Influence of traditional tobacco use on smoking cessation among American Indians

Commercial Tobacco Cessation Interventions for American Indian and Alaska Native Persons Living in the United States: A Narrative Systematic Review of Effectiveness Using a Health Equity Lens

OBJECTIVE

Identify commercial tobacco cessation interventions for American Indian and Alaska Native (AI/AN) communities, focusing on strategies used to advance health equity, including strategies to address social determinants of health (SDOH), community engagement, and cultural tailoring.

DATA SOURCE

We searched Medline, Embase, PsycINFO, Cochrane Library, CINAHL, Scopus, ProQuest Central, Academic Search Complete, JSTOR, and Indigenous/Tribal health-related journals and databases.

STUDY INCLUSION AND EXCLUSION CRITERIA

We included peer-reviewed studies on commercial tobacco cessation for AI/AN persons published January 1998-April 2023 that reported quit rates/attempts. We excluded studies that only used pharmaceutical interventions.

DATA EXTRACTION

Two reviewers independently assessed each study against our inclusion/exclusion criteria. A reviewer extracted data, and another checked for completeness.

DATA SYNTHESIS

Synthesis focused on reported intervention effectiveness and strategies used for addressing SDOH, community engagement, and cultural tailoring. We used a synthesis matrix which allowed for comparison across studies.

RESULTS

We screened 1116 articles and included 12 for synthesis. Of the 12, five engaged community health workers; four included SDOH elements; and six were reported effective. Of these six, five included early-stage community engagement and four were culturally tailored.

CONCLUSIONS

There are few commercial tobacco cessation interventions for AI/AN populations. Building capacity, including tribal capacity, to develop and test multi-level, culturally grounded cessation interventions that address relevant SDOH may advance commercial tobacco cessation efforts in these populations.

Using Bayesian hierarchical models for controlled post hoc subgroup analysis of clinical trials: application to smoking cessation treatment in American Indians and Alaska Natives

Clinical trials powered to detect subgroup effects provide the most reliable data on heterogeneity of treatment effect among different subpopulations. However, pre-specified subgroup analysis is not always practical and post hoc analysis results should be examined cautiously. Bayesian hierarchical modelling provides grounds for defining a controlled post hoc analysis plan that is developed after seeing outcome data for the population but before unblinding the outcome by subgroup. Using simulation based on the results from a tobacco cessation clinical trial conducted among the general population, we defined an analysis plan to assess treatment effect among American Indians and Alaska Natives (AI/AN) enrolled in the study. Patients were randomized into two arms using Bayesian adaptive design. For the opt-in arm, clinicians offered a cessation treatment plan after verifying that a patient was ready to quit. For the opt-out arm, clinicians provided all participants with free cessation medications and referred them to a Quitline. The study was powered to test a hypothesis of significantly higher quit rates for the opt-out arm at one-month post randomization. Overall, one-month abstinence rates were 15.9% and 21.5% (opt-in and opt-out arm, respectively). For AI/AN, one-month abstinence rates were 10.2% and 22.0% (opt-in and opt-out arm, respectively). The posterior probability that the abstinence rate in the treatment arm is higher is 0.96, indicating that AI/AN demonstrate response to treatment at almost the same probability as the whole population.

Understanding American Indian tribal college student knowledge, attitudes, beliefs, and behaviors surrounding alternative tobacco products

OBJECTIVES

To examine knowledge, attitudes, beliefs, and behaviors about alternative tobacco products among American Indian tribal college students.

PARTICIPANTS

One hundred and five tribal college students.

METHODS

Focus groups, one interview, and demographic surveys.

RESULTS

Tobacco use varied across the sample with 35.2% of the participants being users of ENDS products and 29.5% were cigarette smokers. Overall, participants viewed electronic nicotine delivery systems and chewing tobacco as primary examples of alternative tobacco products and described a generational divide between alternative and conventional tobacco product use. Alternative tobacco products were not considered suitable for use in traditional contexts.

CONCLUSIONS

Previously successful cessation programs in this population have relied on cultural tailoring related to traditional tobacco use in American Indian communities. Our findings suggest that this strategy may be less effective for addressing alternative tobacco use. Reliance on the importance of family relationships may prove more impactful in future programming.

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.

Efficacy and Utilization of Smartphone Applications for Smoking Cessation Among American Indians and Alaska Natives: Results From the iCanQuit Trial

INTRODUCTION

There is tremendous need for efficacious and accessible interventions for smoking cessation among American Indians and Alaska Natives. We tested the efficacy of an Acceptance and Commitment Therapy (ACT)-based smartphone application (iCanQuit) versus US Clinical Practice Guidelines-based smartphone application (QuitGuide) for smoking cessation among American Indians and Alaska Natives.

AIMS AND METHODS

We compared cessation, changes in ACT-based processes, engagement and satisfaction between American Indian and Alaska Native iCanQuit (n = 89) and QuitGuide (n = 80) participants enrolled in the iCanQuit trial. The primary outcome was self-reported, complete-case, 30-day point-prevalence abstinence. Follow-up timepoints were 12, 6, and 3 months.

RESULTS

Randomized American Indians and Alaska Natives from 31 US states (70% urban, 30% rural, with 25% of participants residing on tribal land). The outcome data retention rates were 93%, 92%, and 90% at the 12-, 6-, and 3-month follow-ups, respectively, with no differential retention between arms. The 30-day point-prevalence abstinence for iCanQuit versus QuitGuide was 30% versus 18% at 12 months (odds ratio [OR] = 1.96; 95% confidence interval [CI]: 0.90 to 4.26) 25% versus 11% at 6 months (OR = 2.62; 95% CI: 1.06 to 6.45), and 15% versus 6% at 3 months (OR = 2.93; 95% CI: 0.90 to 9.59). Increases in acceptance of internal cues to smoke mediated the effect of treatment on smoking cessation at 12 months. iCanQuit arm participants were also significantly more engaged and satisfied with their assigned application.

CONCLUSIONS

In a nationwide sample with high data retention and participant engagement, this is the first study to show that a digital intervention may be efficacious for helping American Indians and Alaska Natives quit smoking.

IMPLICATIONS

This is the first study to provide evidence of an efficacious, accessible, and engaging treatment for helping American Indians and Alaska Natives quit smoking. Compared to a US Clinical Practice Guidelines-based smartphone application (QuitGuide), an ACT-based smartphone application (iCanQuit) was more efficacious, engaging, and satisfactory among American Indians and Alaska Natives nationwide. Our results will inform the tailoring of the iCanQuit smartphone application for American Indian and Alaska Native tribal communities and organizations with potential for broad dissemination and high impact.

Baseline characteristics of American Indian smokeless tobacco users participating in two pilot cessation studies

American Indians have higher rates of smokeless tobacco (SLT) use than other racial/ethnic groups in the US, yet no efficacious cessation program exists for them. Because tobacco is a sacred plant to many American Indians, it is imperative that a program respect the scared nature of tobacco while encouraging quitting recreational use. All Nations Snuff Out Smokeless (ANSOS) was designed to help American Indian SLT users quit recreational tobacco use while still using it for traditional purposes. We pilot tested the ANSOS 6-month group-based counseling program (N = 48) and a shortened version consisting of a one-time education session (N = 80). Here, we discuss the tobacco characteristics of participants at baseline in both studies. Participants across studies were more likely to be male (74.2%) and have at least a college education (65%). Participants in the one-time education sessions were younger (age 35 vs age 39) and used SLT fewer days per week (4.9 vs 5.7). Two-thirds of those in the full program reported that they often substitute SLT in locations where smoking is not allowed compared to 26%. Participants in the education sessions were more likely to report daily use of traditional tobacco (20% versus 0%). Results suggest that dual use of SLT and cigarettes needs to be addressed, as does the use of SLT to circumvent public smoking rules. The role of traditional tobacco and its relationship to lower SLT use also warrants further investigation.

One-Time Education Sessions to Help American Indian Smokeless Tobacco Users Quit

American Indian (AI) smokeless tobacco use rates are the highest of all racial/ethnic groups within the United States. Despite this, no effective cessation program currently exists that acknowledges the cultural significance of tobacco among many American Indian tribal nations. Participants were smokeless tobacco users, over 18 years of age, and were recruited through community partners. We modified the All Nations Snuff Out Smokeless Tobacco group-based program to be delivered as a one-time education session intervention. This was delivered to 80 participants and follow-up data was collected by self-report at 6-months. The mean age of participants was 35 and most were male (70%). A majority (69%) grew up on a AI reservation; the mean age of first smokeless tobacco use was 16 years of age. Of program completers reached for 6-month post baseline, 46% reported 0 days of SLT use; 13.5% of participants reduced; while 36% reported continued daily use. In intention to treat analysis those lost to follow-up are considered current users, the quit rate was 12.5% and among those who were still using, 4.0% reduced their use. In this study, a one-time education session intervention was effective for those who prefer an individual based approach to quitting SLT use. Follow up strategies to increase participant retention at 6-months should be explored.

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.

Aboriginal youth's perceptions of traditional and commercial tobacco in Canada

Although tobacco has played an important role in Aboriginal culture for millennia, its more recent recreational use has resulted in serious health concerns among Aboriginal users. In Canada, First Nations youth have higher smoking rates than non-Aboriginal youth. The goals of this study were to examine Aboriginal youth's perceptions of traditional and commercial tobacco and to evaluate perception changes following workshops on traditional uses of tobacco by Elders and other community members, native plants used in ceremony and health impacts of cigarette smoking. The twenty-five Aboriginal youth participants ranged in age from 9 to 14 years old. Results show that workshops did not alter participants' knowledge about tobacco and ceremonies but those studied were more effective at articulating their knowledge through open-ended questionnaires after the workshops. These participants were able to identify more traditional tobacco uses and plants that could be used in ceremonies instead of commercial tobacco. Culturally appropriate education about traditional and commercial tobacco use may be effective in limiting its misuse by Aboriginal youth.

Biomolecular archaeology reveals ancient origins of indigenous tobacco smoking in North American Plateau

Chemical analysis of residues contained in the matrix of stone smoking pipes reveal a substantial direct biomolecular record of ancient tobacco (Nicotiana) smoking practices in the North American interior northwest (Plateau), in an area where tobacco was often portrayed as a Euro-American-introduced postcontact trade commodity. Nicotine, a stimulant alkaloid and biomarker for tobacco, was identified via ultra-performance liquid chromatography-mass spectrometry in 8 of 12 analyzed pipes and pipe fragments from five sites in the Columbia River Basin, southeastern Washington State. The specimens date from 1200 cal BP to historic times, confirming the deep time continuity of intoxicant use and indigenous smoking practices in northwestern North America. The results indicate that hunting and gathering communities in the region, including ancestral Nez Perce peoples, established a tobacco smoking complex of wild (indigenous) tobacco well before the main domesticated tobacco (Nicotiana tabacum) was introduced by contact-era fur traders and settlers after the 1790s. This is the longest continuous biomolecular record of ancient tobacco smoking from a single region anywhere in the world-initially during an era of pithouse development, through the late precontact equestrian era, and into the historic period. This contradicts some ethnohistorical data indicating that kinnikinnick, or bearberry (Arctostaphylos uva-ursi) was the primary precontact smoke plant in the study area. Early use likely involved the management and cultivation of indigenous tobaccos (Nicotiana quadrivalvis or Nicotiana attenuata), species that are today exceedingly rare in the region and seem to have been abandoned as smoke plants after the entry of trade tobacco.

Prevalence and Indicators of Household Smoking Bans Among American Indians

More than 58 million nonsmokers in the U.S. encounter secondhand smoke that leads to tobacco-related diseases and deaths every year, making voluntary household smoking bans an important public health goal. American Indians/Alaska Natives are rarely included in research related to household smoking bans. Further, most studies dichotomize household smoking bans into complete bans versus partial/no bans, rendering it impossible to determine if partial and no bans are associated with different or similar risk factors. Using the 2014 Cherokee Nation American Indian Adult Tobacco Survey, our study sought to identify prevalence of household smoking bans, their extent, and their correlates in an American Indian population. This cross-sectional analysis used multinomial logistic regression to determine correlates of complete, partial, and no household smoking bans. Results indicated that approximately 84% of Cherokee households have a complete ban. Younger age, female gender, higher education, higher household income, respondent's nonsmoking status, good health, better awareness of harms related to secondhand smoke, visits with a healthcare provider within the past year, and children in the home were positively and significantly associated with complete household smoking bans. Additionally, there were notable differences between correlates related to partial bans and no bans. These results provide insight for the development of more appropriate interventions for American Indian households that do not have a complete household smoking ban.

Feasibility of Implementing the All Nations Breath of Life Culturally Tailored Smoking Cessation Program for American Indians in Multi-Tribal Urban Communities

Introduction

Prevalence of cigarette smoking is highest among American Indians, yet few culturally appropriate smoking cessation programs have yet been developed and tested for multi-tribal American Indian adult populations. This study examined implementation of the All Nations Breath of Life culturally tailored smoking cessation program in multi-tribal urban and suburban American Indian communities in seven locations across five states (N = 312).

Methods

This single-arm study used community-based participatory research to conduct a 12-week intervention whose primary purpose was to curb commercial tobacco use among American Indians. Participants were followed through month 6 in person and month 12 via telephone. The primary outcome was continuous abstinence from recreational cigarette smoking at 6 months post-baseline, verified through voluntary provision of salivary cotinine levels.

Results

At program completion (12 weeks post-baseline), 53.3% of program completers remained abstinent; labeling those lost to follow-up as smokers resulted in a 41.4% quit rate. At 6 months post-baseline (primary endpoint), 31.1% of retained participants quit smoking (p < .0001 compared to the highest quit rates among multi-tribal populations reported in the literature, 7%); final quit rate was 22.1% labeling those lost to follow-up as smokers (p = .002). Retention rate at endpoint was 71.2%. 12-month follow-up was attempted with all participants and had a retention rate of 49.0%. Of those participants reached, 34.0% were smoke-free.

Conclusions

All Nations Breath of Life shows promise as a smoking cessation program for multi-tribal urban American Indian communities. It can be successfully implemented in a variety of urban settings.

Implications

This is the first large feasibility study of a culturally tailored smoking cessation program for American Indians with good cessation and retention rates in a multi-tribal urban American Indian population. It shows that All Nations Breath of Life can be implemented in multiple urban settings across five states. To our knowledge, this is the first program of its kind to be implemented across multiple heterogeneous urban locations and to include salivary cotinine testing for verification of self-report data across these locations.

Development of a Culturally Appropriate Smokeless Tobacco Cessation Program for American Indians

This study describes a multiphasic approach to the development of a smokeless tobacco cessation program targeted for American Indians (AI) of different tribal nations. The authors gathered formative data from a series of focus groups and interviews to investigate the knowledge, attitudes, and beliefs of AI and smokeless tobacco (SLT) use. Predominant themes emerged from four major topic areas (SLT use, initiation and barriers, policy, and program development) across both studies. This study further assessed educational materials developed for the cessation program for scientific accuracy, readability, and cultural appropriateness. Program materials were scientifically accurate and culturally appropriate. The average corrected reading grade level was 6.3 using the Fry formula and 7.1 using the SMOG formula. Based on this research, a detailed approach to formative research can be used in combination with input from community members to develop health interventions that address health disparities for a specific population.

Smoking in Pregnancy Among Indigenous Women in High-Income Countries: A Narrative Review

INTRODUCTION

Pregnant women in socioeconomically disadvantaged circumstances, such as Indigenous women, have a high prevalence of smoking. Tobacco smoking is the most significant reversible risk factor for the health of Indigenous pregnant women and their babies.

METHODS

As researchers working in this specialized area, we conducted a narrative review of the literature on smoking among Indigenous pregnant women in the United States, Canada, New Zealand, and Australia. We summarize prevalence and factors influencing tobacco use, interventions, and evidence gaps for tobacco control and smoking cessation. Recommendations are made for future interventions, policy changes, and much-needed research.

RESULTS

Common themes emerging across the four countries reveal opportunities for cross-cultural collaborative studies and trials. These include the social-normative use of tobacco as barriers to quitting in pregnancy and the need for evaluations of interventions at the family and community level. Socioeconomic disparities underscore the importance of enhancing the implementation and reach of strategies to prevent and reduce prenatal tobacco smoking among Indigenous women. Elders and community health care providers as role models for nontobacco use could be explored. Qualitative work is needed to understand the barriers and opportunities, such as cultural strengths supporting quitting tobacco to develop more effective approaches.

CONCLUSIONS

Although a high-priority group, there remains a dearth of research on Indigenous women's smoking in pregnancy. Studies have assessed knowledge and attitudes to smoking in pregnancy, and small feasibility studies and a few empirical trials have been conducted. Recommendations for promising culturally appropriate cessation interventions have been made. Larger trials are warranted.

IMPLICATIONS

Strategies to support quitting among pregnant Indigenous women need to be multifactorial and take account of the social determinants of smoking including historical antecedents, community norms, cultural strengths, and recognition of individual and community needs. Cross-country research collaborations have the potential to leverage funding, share expertise, and strengthen approaches to tackle an important and poorly attended health disparity that has a profound impact on the entire life course for Indigenous peoples.

American Indian Tribal College Student's Knowledge, Attitudes and Beliefs about Recreational and Traditional Tobacco Use

INTRODUCTION

American Indians (AI) have the highest smoking rates of any racial/ethnic group in the U.S., in addition to low success rates of tobacco cessation. The substitution of commercial tobacco for traditional tobacco may have played a role in the prevalence rates of recreational tobacco use among AI. The present study explored the impact of tribal college students' knowledge, attitudes and beliefs about traditional tobacco use on their recreational cigarette smoking behaviors.

METHODS

Multiple methods were used to recruit participants attending a tribal college. A total of 101 AI tribal college students completed a demographic survey and participated in focus groups or individual interviews assessing traditional and recreational tobacco use.

RESULTS

AI tribal college student's recreational smoking has an influence on various health behaviors, including poor eating habits, decreased physical activity, and elevated tobacco use in association with alcohol consumption. Differences between the use of and motivation behind smokeless tobacco and cigarette use were seen. In addition, participants reported differences between using tobacco for traditional purposes such as in ceremony or during prayer in comparison to recreational tobacco use. Conclusion: These findings highlight AI students' beliefs about recreational tobacco, smokeless tobacco, and traditional tobacco use. Differences related to behaviors associated with traditional tobacco use have important implications for future cessation efforts for AI smokers.

The Tribal Tobacco Education and Policy Initiative: Findings From a Collaborative, Participatory Evaluation

While the reduction in the overall U.S. smoking prevalence has been declared one of the top 10 public health achievements of the past century, the growing disparity in smoking between American Indians and the general population is one of the biggest challenges of the 21st century. Minnesota in particular has very high smoking rates among American Indians (59%). Tribal Nations in Minnesota share a past of attempted cultural genocide and a present of restoring the strength of their cultural teachings, including the prominence of traditional tobacco as a sacred "first medicine." The Tribal Tobacco Education and Policy initiative works to address this complex and challenging context. This article describes results of a participatory evaluation from 2010 to 2013 in four Minnesota Tribal Nations-three Ojibwe and one Dakota. Tribal Tobacco Education and Policy coordinators used their cultural knowledge to develop community-level strategies, identifying appropriate strategies from best practices on tobacco advocacy, while drawing on the strengths of their own sovereignty and sacred tobacco traditions. Tribal coordinators generated support for policy change by conducting culturally relevant education, engaging tribal members, and nurturing relationships. This approach resulted in norm changes, practices toward restoring traditional tobacco, informal policies, and tribal resolutions to advance smoke-free policies.

Application of the PEN-3 Model to Tobacco Initiation, Use, and Cessation Among American Indian and Alaska Native Adults

American Indian (AI) and Alaska Native (AN) communities confront some of the highest rates of tobacco use and its sequelae. As part of a formative research project investigating stakeholder understandings, preferences, and needs surrounding the use of pharmacogenetics toward tobacco cessation treatment, we sought to characterize sociocultural issues related to tobacco use and cessation. We used the PEN-3 cultural model to frame the research question and analysis of stakeholder interviews with 20 AI/AN patients, 12 health care providers, and 9 tribal leaders. Our study found high knowledge levels of the negative health effects of tobacco use; however, most patient participants ascribed negative health effects only to regular, heavy tobacco use and not to light use, which is more common in the population. The majority of patient participants did not endorse use of tobacco cessation treatment despite evidence of efficacy among AI/AN adults. Health promotion messaging to target low-tobacco consuming AI/AN people is needed. Additionally, messaging to promote tobacco cessation treatment using successful AI/AN former tobacco users to improve community perception of tobacco cessation treatment is recommended.

Why the World Will Never Be Tobacco-Free: Reframing "Tobacco Control" Into a Traditional Tobacco Movement

As successes mount in reducing commercial tobacco use, an alarming disparity has taken shape in Minnesota. Recent studies revealed that overall smoking rates have dropped to 14%, whereas American Indians' rates remain higher than 50%. With support from ClearWay Minnesota, the organization created from the state's tobacco settlement, advocates working within sovereign tribal governments to create smoke-free policies came together to discuss effective strategies within tribal Nations. We discussed the history behind mainstream tobacco control's failure to resonate with Native audiences and the need to reframe the movement to a goal of restoring traditional tobacco practices. We share our insights on this critical area for achieving health equity and provide recommendations for tribes, non-Indian advocates, and funders, with a plea for tribal inclusion in commercial tobacco "end-game" strategies.

Nicotine dependence and psychiatric and substance use disorder comorbidities among American Indians/Alaska Natives: findings from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND

American Indians and Alaska Natives (AI/ANs) have high rates of tobacco use compared to the general population. AI/ANs also have elevated rates of psychiatric and substance use disorders associated with nicotine dependence. However, very few studies have examined the comorbidity between nicotine dependence and psychiatric and substance use disorders within this population.

METHODS

This study analyzes the comorbidity of lifetime nicotine dependence with both current and lifetime psychiatric disorders and substance use disorders in a nationally representative sample of 701 AI/AN women and men.

RESULTS

Using 95% confidence interval testing, lifetime nicotine dependence (29.5%) was associated with all main diagnostic categories (any mood disorder, any anxiety disorder, any personality disorder, any alcohol use disorder, and any drug use disorder) both at the lifetime level and current (12-month) level. Of the lifetime disorders, the strongest associations were with psychosis and drug dependence. For (current) 12-month disorders, the strongest associations were with alcohol dependence and drug dependence. Differences were noted between genders regarding personality disorders.

CONCLUSIONS

Culturally appropriate tobacco screening, prevention, and treatment curricula for adult AI/ANs with dual diagnoses are recommended. Understanding historically based factors that may contribute to psychiatric illness and substance use disorders may assist in more effective nicotine treatments for AI/ANs.

Perceptions, barriers, and suggestions for creation of a tobacco and health website among American Indian/Alaska Native college students

Information concerning American Indian/Alaska Native (AI/AN) Internet use and health information needs is dearth. Our research team explored Internet use among AI/AN college students to determine Internet use in relation to health information seeking behaviors. We used a tobacco site example for participants to describe what they desired in a health site designed specifically for AI/AN. Using a community-based participatory research approach, we conducted 14 focus groups with AI/AN college students (N = 108), to better understand their perceptions of and attitudes toward Internet use and health information needs. Daily Internet use was reported across strata yet health topics investigated differed among groups. Participants in all strata desired a health website that was easy to navigate and interactive. Respectful representation of Native culture was a concern, yet no consensus was reached for a multi-tribal audience. Participants felt a website should use caution with cultural depictions due to the possible misinterpretation. Overall, participants agreed that recreational and traditional tobacco use should be differentiated and the variation of traditional use among tribes acknowledged. Data concerning Internet use for health information among AI/AN college students are needed to establish baseline indicators to effectively address disparities.

Characteristics of American Indian light smokers

INTRODUCTION

American Indians (AI) have the highest smoking rates of any racial/ethnic group in the U.S. and have more difficulty quitting smoking. Little is known about the smoking characteristics of AI smokers. The present study compared the demographic and smoking characteristics of light (≤10 cigarettes per day; N=206) and moderate/heavy (11+ cigarettes per day; N=86) AI smokers participating in a cross-sectional survey about smoking and health.

METHODS

Multiple methods were used to recruit participants in attendance at powwows, health and career fairs, and conferences. A total of 998 AI (76% cooperation rate) completed a survey assessing general health, sociodemographics, traditional and commercial tobacco use, knowledge and attitudes related to cancer, source of health information and care and other health-related behaviors.

RESULTS

AI light smokers were younger and less likely to be married or living with a partner compared to moderate/heavy smokers. AI light smokers were less dependent on smoking and more likely to have home smoking restrictions. There were no differences with respect to number of quit attempts in the past year or the average length of their most recent quit attempt by light vs. moderate/heavy smoking. In addition, a similar proportion of light and heavy smokers reported using tobacco for traditional purposes such as ceremonial, spiritual and prayer.

CONCLUSIONS

These findings highlight important differences between AI light and heavier smokers. Differences related to smoking characteristics such as level of dependence and home smoking restrictions have important implications for the treatment of AI smokers.

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.

Smoke-Free Policies in the Workplace and in the Home among American Indians

OBJECTIVES

American Indians are more likely to smoke, less likely to have smoke-free homes, and potentially less likely to have worksite smoke-free policies. We examined correlates of smoke-free policies at home and work among a community-based sample of American Indians in the Midwest.

METHODS

We examined correlates of smoke-free policies at home and work in a sample of American Indians in the Midwest using a community-based participatory research approach.

RESULTS

66.7% were nonsmokers, 15.6% smoked on some days, and 17.6% smoked every day. The majority (72.4%) had complete smoke-free home policies, 13.1% had partial restrictions, and 14.5% had no rules. Moreover, 62.7% had complete smoke-free worksite policies, 27.9% had partial policies, and 9.4% had no worksite smoke-free policies. Factors associated with having a complete smoke-free home policy included being a college graduate (p=.005) and a nonsmoker versus a nondaily (p=.006) or a daily smoker (p<.001). Correlates of having a complete smoke-free worksite policy included being female (p=.005) and a nonsmoker versus a nondaily (p=.03) or a daily smoker (p<.001). Having complete worksite policies was associated with having smoke-free homes (p<.001).

CONCLUSIONS

Having complete worksite policies was related to having smoke-free home policies; both were associated with being a nonsmoker.

Smoke-Free Policies in the Workplace and in the Home among American Indians

OBJECTIVES

American Indians are more likely to smoke, less likely to have smoke-free homes, and potentially less likely to have worksite smoke-free policies. We examined correlates of smoke-free policies at home and work among a community-based sample of American Indians in the Midwest.

METHODS

We examined correlates of smoke-free policies at home and work in a sample of American Indians in the Midwest using a community-based participatory research approach.

RESULTS

66.7% were nonsmokers, 15.6% smoked on some days, and 17.6% smoked every day. The majority (72.4%) had complete smoke-free home policies, 13.1% had partial restrictions, and 14.5% had no rules. Moreover, 62.7% had complete smoke-free worksite policies, 27.9% had partial policies, and 9.4% had no worksite smoke-free policies. Factors associated with having a complete smoke-free home policy included being a college graduate (p=.005) and a nonsmoker versus a nondaily (p=.006) or a daily smoker (p<.001). Correlates of having a complete smoke-free worksite policy included being female (p=.005) and a nonsmoker versus a nondaily (p=.03) or a daily smoker (p<.001). Having complete worksite policies was associated with having smoke-free homes (p<.001).

CONCLUSIONS

Having complete worksite policies was related to having smoke-free home policies; both were associated with being a nonsmoker.

Best practices guidelines for nurse practitioners regarding smoking cessation in American Indian and Alaskan Native youth

The greatest prevalence of tobacco use in the United States occurs with the American Indian and Alaskan Native (AI/AN). A critical need exists for a culturally specific tobacco cessation option for AI/AN youth. The nurse practitioner is positioned to provide a culturally specific commercial tobacco cessation option by incorporating the transcultural nursing theory into the development of a decision tree to expand understanding of culturally appropriate best practices regarding screening and management of tobacco smoking cessation in AI/AN youth. Presented is the Nurse Practitioner Culturally Specific American Indian and Alaskan Native Youth Decision Tree for Smoking Cessation with supporting evidence-based best practices.