Native American Tobacco Education Project (NATE) Funded by a grant from the CDPHE State Tobacco Education and Prevention Partnership (STEPP)

Partners Native American Cancer Research (NACR) Ute Mountain Ute Tribe

NACR Staff Dr. Burhansstipanov - Project Director Lisa Harjo - Project Coordinator Terri Rattler - Native Sister Rose Lee - Native Sister (Navigators)

Native American Tobacco Education (NATE) Multi-Agency project using Community-Based Participatory Research (CBPR) methodology to develop a sustainable infrastructure for the local tobacco control movement in the Indian community in Denver and at Ute Mountain Ute.

Two Advisory Coalitions one in the Denver Metropolitan Area one within Ute Mountain Ute Reservation.

Purpose to develop an infrastructure that will allow both Native communities to assess local needs and potential strategies to prevent and reduce habitual tobacco use or exposure to secondhand smoke by Native American adolescents and adults, ages 12 to 85.

Expected Outcomes (1)two functional Native Tobacco Coalitions (one in each site) (2)baseline data from local focus and working groups to help the Coalitions prioritize issues; and

Expected Outcomes cont. (3)a list of recommendations based on the focus and working group input by the respective Coalitions for tribal- and geographically-specific tobacco interventions they feel need to be developed in the near future to appropriately address the priorities in culturally respectful manners.

NATE Project Goal To increase Native communities’ capacity for tobacco control by developing two well educated Native American Tobacco Education Coalitions in Denver and Ute Mountain Ute Reservation.

Strategy 1 Educate both of the Native tobacco control coalitions on the latest, most appropriate tobacco prevention and control information and interventions effective within Native and non-Native communities (includes evidence– based and native-specific strategies.)

Strategy 2 The NATE Coalitions will each recruit community members to take part in FG held in March and April in two different geographic locations in their respective communities (4 FG in Denver and 2 FG in Towaoc).

Strategy 3 The NATE Coalition from each site will review the expanded prioritized tobacco topics for their respective area (i.e., two different priority lists which are likely to have some overlap, yet issues specific to the rural or urban communities) and organize the priorities into a strategic plan.

Strategic Plan This strategic plan will include (a) goals for next 3 years; (b) measurable objectives to attain those goals; (c) culturally acceptable and innovative strategies to attain the objectives;

Strategic Plan cont. (d) participant interactive activities to reinforce the behaviors specified within each objective; (e) evaluation strategies specific to each objective; and (f) dissemination of recommendations plan (to local communities, State funders and others as needed).

Strategic Plan This outline will be the beginning of a strategic plan for subsequent funding to develop interventions inclusive of these components that are culturally specific and designed to prevent, reduce, or control habitual tobacco use among Native Americans.

Advisory Coalition Meets every other month for 2 hours Training in beginning and during project. Provides guidance and leadership during gathering of information from community, and development, implementation and dissemination of the plan to the community Continues with Project during subsequent funding to provide leadership

Focus Groups Conducted to gather more information directly from community members Four groups in each site: 2 all ages, 1 youth, and 1 elders. Questions from TAB and Coalition and 2-3 discussion questions 2 hours in duration, 8 participants, $20 each

Overview of Training Ceremonial tobacco use vs. habitual tobacco use Strategies for teambuilding Tobacco Initiatives in Indian Country Stages of Change in and out of Indian Country Tobacco Facts and Fallacies in Indian country

Overview of Training cont. Overview of AIAN Tobacco Surveys Social Norm Strategies ARS – Audience Response System

Second Phase Goal: To continue the work established in the First Phase and add new levels of focus.

Second Phase Strategy 1: Maintenance of a community advisory coalition and expanded partners to guide development, field testing, and implementation efforts for all age groups and sectors in the American Indian Community regarding Tobacco Control.

Second Phase Strategy 2: Develop, refine, and implement age-specific culturally appropriate tobacco use interventions will reduce second hand smoke (SHS), reduce first time starts with tobacco, and increase cessation activities among American Indians.

Second Phase Strategy 3: Develop Native- specific anti-habitual tobacco use messages that can be used in public awareness campaigns to help initiate community members' consideration of new ideas, behavior, and actions.

Second Phase Strategy 4: QUITLINE and QUITNET (Native Adults) Determine cultural appropriateness and sensitivity of the proposed tobacco interventions, especially telephone counseling.

Second Phase Strategy 5: Policy is an essential component of a comprehensive Tobacco Control Movement as it creates environments and opportunities for new behaviors and actions.

Successes Sustainable Infrastructure for Tobacco Control Initiatives – Capacity-Building Tribal and Native Tobacco Policy and Movement Training Youth Intervention for Tobacco exposure reduction and cessation

Colorado Quitline Established a relationship for future work Participated in cultural competency training……. Critiqued Cultural Training Established plan to improve cultural sensitivity training for providing support to American Indian callers.

Challenges Lack of knowledge and experience in the American Indian tobacco control movement. remedied by training and networking at regional Indian tobacco control leadership workshops and seminars.

Challenges Continued competition for the attention of Indian people who smoke. remedied by interventions that are fun and based on some traditional beliefs and practices.

Challenges Ute Mountain Ute Tribe – Working with a tribal nation yielded several challenges that continue to be addressed including:

Challenges Lack of support for the program – Low priority in relationship to other efforts related to education, employment, health, tribal business, etc. Lack of internal stability and coordination with tribal program leadership changes and facility limitations.

Challenges Lack of participation in the advisory council by tribal program representatives and leaders.

Responses The NATE staff at both locations worked to recruit and keep participants in the Ute Advisory Council to provide leadership and support to the program.

Responses Actions taken: The NATE Program worked to take the Advisory Council members including a Ute Mountain Ute Tribal council person to training with other Tribes and Indian people to uplift the issue and educate them on what other tribes are doing and how their efforts can help their community.

Responses NATE staff raised the issue of changing and limited office space to the Tribe on many occasions.

Results NATE staff in Denver provided on-going training to the Ute Mountain Ute staff on the ARS, tobacco control issues, and other topics to support the program in their efforts to get the community involved and participating in the program.

Results The NATE staff in Ute Mountain Ute now has a permanent office and is housed in the Substance Abuse Program.

Future Activities… Sustain Advisory Council Pilot and implement Youth Intervention Promote SHS Reduction and Prevention Strategies including personal policy development Work with Quitline-established cessation program Create culturally sensitive media

Preliminary NATE “Survey” findings  Survey Items Evolved from: oCO TAB instrument oNative American Tobacco Prevention Network (survey tools) oNational Health Interview Survey (2 items) oCalifornia Health Interview Survey o4 National Cancer Institute Native tobacco surveys oNATE Coalition Guidance

 Includes NATE Coalition and focus group (FG) data from both Denver and Ute Mountain Ute Tribe (FG still in process)  Different numbers of responses on selected items as the items were refined to be culturally acceptable to the Native community members  Administered via ARS Preliminary NATE “Survey” findings

Examples of Preliminary NATE “Survey” findings  “Preliminary Data” Comprise total of o52 Denver Natives o25 Ute Mountain Ute Tribal Members  Examples of demographics: o~41% males o~59% females Typical tobacco survey breakout in Indian Country is ~75% respondents are female

Examples of Preliminary NATE “Survey” Demographics DenverUte Mt. Ute N=52 answered the item 21 males (40.4%) 31 females (59%) N=21 answered the item 8 males (30.3%) 13 females (60.7%) Gender

Examples of Preliminary NATE “Survey” Demographics DenverUte Mt. Ute 52 (n=53; 98.1%) 15 (n=17;88%) American Indians The number of people who answered the item

Examples of Preliminary NATE “Survey” Demographics DenverUte Mt. Ute 27 (n=53; 50.9%)15 (n=17;88%) High school or less education

Examples of Preliminary NATE “Survey” Demographics DenverUte Mt. Ute 9 (n=29; 31%)17 (n= ; 62.4%) Primarily raised on reservation

Examples of Preliminary NATE “Survey” Tobacco Behaviors DenverUte Mt. Ute 24 (n=36; 52.2%)8 (n=23; 35.4%) Use tobacco for ceremonies

Examples of Preliminary NATE “Survey” Tobacco Behaviors DenverUte Mt. Ute 27 (n=44; 61.4%)13 (n=23; 55%) Not smoke at all

Examples of Preliminary NATE “Survey” Tobacco Behaviors DenverUte Mt. Ute 17 (n=45; 37.8%)11 (n=24; 47.8%) Yes, smoke when drink alcohol

Examples of Preliminary NATE “Survey” Tobacco Behaviors DenverUte Mt. Ute 41 (n=45; 91.10%)26 (n=26; 100%) Not use chew at all

Examples of Preliminary NATE “Survey” Tobacco Behaviors DenverUte Mt. Ute 30 (n=36; 83.3%)18 (n=26; 67.5%) Never allow smoking in home Allow smoking in home only for special people 1 (n=36; 2.8%)4 (n=26; 16.3%)

Examples of Preliminary NATE “Survey” Tobacco Behaviors DenverUte Mt. Ute 21 (n=45; 46.7%)12 (n=27; 43.5%) No habitual smoking in home at any age

Examples of Preliminary NATE “Survey” Tobacco Behaviors DenverUte Mt. Ute 22 (n=45; 48.9%)11 (n=27; 40.6%) No smoking or chewing in home <18 years

Examples of Preliminary NATE “Survey” NHIS DenverUte Mt. Ute 29 (n=45; 64.4%)16 (n=25; 63.3%) Yes, always wear seat belt Strong correlation between consistent seat belt use and likelihood of adhering to tobacco cessation

Examples of Preliminary NATE “Survey” Tobacco Cessation DenverUte Mt. Ute 30 (n=37; 81.1%)22 (n=22; 100%) Culturally Appropriate Tobacco Quit Programs (“none”, “none that I know of”, “don’t know”)

Examples of Preliminary NATE “Survey” Tobacco Cessation DenverUte Mt. Ute 27 (n=45; 60%)18 (n=30; 57.5%) Yes, I’ve heard of CO Quitline / Quitnet

NATE Staff Lisa Harjo, MA [Choctaw] Terri Rattler [Oglala Lakota] Rose Lee [Navajo] Linda Burhansstipanov [Cherokee] Native American Cancer Research 1835 Franklin Street Denver, CO phone: fax: Native Cancer Survivors' Support Network: web page: What is NATE? NATE is the Native American Tobacco Education Project. It is a community-based initiative to raise awareness in the Denver American Indian community about tobacco. The NATE project is coordinated through Native American Cancer Research (NACR). It is funded through a grant from Colorado’s State Tobacco Education and Prevention Partnership (STEPP) Respect Tobacco Denver, Colorado September 2006 Youth / Children

Based on the responses of the American Indians who participated in the Focus Groups and surveys: 41% first tried tobacco between 14 and 16 years of age 68% were introduced to tobacco by their friends or peers 33% began using tobacco habitually before 20 years of age 57% believe that enforcement for minors is not adequate 87% believe that store owners should have a license to sell tobacco 62% of youth believe that enforcement for minors is not adequate 13% of youth currently smoke tobacco daily What we Learned from our Community 12% of youth use tobacco with alcohol two times a week or less 25% of youth were exposed to second hand smoke in their home What they said “I thought it was cool … every movie you went to, someone was blowing smoke … it looked sophisticated.” “My boyfriend got me to smoke. He was always smoking cigarettes and he said come on, smoke a cigarette… So, I smoked a cigarette. Now I’m hooked.” “Our coach used to smoke … Wow, a coach is smoking and this guy is athletic and everything.” Focus Groups and Surveys NATE conducted a series of Focus Groups and surveys in the Denver Metro Area with American Indian people of all ages during the Spring and Summer of 2006 to learn more about attitudes, beliefs, and behaviors related to tobacco. Who Participated? 59 American Indians who reside in Denver, CO 40% males 60% females

NATE Staff Lisa Harjo, MA [Choctaw] Terri Rattler [Oglala Lakota] Rose Lee [Navajo] Linda Burhansstipanov [Cherokee] Native American Cancer Research 1835 Franklin Street Denver, CO phone: fax: Native Cancer Survivors' Support Network: web page: What is NATE? NATE is the Native American Tobacco Education Project. It is a community-based initiative to raise awareness in the Denver American Indian community about tobacco. The NATE project is coordinated through Native American Cancer Research (NACR). It is funded through a grant from Colorado’s State Tobacco Education and Prevention Partnership (STEPP) Respect Tobacco Denver, Colorado September 2006 Ceremonial Use

What we Learned from our Community How is Traditional Tobacco Used? Focus Groups and Surveys NATE conducted a series of Focus Groups and surveys in the Denver Metro Area with American Indian people of all ages during the Spring and Summer of 2006 to learn more about attitudes, beliefs, and behaviors related to tobacco. Who Participated? 59 American Indians who reside in Denver, CO 40% males 60% females Based on the responses of the American Indians who participated in the Focus Groups and surveys: 60% use tobacco for ceremonial purposes 45% use traditional, non- commercial tobacco for ceremonial purposes Over 50% of American Indians use both traditional tobacco and commercially prepared tobacco for ceremonial purposes 47% use tobacco for non- ceremonial purposes For healing with headaches, fevers, chills, earaches and other illnesses For pain relief from childbirth pains, headaches, and toothaches For relief from symptoms of asthma, stomach aches, and rheumatism As a remedy for wounds As a bug repellant To honor and welcome guests To communicate with the Creator To bind agreements To bless events, buildings, homes, and people

NATE Staff Lisa Harjo, MA [Choctaw] Terri Rattler [Oglala Lakota] Rose Lee [Navajo] Linda Burhansstipanov [Cherokee] Native American Cancer Research 1835 Franklin Street Denver, CO phone: fax: Native Cancer Survivors' Support Network: web page: What is NATE? NATE is the Native American Tobacco Education Project. It is a community-based initiative to raise awareness in the Denver American Indian community about tobacco. The NATE project is coordinated through Native American Cancer Research (NACR). It is funded through a grant from Colorado’s State Tobacco Education and Prevention Partnership (STEPP) Respect Tobacco Denver, Colorado September 2006 General Information

What we Learned from our Community Based on the responses of the American Indians who participated in the Focus Groups and surveys: 41% currently smoke cigarettes 6% currently chew tobacco 38% smoke tobacco when they drink alcohol 58% have smoked more than 100 cigarettes in their life 41% first tried tobacco between 14 and 16 years of age 68% were introduced to tobacco by their friends or peers % began using tobacco habitually before 20 years of age 60% use tobacco for ceremonial purposes 45% use traditional, non- commercial tobacco for ceremonies 18% allow smoking in their home 26% stated a desire to quit smoking 57% believe that enforcement for minors is not adequate 87% believe that store owners should have a license to sell tobacco Focus Groups and Surveys NATE conducted a series of Focus Groups and surveys in the Denver Metro Area with American Indian people of all ages during the Spring and Summer of 2006 to learn more about attitudes, beliefs, and behaviors related to tobacco. Who Participated? 59 American Indians who reside in Denver, CO 40% males 60% females What people said “I don’t think Indians want to quit smoking” “I think tobacco isn’t a risk for us (American Indians) because it was a gift to us from the Creator

NATE Staff Lisa Harjo, MA [Choctaw] Terri Rattler [Oglala Lakota] Rose Lee [Navajo] Linda Burhansstipanov [Cherokee] Native American Cancer Research 1835 Franklin Street Denver, CO phone: fax: Native Cancer Survivors' Support Network: web page: What is NATE? NATE is the Native American Tobacco Education Project. It is a community-based initiative to raise awareness in the Denver American Indian community about tobacco. The NATE project is coordinated through Native American Cancer Research (NACR). It is funded through a grant from Colorado’s State Tobacco Education and Prevention Partnership (STEPP) Respect Tobacco Denver, Colorado September 2006 Quitting

What we Learned from our Community Based on the responses of the American Indians who participated in the Focus Groups and surveys: 41% currently smoke cigarettes 6% currently chew tobacco 38% smoke tobacco when they drink alcohol 58% have smoked more than 100 cigarettes in their life 26% stated a desire to quit smoking 18% would use the Cold Turkey method of quitting without help or counseling 33% began using tobacco habitually before 20 years of age Focus Groups and Surveys NATE conducted a series of Focus Groups and surveys in the Denver Metro Area with American Indian people of all ages during the Spring and Summer of 2006 to learn more about attitudes, beliefs, and behaviors related to tobacco. Who Participated? 59 American Indians who reside in Denver, CO 40% males 60% females 64% were not aware of tobacco quitting programs in the Denver American Indian community 60% had heard of the Quitline or Quitnet ( QUIT) or 91% have never contact the Quitline or Quitnet 26% stated that they would like to quit using tobacco in the next six months 97% were aware of the harm second hand smoke can cause to children and youth, homes, and people

Pregnant females who smoke increase their chances of having a low birth weight baby by up to 39% CO Quitline “Tobacco Use in Colorado” fact sheet, October 2001 Smoking during pregnancy “Facts” Low birth weight may cause stillbirths and newborn deaths. CO Quitline “Tobacco Use in Colorado” fact sheet, October 2001

Within 20 minutes of quitting, blood pressure and pulse rate decrease. Most Smokers regret the day they started smoking. CO Quitline QUIT or Benefits of Quitting “Facts” Within 8 hours of quitting, carbon monoxide and oxygen levels in the blood return to normal. Most Smokers regret the day they started smoking. CO Quitline QUIT or Within 1 day of quitting, the likelhood of heart attack decreases. Most Smokers regret the day they started smoking. CO Quitline QUIT or

Within 2 days of quitting, nerve endings regenerate; sense of smell and taste improve. Most Smokers regret the day they started smoking. CO Quitline QUIT or Benefits of Quitting “Facts” Within 2 weeks, circulation improves and lug function increases. Most Smokers regret the day they started smoking. CO Quitline QUIT or After quitting for 1-9 months, coughing, sinus congestion, fatigue and shortness of breath decrease. Most Smokers regret the day they started smoking. CO Quitline QUIT or

Within 1 year of quitting, the likelihood of heart attack is cut in half. Most Smokers regret the day they started smoking. CO Quitline QUIT or Benefits of Quitting “Facts” Within 5 years of quitting stroke risk is reduced to the same levels as a non- smoker.. Most Smokers regret the day they started smoking. CO Quitline QUIT or

Within 10 years of quitting, risk of dying from lung cancer is about half that of a current smoker. Most Smokers regret the day they started smoking. CO Quitline QUIT or Benefits of Quitting “Facts” Within 15 years of quitting, risk of coronary heart disease and death become roughly equivalent to those who have never smoked. Most Smokers regret the day they started smoking. CO Quitline QUIT or