Northwest Tribal Comprehensive Cancer Program October Quarterly Board Meeting 2016 Kerri Lopez

NTCCP Trainings/Activities Clinical Cancer Update 29 participants (2016) CEU accreditation Tribal Tobacco Summit 50 participants (2016) Tobacco Cessation Basic Tobacco Intervention Skills for AI/AN 18 participants (2015) Tribal BRFSS Inflatable Colon "Kiki” Supporting NW Tribal CRC Education Activities Tribal Cancer Plan Implementation Funding Tribal site visits Cancer 101 Development tribal action plan Participation in tribal prevention, screening and education activity Technical assistance Dissemination of resources

Tribal BRFSS– 6 tribes Complete Two Washington In progress One Oregon Two Oregon Randomized phone Census phone Two Washington Door to door In progress One Oregon Census phone Tribal resolution Development of survey materials and IRB application Cowlitz about the be published: brfss cancer screening rates as good as WA state non Hispanic whites even though higher level of poverty Conclusion: screening successful ; tribal operated clinic ; relationship with clinic, community, and tribal leaders Additional project on access to fresh fruits and vegetables 2/28/2018

Northwest Portland Area Indian Health Board Tobacco Cessation Basic Tobacco Intervention Skills Training (BTIST) for Native Communities 5A’s model 6 Modules topics The curriculum was adapted from the standard 5A’s training by IHS Tobacco Control Task Force and the HealthCare Partnership at the University of Arizona. It is designed to be implemented by medical, dental, pharmacy, behavioral health, nursing, and health education professionals within IHS, Tribal, and Urban Indian health programs. The six modules include: Ask, Advise, Assess, Assist, Arrange Module 1: Health Consequences of Commercial Tobacco Module 2: Tobacco Dependence & Treatment Module 3: Tobacco and Culture Module 4: Intervention Essentials Module 5: Putting Your Skills Into ACTION Module 6: Follow-up Interventions 2/28/2018 Northwest Portland Area Indian Health Board

Tribal Implementation Clinic Integration Results From train - trainers 3 month time 50 clinic/admin staff were trained in the 5A’s BTIST Of 50 staff participants 31 staff formed 4 teams With the goal to increase referrals 41 web-base referrals to the quit-line, 366% increase 51 commercial tobacco users agreed to stop smoking 26 clinical staff members level of knowledge increased Brainstormed how to get more referrals – poster boards in the north and south clinic, mailer sent out to one specific provider's patient list who used tobacco related products, article in Tribal newsletter, word of mouth, Tribal facebook page and Tribal TPEP facebook page 2/28/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Other Implementation 1 on 1 cessation counseling Group classes Referrals to another resource for tobacco cessation All clinic staff training (from receptionist to the IT person) 2/28/2018 Northwest Portland Area Indian Health Board

NTCCP Coalition Meeting Navigation and Communication Topics Communication with patients Resources for Survivors Tobacco Cessation Lung cancer screening Other resources: Housing Financial assistance Transportation Resource Fair: Organizations sharing information with tribes (6) 2/28/2018 Northwest Portland Area Indian Health Board

Youth tobacco training Tobacco Facts Tobacco 101 presentation Tobacco vs. Candy Environmental Scan Tool Group discussion Tobacco 101- what is tobacco, History: Traditions to profits, SHS, Dip chew snuff, e-cigarettes, sales, marketing, targeting AI/AN, and concerns 2/28/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board YIKES 2/28/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Rates AI/AN Women 32.5% of AI/AN women smoke 18% of AI/AN women smoke during pregnancy nationally. **** 2003 data 26% of AI/AN women smoke during their last 3 months of pregnancy. 22.3% of AI/AN women in Oregon smoke during pregnancy, in the last 3 months of pregnancy 16.2% 2/28/2018 Northwest Portland Area Indian Health Board

Tobacco Use in Adults Group Use Year Source AI/AN Adults N/A N/A Idaho BRFSS All Adults 15.9% 2014 Idaho BRFSS 35.3% 2013 Oregon BRFSS NHW Adults 21.4% AI/AN Pregnant Women 35.7% 2000-2001 2009 Oregon PRAMS Analysis NHW Pregnant Women 18.5% 36.6% 2012-2014 Washington BRFSS 16.6%

Tobacco Use in Youth Group Use Year Source AI/AN 11th Grade Students N/A N/A Idaho High School YBRS All 11th Grade Students 10.4% 2015 Idaho High School YBRS AI/AN 8th Grade Students 21.9% Oregon Healthy Teens Survey NHW 8th Grade Students 11.3% 40.2% NHW 11th Grade Students 24.8% AI/AN 10th Grade Students 14.1% 2014 Washington Healthy Youth Survey NHW 10th Grade Students 7.7%

Tobacco Related Cancer Disparities Oregon Incidence 2007-2012 Cancer Site AI/AN Age adjusted rate per 100,000 (95% CI) NHW Lung & Bronchus* 84.561 (71.694, 99.424) 60.6 (59.2, 62.0) Esophagus 8.8 (5.0, 14.9) 5.248 (4.8, 5.7) Colorectal 45.7 (36.7, 56.7) 37.8 (36.7, 38.9) Liver & IBD* 12.7 (8.8,18.4) 6.7 (6.3, 7.2) Stomach 6.5 (3.4, 11.8) 4.9 (4.5, 5.2) Pancreas 13.1 (8.4, 20) 11.7 (11.0, 12.3) Kidney & Renal Pelvis 16.3 (11.7, 22.7) 14.6 (13.9, 15.3) Liver & Intrahepatic Bile Duct

Colorectal Cancer Disparities CRC Screening 2012 (ID, OR, WA)1 AI/AN 36.0% (50-75 yo) CRC Distant Staging 2003-2007 (ID, OR, WA)2 AI/AN 23.9% NHW 18.1% CRC 5 yr Survival 1998-2007 (ID, OR, WA)3 AI/AN 0.4727 (0.4190, 0.5338) NHW 0.5627 (0.5627, 0.5825 1 Indian Health Service: 2012 GPRA results 2 Northwest Portland Area Indian Health Board. Cancer Among Northwest American Indians and Alaska Natives. Portland, OR: Northwest Tribal Epidemiology Center, 2011. 3 Petersen, P. S. Colorectal Cancer Survival Among American Indian and Alaska Native People in the Pacific Northwest: A Thesis. Oregon Health & Science University, Portland, OR, 2011.

Northwest Portland Area Indian Health Board E-cigarettes Facts No FDA approved Currently no sufficient evidence to conclude that e-cigarettes are an effective smoking cessation tool. E-cigarette aerosol can contain heavy metals and cancer causing agents E-liquid contains insufficient amount of nicotine levels Most adults who use e-cigarettes also smoke conventional cigarettes, referred as “dual use” Marketing to youth using Big Tobacco tactics and fun flavors Gateway to smoking or using other tobacco products Myths Safe than conventional cigarettes Healthy alternative Does not cause death E-cigarette aerosol is harmless “water vapor” and is as safe as clean air No second hand smoke Little to no nicotine in e-liquid Fun, Cool, Sexy Cannot overdose on nicotine from e-liquids 2/28/2018 Northwest Portland Area Indian Health Board CDC.gov/tobacco

Northwest Portland Area Indian Health Board Youth E-Cigarette use Current use in Oregon 2015 NHW AI/AN 8th grade 8.6% 13.0% 11th Grade 17.9% 27.0% From: Oregon Health Authority, Public Health Division, Health Promotion and Chronic Disease Prevention section. Current tobacco use and related topics among 8th and 11th graders by race and ethnicity, Oregon 2015. https://public.health.oregon.gov/DiseasesConditions/ChronicDisease/DataReports/Pages/YouthData.aspx. 2/28/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Adult E-Cigarette use Current use in USA 2014 NHW AI/AN ever tried 14.8% 20.2% currently use 4.6% 10.7% From: Nguyen KH, Marshall L, Brown S, Neff L. State-Specific Prevalence of Current Cigarette Smoking and Smokeless Tobacco Use Among Adults — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:1045–1051. DOI: http://dx.doi.org/10.15585/mmwr.mm6539a1 2/28/2018 Northwest Portland Area Indian Health Board

Current Policy Work in Tribal Communities Tribal Admin-Community Campus Health Clinic Education Gathering Space Events & Gatherings Tribally Run Businesses Tribal Housing External Partners 2/28/2018 Northwest Portland Area Indian Health Board

Cancer Challenges - Multifaceted High need for Cancer Resources in AI/AN communities Geographic Isolation Independent Healthcare Systems Low Health Literacy Patient ― Provider Communication Screening – referrals Screening rates for paps and mams going down After care for cancer survivors in tribal community Economic Impact $2,701/person vs $5,841/person (2010 IHS vs 2008 Medicaid) www.ncai.org/resources/ncai-publications/indian-country-budget-request/FY2013_Budget_Health_Care.pdf 2/28/2018 Northwest Portland Area Indian Health Board

NTCCP Tools and Resources Twenty Year Northwest Tribal Comprehensive Cancer Control Plan Northwest Tribal Cancer Resource Guide Cancer 101 Cancer Fact Sheets Appointment Companion Tribal Cancer Action Planning Evaluation of Cancer 101: An Educational Program for Native Settings. Hill TG, Briant KJ, Bowen D, Boerner V, Vu T, Lopez K, Vinson E. J Cancer Educ. 2010 Feb 10.  The past, present, and future of comprehensive cancer control from the state and tribal perspective. Miller SE, Hager P, Lopez K, Salinas J, Shepherd WL. Prev Chronic Dis. 2009 Oct;6(4):A112.  Cancer Care of American Indians and Alaska Natives and Other Racial Groups Enrolled in Public and Private Insurance Plans. Ramsey S, Zeliadt S, Blough D, Lopez K, Buchwald D. Poverty & Public Policy. 2010 Vol. 2: Iss. 1, Article 3.

Tools and Resources Cont. Tribal Tobacco Policy Workbook Northwest Tribal Colorectal Cancer Screening Toolkit Second Wind Curriculum NPAIHB Tribal Profiles State level Multiple Presentations E-Cigarettes, Pregnancy & smoking, Cancer Resources, Cancer Survivor support group support and Cancer Action Planning Multiple factsheets HPV, Tobacco, SHS, E-cigarettes, Smoke-free Homes, etc. 2/28/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board NTCCP Staff Kerri Lopez; NTCCP Project Director Eric Vinson; NCCP Coordinator Antoinette Aguirre; Cancer Prevention Coordinator Ryan Sealy; WEAVE NW Tobacco Specialist 2/28/2018 Northwest Portland Area Indian Health Board