Summer 2001 Issue
Cultural Sensitivity Key to Tobacco Control Interventions
Tobacco means different things to different people, and its significance varies across cultures. To help people stop smoking and prevent new smokers from starting, it is necessary to understand the cultural context of tobacco use. Evaluating this cultural element is the principal focus of scientists at the University of Arizona’s Prevention Research Center (PRC), who are conducting tobacco control research in the multiethnic communities of Arizona and its border states.
The Arizona center is one of a network of university-based prevention research centers devoted to studying health promotion and disease prevention and demonstrating new and innovative techniques for enhancing public health. The PRCs were first funded by Congress in 1986 and operate under a cooperative agreement with the Centers for Disease Control and Prevention (CDC). The PRCs are community-based and work in cooperation with local and state public health entities to study health issues particular to their local communities. Currently there are 24 centers throughout the United States, each conducting research, with technical support from CDC, on public health issues ranging from HIV prevention and reproductive health to depression among seniors.
“The quality of research at the PRCs is excellent,” says Lynda Doll, director of the PRC Program in CDC’s Division of Adult and Community Health. “And they have strong connections and working relationships with their communities.” This includes state and local health departments, hospitals, health maintenance organizations, schools, police departments, and many other groups.
The CDC Foundation, with financial support from the American Legacy Foundation, awarded the Arizona center one of nine contracts to gain a better understanding of the effectiveness of tobacco control work in states and localities nationwide. Arizona center scientists are analyzing the degree to which four southwestern border states (Arizona, California, New Mexico, and Texas) have addressed and implemented CDC’s Best Practices for Comprehensive Tobacco Control Programs in Hispanic and Native American communities. These guidelines provide states with recommended strategies to prevent and reduce tobacco use, eliminate nonsmokers’ exposure to environmental tobacco smoke, and identify and eliminate disparities related to tobacco use and its effects among different population groups.
“We start with CDC’s guidelines, adapt and develop them for a particular group, and then look at what works and why,” says Michael Lebowitz, M.D., director of the Arizona center. Lebowitz says such research is possible because of the special ability of the PRCs to assess the nature of a community and its interactions and to evaluate how specific ethnic populations deal with health matters. “We’ve been working with Native American and Hispanic communities for over fifteen years,” he says, “so we have a good basis for this project.”
Myra Muramoto, M.D., M.P.H., one of two principal investigators at the Arizona center, divides her time between university research and family practice. “You have to respect the culture of a community if you’re going to have an impact on behavior,” she says. As an example, Muramoto points to ceremonial use of tobacco among Native Americans. “We have to make it very clear that our intention is not to interfere with ceremonial use, while at the same time, getting out the message about the dangers of commercial tobacco use.”
Hispanic communities pose different challenges. “In our southwest Hispanic communities, respect for family and the community is of primary importance,” says Muramoto. “Community members told us that concern for the health of the family would be a culturally relevant way to engage people in smoking cessation interventions.” But, she says, these values present special challenges. “For example, say you’ve decided to quit smoking, and your father’s best friend, an elder you respect, offers you a cigarette. How do you refuse without insulting him?”
Jesse Nodora, Dr.P.H., is local projects administrator at the Arizona Department of Health Services’ Office of Tobacco Education and Prevention Programs and co-principal investigator on the project. He says that designing culturally sensitive interventions goes beyond the broad categories of Hispanic and Native American. “Within each of the several different tribes in Arizona and our border areas, there are multiple clans and family groups, each with its own cultural practices.” In addition, he says, many of the multicultural groups are made up of members of different tribes. In the Hispanic community, Nodora says, similar issues exist.
“‘Hispanic’ is a catchall label,” he says. “Those boxes that you check on census forms for ‘white,’ ‘black,’ ‘Hispanic,’ or ‘Asian,’ don’t really mean much. These include people who have been in this country for five or six generations and those who have been here only a few months. What works in one group may not work in another.”
This intimate understanding of the role tobacco plays within a given community made the PRCs ideally suited to help carry out the mission of the American Legacy Foundation. “We’re deeply committed to supporting research to identify those programs that work best to curb tobacco’s tragic tolls,” says Cheryl G. Healton, Dr.P.H., president and CEO of Legacy. “This funding will identify the types of programs in communities that can be replicated in cities and towns from coast to coast to help extinguish tobacco use.”
- Rosemarie Perrin