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 created 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 disparities 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 differences 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 capture more details embedded in the patterns of use that impact prevention and treatment: “tobacco-related health disparities are differences in exposure to tobacco, tobacco use initiation, current use, number of cigarettes smoked per day (cpd), quitting/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 along the tobacco-disease continuum, different trajectories that lead to health consequences, and how various social, community, and societal level factors that interact with tobacco use/exposure contribute to the development of or amelioration of 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 recognizes the heterogeneity within each aggregate racial/ethnic group where possible. The aggregate categories include people who come from diverse cultures, nationalities, 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 population 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, 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 migrations [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/ethnic 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 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/ethnic 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 further 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 disparities 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 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 marketplace 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 population becomes more diverse, it becomes more important to monitor changes in access to care and quality care among racial/ethnic and socioeconomic groups .

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].

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 students, 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 % reported cigarette use, and 8.2 % reported cigar use in the past 30 days. Among middle school students, 3.9 % reported electronic cigarette use, 2.5 % reported hookah use, 2.5 % reported cigarette use, and 1.9 % reported cigar use in the past 30 days [50].

The 2014 data also showed differences in the use of combustibles and noncombustibles by race/ethnicity. Among high school students, 10.8 % of Whites, 4.5 % of African Americans, 8.8 % of Hispanics, and 5.3 % of non-Hispanic others reported cigarette use in the past 30 days. Among middle school students, 2.2 % of Whites, 1.7 % of African Americans, and 3.7 % of Hispanics reported cigarette use in the past 30 days. Data were not reported for “other” race/ethnicity. Among high school students, 8.3 % of Whites, 8.8 % of African Americans, 8.0 % of Hispanics, and 2.6 % others used cigars in the past 30 days. Among middle school students, 1.4 % of Whites, 2.0 % of African Americans, and 2.9 % of Hispanics used cigars in the past 30 days. Data were not reported for “other” race/ethnicity [50].

Noncombustible use increased from 2012 and use rates were largely driven by increases in electronic cigarettes. Among high school students, 15.3 % of Whites, 5.6 % of African Americans, 15.3 % of Hispanics, and 9.4 % of non-Hispanic others reported electronic cigarette use in the past 30 days. Among middle school students, 3.1 % of Whites, 3.8 % of African Americans, and 6.2 % of Hispanics reported electronic cigarette use in the past 30 days. Among high school students, 9.4 % of Whites, 5.6 % of African Americans, 13.0 % of Hispanics, and 6.0 % of non-Hispanic others reported hookah use in the past 30 days. Among middle school students, 1.4 % of Whites and 5.6 % of Hispanics reported hookah in the past 30 days. Data were not reported for African American middle school students and “other” race/ethnicity [50].

The most recent data are not reported by SES indicators. Parental education has often been used as a proxy for SES [51], but the data are difficult to interpret since parental education does not necessarily predict smoking rates among adolescents .

Healthy People 2020 seeks to reduce current cigarette smoking among adults aged 18 and over to less than 12 % as a strategy to help reduce tobacco-related and tobacco-caused diseases and conditions in the USA [10]. Smoking rates among adults are slowly declining. In 2013, an estimated 17.8 % of adults smoked cigarettes [4]. The most recent data show that smoking rates among adults are highest among individuals reporting multiple races, followed by American Indians and Alaska Natives, Whites, African Americans, Hispanics, and Asians, respectively (see Table 2.4 and Fig. 2.2). Smoking decreases with educational attainment and is higher among persons in poverty compared to persons not in poverty (see Table 2.4; Figs. 2.3 and 2.4). However, there were no significant changes from 2005 to 2013 in smoking by educational attainment status. Current smoking among persons in poverty did not change in the years 2005 and 2013. Smoking rates are lower among women compared to men, but patterns of disparities by race/ethnicity and SES are similar for men and women [4].