Kristine Rhodes, M.P.H. Jean Forster, Ph.D. University of Minnesota School of Public Health For the American Indian Community Tobacco Project Steering Council September 7, 2007 Patterns of Tobacco Use Among American Indians in Minneapolis-St. Paul

AICTP Steering Council

Describe urban Indian history and current status as context Describe difference between traditional, spiritual and addictive uses of tobacco Define need for different research paradigm CBPR, Reality-Based Research Illustrate their application in the AICTP Present AICTP results to date Describe how the research findings = action Goals for This Presentation

 Pre-colonization history  Post-colonization history  Assimilation/eradication  Termination of federal responsibility  Relocation  Self-determination Twin Cities Urban Indian Population

Current situation:  33,000 American Indians in Twin Cities  41% of Minnesota Indian population  35% households in poverty  High unemployment rate  Low high school graduation rate  Inadequate health care

Asema or Cansasa Broadleaf Tobacco Photo Source: Wikipedia.com Nicotiana tabacum Snuff Pipe Red willow “kinnickinick” Shell for Smudging Nicotiana rustica Traditional Tobacco Use Asema, Cansasa, Kinnickinick

High rates of addictive smoking Upwards of 50% High rates of related health problems Cancer, especially lung cancer Cardiovascular disease Diabetes Little useful information Actual rates of smoking Why American Indians smoke more American Indian-specific prevention Recreational Tobacco Abuse

Methodological, conceptual flaws limit usefulness of existing research Distrust between University and American Indian community We need a different research paradigm…

Dominant research paradigm  problematizes Indigenous culture  takes research findings out of context  generates knowledge for its own sake  doesn’t reflect the knowledge of Indigenous community Decolonizing Methodologies: Research and Indigenous Peoples Linda Tuhiwai Smith, Maori education specialist University of Auckland

Recognizes the community as basic unit Builds on community strengths, resources Facilitates partnership in all phases of research Integrates knowledge, action for mutual benefit Community-Based Participatory Research Incorporates aspects of Indian culture Uses research methods culturally appropriate Involves American Indians in all aspects of research Reality-Based Research - John Poupart

Predominantly American Indian Final authority on all aspects of the research Research questions Protocols and instruments Data collection Analysis and interpretation Dissemination and action Opportunities to participate in all phases Financial resources shared Monthly working meetings AICTP Steering Council

What are the cultural strengths of the Twin Cities American Indian community? What are the tobacco-specific issues? How could cultural strengths address these tobacco issues? Research Questions

Elder talking circles In-person structured interviews of adults School-based surveys of youth Community reaction/ interpretation Dissemination Community Scientific Research Plan

Four talking circles in Minnesota Snowball recruitment Led by American Indian elder Community locations (2 urban and 2 reservation) Incentives: Meal and cash Opportunity to respond to summary findings before finalized & distributed Elder Talking Circles

Encourage parents to lead by example Develop & offer better cessation assistance Creative community-wide education More smoke-free areas & events Promote traditional tobacco teachings & use Increase access to traditional tobacco Elder Talking Circles - Summary

Flier, The Circle ad, referrals N=300 Ages 18-74, reflecting population age, gender distribution Administered by Native SC members Community locations $25 gift card Reaction talking circles Adult Interviews

Tribal Affiliation Anishinabe/Ojibwe 70% Dakota/Lakota 19% Ho-chunk 2% Other 9% Arapaho, Blackfeet, Chickasaw, Menomonie, Navajo, Northern Cheyenne, Omaha, Oneida, Ponca, Seneca, Southern Cheyenne, Three Affiliated Tribes Age Distribution years21% years20% years26% years15% years12% 65+ years 7% Gender Female53% Male47% Participant Characteristics (N=300)

Overall80.3% Female85.9% Male74.0% Never smoker90.3% Former smoker87.3% Current smoker75.5% Traditional/Spiritual Tobacco Use

Smoking Status (N=300) Current 62% Former 26% Never 12%

51.7% among Native Americans in Minnesota (reported) 40.4% among Native Americans in U.S. 21.1% among general population in Minnesota Compared to…

Age Smoking Status by Age (N=300)

Desire to Quit (N=186)

Tried to quit 6+ times (83%) Tried to quit times (69% vs. 42%) Smoke-free home (82% vs. 61%) Someone close is upset about their smoking (64% vs. 47%) Tried to quit in past year (64% vs. 28%) Who REALLY want to quit?

Length of Most Recent Quit Attempt Among Current Smokers (n=186)

Total N=77 Less than 1 month10.4% Between 1 month and 1 year18.2% More than 1 year71.4% Time Since Last Cigarette, Former Smokers

Former Smoker N=77 Current Smoker* N=126 Health reasons48.0%78.6% Pregnancy (women)12.8%1.6% Dislike smoking15.6%6.3% Family6.5%3.2% Practice traditional ways3.9%0 Too expensive1.3%5.6% *Among those who want to quit Main Reason for Quitting

Knowledge of Cessation Resources in the Indian Community (n=300)

78% Quit on my own 61% Talk to a doctor or nurse 59% Try medications 57% Read a book or pamphlet 56% Talk to a spiritual advisor 42% Ask friends/ family for help 38% Try acupuncture 32% Attend a stop smoking program 23% Call a quit smoking hotline 16% Go to a quit smoking website Desired Cessation Assistance

Men more willing to: just quit on their own - 85% vs. 71% Women more willing to: call a quit line - 32% vs. 13% visit a website - 20% vs. 11% try acupuncture - 50% vs. 26% Ways to quit…differences by gender

year-old smokers less willing to: talk to a doctor or nurse - 35% vs. 61% Ages 55+ more willing to : attend a smoking cessation program/group - 52% vs. 32% Ages 55+ less willing to: ask friends/ family for help - 20% vs. 42% just quit on own - 56% vs. 77% Ways to quit…differences by age

Talk to kids about the dangers of smoking Lead by example, be a good role model and don’t smoke around children Teach kids about traditional tobacco Get kids involved in positive activities Parents set no smoking rules for their kids Parents quit smoking first Offer more school programs about tobacco Adult Recommendations

Youth Survey N=388 American Indian youth year-olds Paper and pencil Surveys administered by AICTP staff Recruitment St. Paul Schools Minneapolis A.I. youth programs Participant and school/program incentive

Participant Characteristics Tribal Affiliation Anishinabe/Ojibwe58% D/L/N akota40% Ho-Chunk5% Diné1% Other:5% Age Distribution 11 or younger9.5% 129% 1313% 1417% 1521% 1615% 1710% 18 or older5% Gender Female: 50.3% Male: 49.7%

Youth: Traditional Tobacco Use How often do you use tobacco for ceremony, prayer or traditional reasons? N=213 (64%) Daily 5% Weekly13% Monthly15% A few time per year or less66% What type of tobacco do you usually use for ceremony, prayer or traditional reasons? Native tobacco38% Pouch/packaged36% Cigarettes14% Other12%

Youth Smoking Status by Age

Youth Smoking Status by Type of Tobacco Used for Spiritual Use

Youth Smoking Status by Perceived Parental Attitude

Parents talk to kids about the dangers of smoking Parents set no smoking rules for their kids Get youth involved in other activities Offer more education on the dangers of smoking Teach kids about traditional tobacco Stop selling cigarettes Youth Recommendations

Website: Share results with community Community events Presentations to community groups Data reports for community Newspaper reports, paid ads Co-author scientific papers Intervention development Next Steps for the AICTP Partnership

High spiritual use of tobacco Widespread acknowledgement of problem Strong belief in community’s role to solve Importance of children to community Change in social norms around alcohol use Cultural Strengths of Urban American Indian Community