Smoking-cessation strategies for American Indians: should smoking-cessation treatment include a prescription for a complete home smoking ban?

Understanding determinants of lung cancer preventive care in at-risk urban American Indians and Alaska Natives: A mixed-methods study

Introduction

Lung cancer is the leading cause of cancer death among American Indian and Alaska Native (AI/AN) people, and AI/AN people have the highest rate of smoking of any racial or ethnic group in the US. There is limited research to inform culturally-relevant strategies for lung cancer prevention inclusive of lung cancer screening (LCS). The objective of this study was to understand determinants of LCS and tobacco cessation care in at-risk urban-dwelling AI/ANs.

Materials and Methods

This was a mixed-methods community-based participatory research study including complimentary qualitative discussions and surveys conducted in Seattle, Washington, USA from 2022 to 2023. The study measures and analytic approach integrated the Consolidated Framework for Implementation Research and Tribal Critical Race Theory and qualitative transcripts were analyzed using thematic analysis. Participants were self-identified AI/AN people who were age ≥ 40 and had ≥ 10-year history of commercial cigarette smoking.

Results

Forty-five participants completed surveys and participated in discussions, 48% were female, the median age was 58 and median smoking history was 24 pack-years of commercial cigarette use. Themes revealed prominent barriers to LCS care including access, costs, awareness, and fear. Many reported previous negative and discriminatory encounters within and outside the health system which may also serve as barriers. Most participants endorsed cancer screening and increased education, recommending Indigenous-centered, delivered, and tailored programs, as well barrier-directed support.

Conclusions

In a broad sample of at-risk urban-dwelling AI/AN people, our findings suggest enthusiasm for preventive care but several complex barriers. Participants endorsed culturally-tailored programs which could provide relevant education and address barriers.

Smoking Cessation Interventions in Indigenous North Americans: A Meta-Narrative Systematic Review

INTRODUCTION

Indigenous North Americans have the highest cigarette smoking prevalence among all racial and ethnic groups in the United States. We seek to identify effective components of smoking cessation interventions in Indigenous people in the United States associated with favorable cessation outcomes.

METHODS

A review of literature studying smoking cessation interventions in Indigenous North Americans (American Indians and Alaska Natives) from January 2010 through August 2021 was completed. The primary objective of this study was to identify components of interventions associated with positive smoking cessation outcomes in Indigenous people. The studies identified were synthesized in a meta-narrative approach.

RESULTS

Ten studies out of 608 titles were included (6 randomized trials, 2 single-arm studies, 1 cohort study, and 1 prospective observational study). Five categories of smoking cessation interventions were identified; phone or web-based tools, culturally-tailored interventions, the inclusion of Indigenous study personnel, pharmaceutical cessation aids, and behavioral health interventions. Phone and web tools, cultural tailoring, and inclusion of Indigenous personnel conditions inconsistently influenced smoking cessation. Pharmaceutical aids were viewed favorably among participants. Individualized behavioral counseling sessions were effective at promoting smoking cessation, as was input from local communities in the planning and implementation phases of study.

CONCLUSION

A successful smoking cessation intervention in Indigenous North Americans includes Tribal or community input in intervention design and implementation; should provide individualized counseling sessions for participants, and offer access to validated smoking cessation tools including pharmacotherapy.

IMPLICATIONS

This study identifies a paucity of smoking interventions utilizing standard of care interventions in Indigenous North Americans. Standard of care interventions including individualized cessation counseling and pharmacotherapy were effective at promoting cessation. The use of novel culturally tailored cessation interventions was not more effective than existing evidence-based care with the exception of including Tribal and local community input in intervention implementation. Future smoking cessation interventions in Indigenous North Americans should prioritize the use of standard of care cessation interventions.

Indigenous Smoking Behaviors in Olmsted County, Minnesota: A Longitudinal Population-Based Study

OBJECTIVE

To describe smoking behaviors and pharmaceutical cessation aid uptake in a population-based Indigenous cohort compared with an age- and sex-matched non-Indigenous cohort.

PATIENTS AND METHODS

Using the health record-linkage system of the Rochester Epidemiology Project (January 1, 2006, to December 31, 2019), smoking data of Indigenous residents of Olmsted County in Minnesota were abstracted to define the smoking prevalence, incidence, cessation, relapse after cessation, and pharmaceutical smoking cessation aid uptake compared with a matched non-Indigenous cohort. Prevalence was analyzed with a modified Poisson regression; cessation and relapse were evaluated with generalized estimating equations. Incidence was evaluated with a Cox proportional hazards model.

RESULTS

Smoking prevalence was higher in the Indigenous cohort (39.0% to 47.0%; n=898) than the matched cohort (25.6% to 30.3%; n=1780). Pharmaceutical uptake was higher among the Indigenous cohort (35.8% of n=584 ever smokers vs 16.3% of n=778 ever smokers; P<.001). Smoking cessation events occurred more frequently in the Indigenous cohort (relative risk, 1.10; 95% CI, 1.06 to 1.13; P<.001). Indigenous former smokers were more likely to resume smoking (relative risk, 3.03; 95% CI, 2.93 to 3.14; P<.001) compared with the matched cohort. These findings were independent of socioeconomic status, age, and sex.

CONCLUSION

Smoking in this Indigenous cohort was more prevalent compared with a sex- and age-matched non-Indigenous cohort despite more smoking cessation events and higher use of smoking cessation aids in the Indigenous cohort. The relapse rate after achieving cessation in the Indigenous cohort was more than three times higher than the non-Indigenous cohort. This finding has not been previously described and represents a potential target for relapse prevention efforts in US Indigenous populations.

With socioeconomic status controlled, cigarette use is lower among American Indians/Alaska Natives than whites

BACKGROUND

Higher crude prevalence of cigarette use among American Indians/Alaska Natives (AI/AN) than non-Hispanic whites (NHW) has helped engender an assumption that race/ethnicity explains the difference. This study examines whether being AI/AN versus NHW predicts greater use when socioeconomic status and demographics are controlled.

METHODS

Data came from the National Survey on Drug Use and Health (2013-2017). Using logistic regressions with socioeconomic (income, education) and demographic (gender, age, marital status) controls, differences between AI/AN (n = 4,305) and NHW (n = 166,348) regarding heavier cigarette use (past month daily use, past month use of 300+ cigarettes, and nicotine dependence) and current cigarette use (past month use plus 100+ cigarettes in lifetime) were assessed. Adjusted predicted probabilities were also constructed.

RESULTS

NHW, compared to AI/AN, had greater odds of daily use: adjusted odds ratio (AOR) = 1.23 (95% CI: 1.03-1.49); predicted probabilities-15.3% and 13.0%, respectively. NHW had greater odds of using 300+ cigarettes: AOR = 1.47 (CI: 1.19-1.83); predicted probabilities-13.6% and 9.9%. NHW had greater odds of being nicotine dependent: AOR = 1.57 (CI: 1.31-1.89); predicted probabilities-10.3% and 7.1%. A difference in current use was not found. As controls, income and education were especially impactful.

CONCLUSIONS

With controls, particularly for socioeconomic status, heavier cigarette use was lower among AI/AN than NHW, and a current cigarette use difference was not indicated. This contradicts the idea that being AI/AN versus NHW independently predicts greater cigarette use, and it underscores the importance of socioeconomic status for understanding cigarette use among AI/AN.

Predictors of Tobacco Cessation Among American Indian/Alaska Native Adults Enrolled in a State Quitline

Background: High rates of smoking are documented among some American Indian and Alaska Native (AI/AN) communities, with potential variability by region and urban/rural settings. Quitlines are a cost-effective strategy for providing evidence-based cessation treatment, but little is known about the effectiveness of quitline services for the AI/AN population. Objectives: This study compared demographic characteristics, tobacco use, and cessation and program utilization behaviors between AI/AN (n = 297) and Non-Hispanic White (NHW; n = 13,497) quitline callers. The study also identified predictors of 30-day cessation at 7-month follow-up among AI/AN callers and determined if predictors were different between AI/AN and NHW callers. Methods: Data from callers to the Arizona Smokers' Helpline between January 2011 and June 2016 were analyzed. Results: At enrollment, AI/AN callers were less likely to use tobacco daily and were less dependent on nicotine compared to NHW callers. Both groups reported similar rates of 30-day cessation at 7-month follow-up (37.3% and 39.7% for AI/AN and NHW callers, respectively). For AI/AN callers, 30-day cessation was significantly associated with tobacco cessation medication use (OR = 2.24, 95% CI: 1.02-4.93), number of coaching sessions (OR = 1.14, 95% CI: 1.04-1.26), and other smokers in the home (OR = 0.41, 95% CI: 0.19-0.91). The effect of other smokers in the home was significantly different between AI/AN and NHW callers (p = .007). Conclusions: Different individual characteristics and predictors of cessation among AI/AN callers compared to NHW callers were documented. Findings may be used to inform the development of culturally-tailored strategies and protocols for AI/AN quitline callers.

Adaptation of a brief smoke-free homes intervention for American Indian and Alaska Native families

BACKGROUND

The goal of adaptation is to maintain the effectiveness of the original intervention by preserving the core elements that account for its success while delivering an intervention that is tailored to the new community and/or cultural context. The current study describes the process of adapting an evidence-based smoke-free homes (SFH) intervention for use in American Indian/Alaska Native (AI/AN) households.

METHODS

We followed a systematic adaptation process. We first assessed the community through focus groups coordinated in collaboration with tribal partners. Because our team included the original developers of the intervention, the steps of understanding the intervention, selecting the intervention and consulting with experts were simplified. Additional steps included consulting with stakeholders through a national work group and collaboratively deciding what needed adaptation.

RESULTS

A number of key themes pertinent to the adaptation of the SFH intervention were identified in the focus groups. These included the gravity of messaging about commercial tobacco use; respect, familialism, and intergenerationalism; imagery, including significant symbolism, colors, and representative role models; whether and how to address traditional tobacco; and, barriers to a SFH not adequately addressed in the original materials.

CONCLUSIONS

Adaptation of an intervention to create smoke-free homes in AI/AN families necessitated both surface structure changes such as appearance of role models and deep structure changes that addressed core values, and beliefs and traditions.

Life course transitions and racial and ethnic differences in smoking prevalence

This study aims to: (1) describe trajectories in the likelihood of smoking by racial or ethnic group across the transition to adulthood, (2) identify the influence of achieved socioeconomic status (SES) and the nature and timing of adult role transitions, and (3) determine the extent to which achieved SES and adult roles mediate the effects of race and ethnicity on smoking. The analyses use U.S. longitudinal data from the National Longitudinal Study of Adolescent Health (Add Health), which follows a representative national sample over four waves and from ages 11-17 in 1994/95 to 26-34 in 2007/08. Growth curve models compare trajectories of smoking likelihood for white, black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native individuals. While whites have higher rates of smoking than blacks and Hispanics during their teen years and 20s, blacks and Hispanics lose their advantage relative to whites as they approach and enter their 30s. American Indian/Alaska Natives show high rates of smoking at earlier ages and an increasing likelihood to smoke. Although life course transitions are influential for smoking prevalence in the overall U.S. population, SES and the nature and timing of adult role transitions account for little of the gap between whites and black, Hispanic, and American Indian/Alaska Native individuals. Racial and ethnic disparities in adult smoking are independent of SES and life transitions, pointing to explanations such as culturally specific normative environments or experiences of discrimination.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Interventions for smoking cessation in Indigenous populations

BACKGROUND

Tobacco use in Indigenous populations (people who have inhabited a country for thousands of years) is often double that of the non-Indigenous population. A disproportionate burden of substance-related morbidity and mortality exists as a result.

OBJECTIVES

To evaluate the effectiveness of smoking cessation interventions in Indigenous populations and to summarise these approaches for future cessation programmes and research.

SEARCH METHODS

The Cochrane Tobacco Addiction Group Specialised Register of Trials was searched (April 2011), with additional searches of MEDLINE (May 2011). Online clinical trial databases and publication references were also searched for potential studies.

SELECTION CRITERIA

We included randomized and non-randomized controlled trials for smoking cessation interventions in Indigenous populations. Interventions could include pharmacotherapies, cognitive and behavioural therapies, alternative therapies, public policy and combination therapies. No attempts were made to re-define Indigenous status for the purpose of including a study in this review.

DATA COLLECTION AND ANALYSIS

Data pertaining to methodology, participants, interventions and outcomes were extracted by one reviewer and checked by a second, whilst methodological quality was extracted independently by two reviewers. Studies were assessed by qualitative narrative synthesis and where possible meta-analysis. The review process was examined by an Indigenous (Aboriginal) Australian for applicability, acceptability and content.

MAIN RESULTS

Four studies met all of the eligibility criteria for inclusion within the review. Two used combination therapies consisting of a pharmacotherapy combined with cognitive and behavioural therapies, whilst the remaining two used cognitive and behavioural therapy through counselling, one via text message support and the other delivered via clinic doctors trained in smoking cessation techniques. Smoking cessation data were pooled across all studies producing a statistically and clinically significant effect in favour of the intervention (risk ratio 1.43, 95%CI 1.03 to 1.98, p=0.032), however following sensitivity analysis a statistically non-significant but clinically significant effect was observed in favour of the intervention (risk ratio 1.33, 95%CI 0.95 to 1.85, p=NS) .

AUTHORS' CONCLUSIONS

A significant health disparity exists, whereby Indigenous populations, a minority, are over-represented in the burden of smoking-related morbidity and mortality. This review highlights the paucity of evidence available to evaluate the effectiveness of smoking cessation interventions, despite the known success of these interventions in non-Indigenous populations. Due to this lack of published investigations, the external validity of this review is limited, as is the ability to draw reliable conclusions from the results. The limited but available evidence reported does indicate that smoking cessation interventions specifically targeted at Indigenous populations can produce smoking abstinence. However this evidence base is not strong with a small number of methodologically sound trials investigating these interventions. More rigorous trials are now required to assist in bridging the gap between tobacco related health disparities in Indigenous and non-Indigenous populations.