African Americans who want to quit smoking face unique challenges. In a new study reported in the July 24 Journal of the American Medical Association (Vol. 288, No. 4: 468-474), researchers looked at accepted treatments for smoking cessation and how they worked in the African-American community.

"African Americans living in the inner city, for example, have a smoking rate as high as 45%, while the general population's rate is 25%," said Jasjit S. Ahluwalia, MD, MPH, and colleagues from the University of Kansas School of Medicine in Kansas City.

Compared with whites, African Americans may try to quit smoking more times in any given year, said the authors. But, they pointed out that the success rate is 34% lower for African Americans than it is for whites.

Also, African Americans smoke fewer cigarettes per day than whites (15 vs. 25), said the authors. Generally, they choose higher tar and menthol cigarettes and are more likely to smoke within 10 minutes of awakening.

Add the fact that cigarette toxins clear from African-Americans blood more slowly than in whites, then a picture of a serious problem emerges for the African-American community.

To find out what might help African Americans stop smoking, the researchers studied 600 African-American smokers in a local clinic between February 1999 and April 2000.

Half of the smokers received a medication called bupropion to help them stop smoking. The other half received a placebo, a pill that looked just like the bupropion, but didn't contain any of the medicine.

Bupropion has helped smokers stop smoking, either alone or in combination with nicotine replacements. But, many of the previous studies were conducted in smokers who were white and had a middle- or upper-level socioeconomic background.

In this study, another part of the treatment included counseling with African-American trained counselors. This was done to remove any question of whether the counselors understood the issues unique to African Americans, their culture, and their community.

Smokers received the medicine for seven weeks and then were rechecked at six months. About one in five of the smokers who took the medicine still had not resumed smoking. A little more than one in 10 of the smokers who took the placebo had stopped.

These results show that the medication helped them to stop smoking, but the results weren't as good as in other studies. The authors thought this might be due to high amounts of stress found in lower-income people.

Another possible reason was that African Americans smoke more menthol cigarettes, which may make quitting more difficult.

The authors concluded that one way to improve the "quit rates" for African Americans would be through increased access to medications as part of health insurance programs, especially Medicare and Medicaid. This would make an investment in reducing the differences in access to health care that exist in the US, they said.

Just as important, the study noted, is to reach the goals of Healthy People 2010 set by the US government. Significant decreases in smoking among "special populations" such as African Americans must occur.

In an editorial in the same journal, Neal Benowitz, MD, from the University of California in San Francisco, raised the question about the value of trials such as these in racial and economic groups.

"The adverse health effects of smoking are even greater in African Americans, who have a higher risk of lung cancer compared with whites, and also are increased among the poor, who are much more likely to be smokers and to have other risk factors, such as hypertension, diabetes, and obesity that interact with cigarette smoking to promote cardiovascular disease."

In commenting on the study, Otis Brawley, MD, associate director of the Winship Cancer Institute of Emory University in Atlanta, emphasized the importance of recognizing that differences in smoking behaviors are more cultural than physical in nature.

"There are differences in the way people smoke in the northeastern United States compared to the south," said Brawley, who is internationally known for his interest in the health of minorities.

"The types of cigarettes, the marketing approaches based on cultural differences, and the fact that poor people smoke more intensely" all contribute to these differences, he noted.

"Black populations have different cultures," he said. "The culture in Kansas (from where the study was reported) may be different than in Philadelphia, New York, or Detroit. So the same results may not be seen in other places."

That said, Brawley continued, "My only concern is that people realize the term African American means more culture than biology. Race is not a biologic category. Geographic origin is important."

"We need to use these interventions," said Brawley. "They work in all people. This study shows you can go into another culture that views smoking differently and still do something that works."

Brawley also noted that cultural sensitivity and understanding are important parts of any effort to help people quit smoking.

"People judge people," he noted, "so they look for that understanding in those who are trying to help them stop smoking. A black counselor is more likely to understand the issues, but a white or Asian counselor with understanding would do just as well."

Benowitz stressed translating research into effective programs that can be part of every minority community.

"Smoking cessation treatments that address the cultural needs and perspectives of Asian, Hispanic, Native American, and Pacific Islander populations are likely to be more effective than treatments that do not address cultural issues," he said.

The bottom line for everyone, he noted, is that "cigarette smoking remains the most important preventable cause of premature morbidity and mortality in the United States and other developed countries."