TOBACCO USE AMONG CUBAN MIGRANTS AT GUANTANAMO BAY, CUBA
To the Editors:
We wish to call attention to a public health problem related to the U.S. military's policy on the availability of tobacco among Cuban migrants at Guantanamo Bay, Cuba.
As is well known, political challenges and economic hardship in Cuba contributed to a major population exodus in 1994. After taking to the water, often in unseaworthy boats, approximately 29 000 to 35 000 Cubans were intercepted in international waters by the U.S. Coast Guard and taken to Guantanamo Bay Naval Base (GTMO), Cuba. While the migrants were in detention camps waiting to be processed¾a wait which usually lasted many months¾the U.S. military distributed 20 cigarettes daily to each migrant over 18 years of age, regardless of the migrant's smoking status.
Tobacco use has been reported to be a major public health concern in Cuba. Although cigarettes were previously rationed in that country in order to increase tobacco export products, in the early 1980s Cuba ranked among the top five countries in the world in per capita smoking prevalence (13). In the mid-1980s, smoking-related diseases accounted for 30% of all deaths in Cuba (4). Couceyro (as cited in Matorrales¾2) reported that 57% of Cuban men and 42% of Cuban women used tobacco. Padron-García reported a smoking prevalence of 43% among pregnant Cuban women (5), while Pletsch found the prevalence of smoking to be 22.6% among Cuban-American women of childbearing age (6). A Havana-based survey among first- through third-year nursing students found that 39.6% used tobacco (2).
Given the tremendous adverse effects of tobacco use on public health, and a surplus and hoarding of cigarettes in the GTMO camps (personal observation), a survey was conducted among the GTMO migrants to provide a baseline for initiating smoking prevention and cessation programs. The objectives of the study were to determine the prevalence of smoking in the Cuban migrant population, the age at smoking initiation, and the effect of a cigarette surplus in the camps on the initiation of the smoking habit.
In May 1995, a tent-to-tent smoking health risk survey was conducted in a section of one of the Cuban migrant camps occupied by 1 600 men and 300 women. The overall Cuban migrant population at GTMO at the time was listed as 18 037 men and 2 711 women distributed among 12 camps, three of which housed males only. The age distribution of the total migrant population was given as 4% between 4 months and 17 years, 56% between 18 and 30 years, and the remaining 40% between 31 and 75 years. At the time of the survey, most of the migrants had lived in the camps for one year (7).
With the help of one Cuban translator/assistant, the survey was conducted over a two-week period. The questionnaire used for the survey contained closed-ended questions regarding demographic information and tobacco use history. The 26-item questionnaire was written in Spanish and had been pre-tested on 35 migrants who lived in another camp. The questionnaires were distributed about 11:00 a.m., by which time approximately 70% of the migrants were in their tents in order to escape the hot sun, to play cards and dice games, and to socialize. Questionnaires and informed consent forms were distributed to occupants of two tents at a time; the number of people per tent averaged 14. The assistant waited at each tent until the questionnaires were completed and returned. A total of 566 questionnaires (response rate = 95%) were collected, representing 30% of the target camp's population.
Among the 566 individuals who participated in the survey, 20% (111) were women and 80% (455) were men. Survey participants' ages ranged from 15 to 65 years. The overall female-to-male camp population ratio was 1:6.6, similar to the 1:5 ratio of the survey participants.
Forty-nine percent (279/566) of the migrants used tobacco on a daily basis. The crude prevalence of smoking was 38% (42/111) for women and 52% (237/454) for men. The highest prevalence of smoking was observed among persons aged 30 to 49 years for both women and men (46% and 61%, respectively), and the lowest among persons 15 to 19 (30% for females and 28% for males). Among smokers, the median number of cigarettes smoked per day was 20 for males, 30 for women between the ages of 30 and 39 years, and 20 for women of other ages. Ninety-two percent (256/279) of the smokers reported having a "sufficient" supply of cigarettes, while the remaining 8% (23/279) wanted more cigarettes.
Despite the abundance and general availability of cigarettes in the camps and the stressful living conditions, only 7% (21) of previously nonsmoking migrants had started smoking while in the camps: 6 women aged 22 to 43 years and 15 men aged 22 to 50 years. None of the previous nonsmokers reported smoking prior to arrival in GTMO. Nine, however, responded that at least one parent was a current smoker. The daily cigarette consumption of this group of new smokers ranged from 2 to 60, with a median of 20 cigarettes. All of the new smokers cited stress as a factor contributing to their initiation of tobacco use.
Among all smokers, 57% (158/279) began smoking by the age of 15 years. The mean age of first smoking increased with present age, with current teenagers initiating smoking at an average age of 15.4 years, 2029-year-olds at 16.9 years, 3039-year-olds at 16.3 years, 4049-year-olds at 18.3 years, and 5065-year-olds at 18.7 years. Gender-specific analysis showed that 25% of the male and female smokers had used tobacco by the ages of 14 and 13 years, respectively, while 75% had smoked by the time they reached 18 and 20 years of age, respectively.
The overall relative risk of respiratory problems (self-reported asthma, dyspnea, and bronchitis) associated with smoking was 1.7 (95% confidence interval (CI) = 1.0 to 2.8), an increase attributable primarily to an increased risk among males (relative risk for males = 2.0 (95% CI = 1.2 to 3.6)). The prevalence of self-reported, chronic respiratory illness was 18.9% among smokers and 13.9% among nonsmokers. These prevalences seem high. It may be that this information was subject to overreporting because the definitions of asthma, chronic bronchitis, and shortness of breath were not included in the questionnaire. For example, a simple cough may have been reported as "bronchitis." Bang et al. reported age- and gender-specific chronic bronchitis prevalences of between 1.5% and 3.5% among Cuban-Americans (8).
The cigarette brands distributed in the GTMO camps were Pony (filter kings), made by the Star Tobacco Corp., Petersburg, Virginia (these cigarettes are U.S. tax-exempt for use outside the United States of America), and Class 'A' Quality Cigarettes (king size, filter lights), made by the Gary Tobacco Company, U.S.A./Permit No. TP-42-NC. Packages for both brands exhibit a Surgeon General's warning in English. The Pony warning reads "Cigarette smoke contains carbon monoxide," while the warning on Class 'A' Quality Cigarettes packs reads "Quitting smoking now greatly reduces serious risks to your health." Essentially none of the migrants, however, could read either warning because of a language barrier.
The sampling plan utilized in the present study (a one-time, cross-sectional survey in one area of one of the camps) may have resulted in a sample that was somewhat unrepresentative of all migrants with respect to their smoking habits. Nevertheless, the overall smoking prevalence among Cuban men and women at Guantanamo Bay is similar to published data from Cuba, with a higher percentage of males than females who smoke (2, 5). According to the present survey, smoking habits are formed early in life, perhaps explaining why so few migrants (7%) initiated tobacco use while incarcerated, despite the abundance of cigarettes and the stressful living conditions. However, even if only 7% of the total initially nonsmoking migrant population started smoking while incarcerated, an estimated 1 100 to 1 300 migrants became tobacco users among the 29 000 to 35 000 migrants taken to GTMO. Further, the military was under no obligation to provide cigarettes and, instead, could have limited the availability of cigarettes in the camps. Many migrants mentioned that they had increased their tobacco use while in the camps, a question that, regrettably, was not included in the survey questionnaire.
Because approximately 90%95% of the 36 000 Guantanamo Bay migrants immigrated to the United States, where cigarettes are readily available and affordable, the question of how the promotion of tobacco use at Guantanamo Bay affected their overall smoking habits is of particular relevance. If the prevalence of smoking continues at the level found in the present study, the future personal health care costs associated with smoking-related illness among Cuban-Americans will be substantial. The rationale for providing an abundance of free cigarettes in camps is not known. It seems imperative, however, that U.S. military leaders who are involved in migrant operations bear in mind the health consequences of their decisions regarding tobacco. In addition, the cost of operating migrant camps might be reduced substantially by limiting free daily cigarette distribution, which (at fifty cents per pack) is estimated to have cost over US$ 5 million for the peak year at GTMO.
Heinke P. Bonnlander1
American Refugee Committee
Annette MacKay Rossignol
Department of Public Health
Oregon State University
Waldo Hall 322
Corvallis, OR 97331-6406, USA
1. Centers for Disease Control, US Public Health Service. Recent trends in tobacco consumption¾Canada and other countries. Morbid Mortal Wkly Rep 1984;32:320323.
2. Matorrales FE. Nursing and the smoking habit. Rev Cubana Enferm 1990;6:165174.
3. Guttmacher S. The prevention of health risk in Cuba. Int J Health Serv 1987;17:179189.
4. Masironi R, Rothwell K. Tendances et effets du tabagisme dans le monde. World Health Stat Q 1988;41:228241.
5. Padron-García DM, Sánchez-Peres BB. Tobacco use and pregnancy. Rev Cubana Enferm 1990;6:6268.
6. Pletsch PK. Prevalence of cigarette smoking in Hispanic women of childbearing age. Nurs Res 1991;40:103106.
7. GTMO Joint Task Force. Migrant Operations Daily Update, Cuban Demographics. Wednesday, 3 May 1995.
8. Bang KM, Gergen PJ, Carroll M. Prevalence of chronic bronchitis among U.S. Hispanics from the Hispanic health and nutrition examination survey 198284. Am J Public Health 1990;80: 14951497.
1 At the time of the study, this author was employed at GTMO, Cuba, by the World Relief Corporation, which gave its permission for the study to be conducted.