For American Indians, a way to quit smoking without forsaking traditional tobacco

November 30, 2012

By C.J. Janovy

Julia White Bull

Smoking is a health hazard — there's no debate about that. For many American Indians, however, tobacco is central to sacred traditions — so giving it up complicates the already difficult matter of kicking an addiction. And with American Indians experiencing the highest number of smoking-related deaths per capita, the need is urgent. Thanks to programs developed by researchers at the University of Kansas Medical Center and the American Indian Health Research & Education Alliance, American Indians are finding it easier to quit smoking without forsaking their culture.

In 2004, researchers from KU Medical Center joined colleagues at the Oklahoma Area Indian Health Services and focus-group representatives from more than 20 Indian nations to address the issue. At the time, several efforts to create smoking-cessation programs for Native populations around the country had been tried with varying results, and none had been scientifically tested. The collaborators developed a new program based on several cessation programs available throughout the country. Among other things, focus-group participants had emphasized the importance of family and respect for elders, so researchers knew they needed to include relatives for support and elders as authority figures who could speak on traditional tobacco use.

In the years that followed, researchers created a program called All Nations Breath of Life and designed a five-year study to see how well it worked. Approximately 500 people have now gone through the program. Research teams finished gathering data in October, and though it will take months to analyze the results, preliminary data shows that the program is working: In a trial of more than 300 people, the quit rate at six months was 37 percent, compared to the 8-10 percent quit rate for American Indians using other programs.

Saying "goodbye" to tobacco

"I smoked one pack a day for 14 years — from the age of 13 to 27," says Julia White Bull, who began attending All Nations Breath of Life groups in 2009, as a student at Haskell Indian Nations University. It's taken more than one try, but she has now been smoke-free for more than a year.

"We do know some things already," says Charlotte McCloskey, Ph.D., a clinical assistant professor in KU Medical Center's Department of Family Medicine, who has been a project manager on the trial. "We know that people enjoy coming together for something that's really hard to do."

Participants meet in small groups nine times over 14 weeks, forming a support network in the process. Medical help from nicotine patches, gum or the smoking cessation drug Chantix is free for those who request it. And there are smaller incentives such as water bottles or stress balls. "If you see one on your desk, that will at least give you a reason to pause before smoking," McCloskey notes.

Also, McCloskey says, "We know that people feel respected. We separate commercial, habitual use of tobacco from traditional, ceremonial tobacco use. We have a ceremony when someone says goodbye to their tobacco use. In one session, the family is invited in for a meal, because we know that the actions of one person in a family affect all."

That approach resonated for White Bull. "The meetings were very motivating and encouraging," she says. "Knowing that there were other people on the same path as we were — they smoked the same amount, they struggled with health issues. Every time we saw each other we would encourage each other not to smoke."

After her college experience with All Nations Breath of Life, White Bull applied for an internship at KU Medical Center's Center for American Indian Community Health (CAICH). The center was created after the National Institutes of Health awarded KU Medical Center a $7.5 million grant in 2010. Led by principal investigator Christine Daley, Ph.D., an associate professor in the Department of Family Medicine, the center works to close health disparities in rates of cancer, diabetes and other health issues, while honoring American Indians' unique cultural framework.

After her internship with the center, White Bull joined the center's staff and has helped others quit smoking.

"After I quit, I started running, changed my routine, changed my diet and started facilitating a group. It was good to share my story with them — that I'd smoked a pack a day for 14 years and was a successful quitter. That was encouraging to them," White Bull says.

A program in demand

"What we are doing is radically different from what has been provided via the American Lung Association and the American Cancer Society," McCloskey explains. "Those are good programs, but they're clinical and fear-based, which doesn't help us. We cover the risks of smoking, of course, but when we got together with our focus groups in the community, we saw the difference between our ways of understanding tobacco versus 'Quit because it's bad for you.'"

When a smoker begins the program, facilitators take saliva samples, testing for cotinine to determine nicotine levels. They test again at the end of the 14 weeks, then follow up after six months and one year. "I'd love to tell you that everyone who's come through the program has quit smoking. They don't," McCloskey says. "It's a process for everyone."

But the process is more difficult for American Indians, who have a higher rate of smoking — but less success quitting — compared to other ethnic groups.

All Nations Breath of Life is now starting to roll out in other cities, including Denver and Dallas, and on several reservations. McCloskey says as many as 30 groups have started up around the country.

Rachel Simpson, M.A., a researcher with the Centers for American Indian and Alaska Native Health at the University of Colorado's Anschutz Medical Campus, saw a flier for All Nations Breath of Life on a table at the Denver March Powwow, one of the largest and best-known powwows in the nation. 

"I thought, 'Wow this is something we could really use," says Simpson, who also serves on the board of directors of the Denver Indian Health and Family Services clinic. She contacted McCloskey, who then traveled to Denver with White Bull to train Simpson and other community health educators in the program.

Groups started meeting at Denver Indian Health and Family Services and the Rocky Mountain American Indian Chamber of Commerce in January 2012, and Simpson says she's been surprised at the response. "We had almost 100 percent attendance at every session," she says. "I work in research, I see a lot of different studies, and I know it's hard to get people motivated to come to weekly meetings. But our people were passionate about coming to their weekly meetings."

Other programs are available to help smokers who want to quit, Simpson says, but this one is different. "This was deeply meaningful, and really hit at something that's just so important to people, which is our Native identity. Because we're an urban clinic it can be a little tougher to stay connected to our Native communities. This program helped people to deepen their connections and identity, and that helped them to overcome their addiction to commercial cigarettes."

As word gets out, Simpson says, the Denver center has been hearing from people who want to know when the next group starts. "We're seeing lots and lots of demand, much more than for other programs," she says. "It's fascinating because this program is so much more intense. It's hard for people to go to weekly meetings — to set up child care, transportation. For people to be so dedicated that they're willing to show up every week — that's impressive."

As the research teams begin analyzing the data, they're also looking at how well the program has worked on reservations, including its effectiveness when delivered via televideo to extremely rural reservations.

"So many people who are dying don't need to," McCloskey says. "We want to do something that helps."

Last modified: Dec 26, 2012