. Fagan

a
15
Percentage

10
White, non-Hispanic
Black, non-Hispanic

5 Hispanic
Other race, non-Hispanic

0 Tobacco† Cigarettes Cigars Pipes Other Electronic Smokeless

combustibles cigarettes tobacco∗∗
Tobacco use behavior

b
30

25

20
Percentage

White, non-Hispanic
15
Black, non-Hispanic
10 Hispanic
Other race, non-Hispanic
5

0
Tobacco† Cigarettes Cigars Pipes Other Electronic Smokeless
combustibles cigarettes tobacco∗∗
Tobacco use behavior

Fig. 2.1 (a) Percentage of middle school students currently using* tobacco products, by school
level, sex, race/ethnicity, and product type—National Youth Tobacco Survey, United States, 2012.
(b) Percentage of high school students currently using* tobacco products, by school level, sex,
race/ethnicity, and product type—National Youth Tobacco Survey, United States, 2012

Among adolescents, tobacco use varies by tobacco product. Combustibles,

including cigarettes and cigars, have historically been used more commonly than
other tobacco products and to our knowledge, pose a higher risk for respiratory
disease than noncombustibles (see Fig. 2.1). In 2012, among middle school stu-
dents, past 30-day tobacco use rates were highest among Hispanics, followed by
African Americans, Whites, and others, respectively. Among high school students,
past 30-day tobacco use was highest among Whites, followed by African Americans,
Hispanics, and others, respectively. Among middle school students, cigarette use
was highest among Hispanics, but among high school students, cigarette use was
most prevalent among Whites. The prevalence of cigar use was highest among
African Americans, followed by Hispanic, White, and other middle and high school
students, respectively [49].
In 2014, a major shift occurred in the use of combustibles and noncombustibles
among young people. Past 30-day use rates of electronic cigarettes and hookah
increased and surpassed past 30-day use of cigarettes overall. Among high school
students, 13.4 % reported electronic cigarette use, 9.4 % reported hookah use, 9.2 %
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