Risk and Promotive Factors Related to Cannabis Use Among American Indian Adolescents.

Reservation-dwelling American Indian adolescents are at exceedingly high risk for cannabis use. Prevention initiatives to delay the onset and escalation of use are needed. The risk and promotive factors approach to substance use prevention is a well-established framework for identifying the timing and targets for prevention initiatives. This study aimed to develop predictive models for the usage of cannabis using 22 salient risk and promotive factors. Models were developed using data from a cross-sectional study and further validated using data from a separate longitudinal study with three measurement occasions (baseline, 6-month follow-up, 1-year follow-up). Application of the model to longitudinal data showed an acceptable performance contemporaneously but waning prospective predictive utility over time. Despite the model's high specificity, the sensitivity was low, indicating an effective prediction of non-users but poor performance in correctly identifying users, particularly at the 1-year follow-up. This divergence can have significant implications. For example, a model that misclassifies future adolescent cannabis use could fail to provide necessary intervention for those at risk, leading to negative health and social consequences. Moreover, supplementary analysis points to the importance of considering change in risk and promotive factors over time.

The relationship between depressed affect, parental monitoring, and sex on cannabis use among American Indian youth.

BACKGROUND AND OBJECTIVES: American Indian (AI) adolescents report higher rates of cannabis use than national US adolescents. Previous study examined interactive relationships between depressed affect and family factors on AI adolescent alcohol use. These factors have not been investigated for cannabis use. We examined whether parental monitoring dampened risk for cannabis use due to depressed affect, and potential moderation by sex. METHODS: We measured cannabis use, depressed affect, parental monitoring, and sex among reservation area AI youth among students in grades 7-12 attending 45 schools. We used censor-inflated regression models to identify parental monitoring as a moderator of the relationship between depressed affect and cannabis use. RESULTS: In the logistic portion of censor-inflated models, level of depressed affect and parental monitoring significantly related to last 30-day cannabis use. Higher levels of parental monitoring at lower levels of depressed affect related to lower likelihood of cannabis use. Female students had greater likelihood of endorsing cannabis use at higher levels of depressed affect. In the linear portion of the censor-inflated regression models, sex and level of parental monitoring significantly related to cannabis use frequency. Male students endorsed more frequent cannabis use while higher levels of parental monitoring related to lower frequency of use. DISCUSSION AND CONCLUSIONS: Parental monitoring may dampen the effect of depressed affect on cannabis use among AI youth on reservations. SCIENTIFIC SIGNIFICANCE: Future interventions should foster skill-building prevention efforts directed at coping with depression, along with parental training for effective monitoring. Special attention to AI female adolescents may be indicated.

School-related Promotive Factors Related to Cannabis Use Among American Indian Adolescents.

Reservation-dwelling American Indian adolescents are at exceedingly high risk for cannabis use. Prevention initiatives to delay onset and escalation of use are needed. School engagement and student's positive experiences at school have been identified as key promotive factors against cannabis use in the general population of adolescents, but little work has examined these factors among American Indian youth. Seven school-related promotive factors were examined as predictors of past 30-day cannabis use (measured 6 months later), controlling for previous onset of cannabis use as well as a set of relevant potential confounders. Models were tested using 280 adolescents in 6th or 7th grade at the start of the study from two reservation-based schools in the US. Students were surveyed three times, with 6 months in between each survey. The average age at the start of the study was 11.99 years (SD = 0.87) and 54% of participants were female. Using a cumulative logit model to predict past 30-day use, American Indian youth who reported greater school bonding, academic aspirations, proclivity to endeavor in their studies, and interest in school at Wave 2 reported less 30-day cannabis use at Wave 3 (controlling for onset of cannabis at Wave 1 and several other control variables). No evidence of an effect of self-reported grades, perceived safety, or participation in school-related extracurricular activities was found. Given substantial deterioration of these school-related promotive factors over time, and the effect of the school-related promotive factors on subsequent cannabis use, efforts to design and test interventions to promote school engagement as a protective measure against cannabis use is warranted.

Opioid Misuse Among American Indian Adolescents.

Objectives. To present data for opioid misuse among US reservation-based American Indian (AI) adolescents and to compare these data with national rates from Monitoring the Future (MTF).Methods. Data were from a national sample of 33 schools participating in a substance use epidemiological survey of reservation-based AI adolescents during 2018 and 2019. Participants were 8th-, 10th-, and 12th-grade AI students (n = 1592). Measures included 12-month and 30-day use of OxyContin, Vicodin, heroin, and narcotics. We computed prevalence and compared it with MTF national prevalence.Results. Across grades, AI youths demonstrated significantly greater past 12-month and 30-day opioid use relative to a national sample. Significant absolute differences in 12-month and 30-day prevalence levels ranged from 1.6% (8th-grade heroin) to 4.7% (12th-grade narcotics) and from 1.6% (12th-grade narcotics) to 1.8% (12th-grade heroin), respectively.Conclusions. Opioid misuse prevalence levels were significantly greater for reservation-based AI adolescents relative to national prevalence levels.Public Health Implications. Findings suggest that implementation of evidence-based efforts, adapted or developed to be culturally appropriate, should be significantly increased in tribal communities, along with policies to address the unique social, economic, and health issues they face.

Be under your own influence: Effectiveness of a Culturally-Adapted drug prevention campaign targeting Reservation-Dwelling American Indian youth.

Be Under Your Own Influence (BUYOI) is a previously validated school-based intervention designed to delay adolescent substance use (SU) initiation. This study examined the effectiveness of a culturally-adapted version of BUYOI in delaying SU initiation among reservation-dwelling American Indian (AI) youth. Five reservation-based middle schools participated. Three schools were randomly assigned to receive BUYOI-AI (N = 321), and two schools served as controls (N = 176). Beginning in 7th grade, all participating students completed four assessments over the study period. Discrete time hazard models estimated the effects of BUYOI on students' risk of initiating alcohol, alcohol intoxication and marijuana before the end of 8th grade. AI students exposed to BUYOI had a lower risk of initiating alcohol use or intoxication, though sex moderated the effect on intoxication. These findings provide preliminary support for the effectiveness of a culturally-adapted version of BUYOI in delaying AI youth's first-time alcohol use and intoxication.

Predictors of Substance Use Latent Classes Among American Indian Youth Attending Schools On or Near Reservations.

BACKGROUND AND OBJECTIVES: Identical latent classes of substance use for 7 to 8 grade and 9 to 12 grade American Indian (AI) youth living on or near reservations suggest that patterns of substance use are established early among these youth. This study examines relationships of substance-related factors to latent class membership and whether these relationships differ by grade group. METHODS: In-school surveys were administered to 1503 7 to 8 grade and 1995 9 to 12 grade students from 46 schools on or near reservations during the 2009/2010 to 2012/2013 school years. Four-class latent class models of substance use were specified and five classes of substance-related factors (peers, substance availability, perceived harm, family, early initiation), plus grade level and gender, were evaluated as predictors. RESULTS: For 7 to 8 grade students, substance-related factors differentiated nonusers from users, while for 9 to 12 graders, these factors also differentiated types of users. Early initiation and peer factors were strongly related to class membership, while other factors were less strongly related. DISCUSSION AND CONCLUSIONS: Early initiation of alcohol or marijuana is strongly related to being in a substance-using class for AI youth. Because these youth tend to initiate use earlier that other US youth, prevention resources should be targeted to reaching them and their families before age 12. SCIENTIFIC SIGNIFICANCE: Predictors of latent classes of substance use were identified for reservation-based AI youth. While the classes were identical for 7 to 8 grade and 9 to 12 grade youth, predictors varied across grade group, which may inform how best to develop prevention efforts unique to middle and high school AI youth.

The Role of Future Orientation and Self-determination on American Indian Adolescents' Intentions to Use Alcohol and Marijuana.

Substance use (SU) rates among American Indian (AI) adolescents have been greater than national rates for decades, with little progress made on reducing them. Reasons for this may include lack of evidence on which to base effective interventions, the uniqueness of this population, and the overall lack of attention that this population has received in reducing socioeconomic and health disparities. Moreover, there has been limited focus on understanding how positive individual characteristics may serve as protective factors for AI adolescents. Using data from 379 AI youth living on or near four northern plains reservations, the current study examines the relationship between future orientation (FO) and self-determination (SD) and intentions to use alcohol and marijuana, with negative consequences of SU for future goals and autonomy evaluated as potential mediators. SEM models were estimated for alcohol use and marijuana use intentions, with two separate models for each dependent variable-one assessing the direct and indirect effects of FO via perceived consequences for future goals and the other assessing the effects of SD via perceived consequences for autonomy. All models displayed good fit, but the pattern of significant effects varied by substance, by construct (FO vs. SD), and by gender. Findings suggested that SD, and more proximally, perceived consequences of use for autonomy, may be particularly useful promotive factors to target SU prevention in AI adolescents. Culturally congruent interventions designed to promote SD and autonomous motivations to abstain may be particularly impactful within a young AI adolescent population, as early adolescence represents a critical period of development for personal autonomy and identity.

The Imperative for Research to Promote Health Equity in Indigenous Communities.

Health disparities exact a devastating toll upon Indigenous people in the USA. However, there has been scant research investment to develop strategies to address these inequities in Indigenous health. We present a case for increased health promotion, prevention, and treatment research with Indigenous populations, providing context to the recent NIH investment in the Intervention Research to Improve Native American Health (IRINAH) network. We discuss the disproportionate costs and consequences of disparities borne by Indigenous groups, the limited evidence base on effective intervention for this population, how population uniqueness often makes transfer of existing intervention models difficult, and additional challenges in creating interventions for Indigenous settings. Given the history of colonial disruption that has included genocide, forced removal from lands, damaging federal, state and local policies and practices, environmental contamination, and most recently, climate change, we conclude research that moves beyond minor transformations of existing majority population focused interventions, but instead truly respects Indigenous wisdom, knowledge, traditions, and aspirations is needed, and that investment in intervention science to address Indigenous health disparities represent a moral imperative.

Early onset of cannabis use and alcohol intoxication predicts prescription drug misuse in American Indian and non-American Indian adolescents living on or near reservations.

BACKGROUND: Prescription drug misuse (PDM) is a growing issue within the American Indian (AI) population, especially in younger populations. OBJECTIVES: This study estimates relationships between PDM and early initiation (prior to 14 yrs) of cannabis use and alcohol intoxication for a national sample of AI and non-AI adolescents attending schools on or near reservations. METHOD: Participants were 2580 students (50.2% female; 58.1% AI), ages 15-18, attending schools located on or near an AI reservation. Four models of PDM were estimated: 1) demographic variables; 2) demographics plus cannabis use initiation status; 3) demographics plus alcohol intoxication initiation status; and 4) all variables. All analyses were conducted using multilevel modeling. RESULTS: Results indicated that early onset of cannabis use and alcohol intoxication were individually significant predictors of PDM for AI and non-AI adolescents, with odds ratios (OR) of 47.00 for cannabis (p <.01) and 35.73 (p <.01) for intoxication and with no significant differences by race (AI vs. non-AI). Results also indicated a greater likelihood of PDM when a student was an early initiator of both cannabis use and intoxication than when they were one or the other. Finally, there was a significantly greater association between cannabis use and PDM (ORearlycannabis = 24.95, p <.01) than between intoxication and PDM (ORearlyintoxication = 3.98, p <.01) when both predictors were in the model. CONCLUSIONS: These findings suggest that for AI and non-AI youth who have some shared living experience, early initiation of cannabis use and alcohol intoxication are risk factors that are similarly related to PDM and that targeting early initiation for both groups of adolescents is critical in prevention of PDM.

Self-esteem, cultural identification, and substance use among American Indian youth.

OBJECTIVES: Determine potential mediating and moderating effects of self-esteem on the relationship between cultural identification and substance use among American Indian (AI) youth. METHODS: Anonymous surveys were administered to middle and high school AI students assessing levels of last month alcohol and marijuana use, cultural identification, and self-esteem. Structural equation modeling assessed potential mediating and moderating effects of self-esteem on the relationship between AI and white identification on alcohol and marijuana use. RESULTS: No mediating effects were found for middle school students. Among high school students, no mediating effects were found for alcohol. Among female high school students, a small mediating effect was found between AI identification and marijuana use, with AI identification protecting against use. Across all students, no moderating effects of self-esteem were found. CONCLUSIONS: The literature on cultural identification and substance use among minority youth is unclear. It was anticipated that consideration of self-esteem as a potential mediator or moderator might help clarify some of the confusion. However, no moderating effects were found and mediating effects were limited to female high school students for marijuana. Consideration should be given to assessing other measures of cultural identification and subscales of self-esteem to confirm that these findings are robust.

Cultural Adaptation of the Be under Your Own Influence Media Campaign for Middle-School American Indian Youth.

American Indian (AI) adolescents living on reservations report much higher substance use rates compared to other youth yet there are few effective prevention interventions developed for them. This paper presents findings from formative research undertaken to guide adaptation for AI youth of a prevention intervention, Be Under Your Own Influence (BUYOI), previously found to be effective in reducing substance use among middle-school youth. We conducted focus groups with 7th graders, the primary target audience, and photovoice with 11th graders, the role models who would help deliver the campaign, to inform surface and deep structure adaptation. Both age groups noted the pervasiveness of substance use on the reservation and indicated that this posed a major challenge to being drug and alcohol free. Students also described aspects of their community that tied to signs of social disorganization. However, these youth have much in common with other youth, including high future aspirations, involvement in activities and hobbies, and influence from family and friends. At the same time, there were important differences in the experiences, environment, and values of these AI youth, including emphasis on different types of activities, a more collectivist cultural orientation, tribal identity and pride, and the importance of extended families.

Alcohol consumption among rural African American and White adolescents: The role of religion, parents, and peers.

Although studies have examined ethnic differences in psychosocial factors and adolescent alcohol use, most have not examined these relationships for rural adolescents. The Community Drug and Alcohol Survey (CDAS) was completed by 23,163 rural adolescents attending African American secondary schools. Multilevel analysis tested the hypothesis of stronger relationships of peer use and religiosity with alcohol use and a weaker relationship for parental permissiveness and alcohol use for White compared to African American adolescents. Results suggested that peer use, religiosity, and parental permissiveness were more strongly associated with changes in alcohol use for White adolescents. Findings provide insight for alcohol prevention among rural adolescents.

The Role of Norms in Marijuana Use Among American Indian Adolescents.

American Indian adolescents residing on reservations report high levels of marijuana use. Understanding the relationships between normative mechanisms and marijuana use in this group can be especially important in designing effective strategies to prevent use. Participants were 3446 students identifying as American Indian in grades 7-12 across four academic years (2009-2012) from 45 schools. Multilevel logistic analysis was used to examine the relationships between lifetime, last month, and frequent marijuana use and measures of the normative environment. Descriptive and injunctive norms were distinctly and directly associated with all measures of marijuana use, with family injunctive norms showing a strong relationship to use (0.49 < OR < 0.58 for a 9th grade student). Family injunctive norms moderated the relationship between descriptive norms and lifetime and last month use (OR = 0.79 and 0.82, respectively), with higher family disapproval associated with a weaker relationship between descriptive norms and use. Anticipatory socialization was positively related to all measures of marijuana use, with the relationship stronger for lifetime and last month use than for frequent use (OR = 1.88, 1.74, and 1.30, respectively). A contextual variable of descriptive norms was related to lifetime and last month use (OR = 1.66 and 1.51, respectively) but not frequent use. These findings reinforce the importance of parental norms in reducing the likelihood of using marijuana. In addition, prevention strategies that increase the perception that healthy behaviors not involving marijuana use are an enjoyable way to socialize may be more effective in preventing occasional marijuana use.

A Longitudinal Examination of the Relation Between Internalizing Problem Behaviors and Early Adolescent Cigarette Smoking.

OBJECTIVE: The purpose of the present study was to investigate the longitudinal relation between internalizing problem behaviors (measured with the anxious/depressed and somatic complaints subscales of the Achenbach Teacher's Report Form) and self-reported cigarette smoking behavior and intentions during early adolescence. In addition, a possible mediating role of perceived harm was investigated. METHODS: Sixth graders and their teachers were surveyed in the sixth grade and students were surveyed again in the seventh grade. Smoking behavior and intentions were assessed with five items including lifetime use, 30-day use, tobacco user status (nonsmoker to heavy smoker), and two intentions/behavioral expectations items. In addition to perceived harm from smoking, reasons for smoking and reasons for not smoking were included on the survey. RESULTS: As hypothesized, teacher reports of sixth-grade internalizing problem behaviors were negatively related to seventh-grade smoking behavior and intentions. Moreover, perceived harm from smoking was negatively related to smoking and intentions. The hypothesized mediating role of perceived harm in the internalizing to smoking relationship was not supported. CONCLUSIONS: Potential differences in the relation between internalizing and smoking across adolescence are discussed. Specifically, the results of the present study and an examination of prior literature suggest that in early adolescence internalizing problems are negatively related to cigarette smoking, whereas in middle and late adolescence the opposite is true.

The moderating effects of perceived emotional benefits on inhalant initiation among American Indian and white youth.

BACKGROUND: Inhalant use co-occurs with emotional distress. Inhalant use may be a means of self-medicating distress, but more recent study focuses on the cognitive appraisal of personal benefits of using substances. OBJECTIVES: Objectives were to determine whether emotional distress variables predict early versus later initiation of inhalant use, whether such relationships differ between American Indian and white youth, and whether perceived emotional benefits of inhalant use moderates the relationship between emotional distress and stage of inhalant initiation. METHODS: Data were from a study of 7-12th grade American Indian youth who live on or near reservations. A total of 856 students from 32 schools surveyed from 2009 to 2012, who reported having used inhalants (American Indian = 683; white = 173), were surveyed about age first use of inhalants, levels of emotional distress, and perceived benefits of inhalant use. SEM models were used to assess study objectives. RESULTS: Depression and anger did not discriminate between early and later initiation. Lower self-esteem related to earlier initiation, but only among American Indian students. Perceived emotional benefits of inhalant use did not moderate the relationship between self-esteem and stage of initiation. DISCUSSION AND CONCLUSIONS: Among middle school and high school American Indian and white youth living on or near American Indian reservations, emotional distress is not strongly related to stage of inhalant initiation. SCIENTIFIC SIGNIFICANCE: These findings raise questions about the timing and strength of relationship between emotional distress and early inhalant initiation. Prospective studies are need to assess this relationship more fully.

Can High and Consistent School-Related Protective Factors Prevent Cannabis Use Among American Indian Middle School Students?

BACKGROUND: High cannabis use rates among American Indian (AI) adolescents necessitate the identification of factors that protect against early cannabis initiation. METHODS: Data collected from 279 AI middle school students attending reservation-based schools in 2018 and 2019 were analyzed. Three waves of data, with approximately 6 months between each, were used. A repeated measures latent class analysis examined a school-related protective factor index over three waves. The predictive power of lifetime cannabis use on school protection class membership was estimated, along with differences in past month cannabis use at follow-up 2 across school protection classes while holding baseline use constant. RESULTS: Four school protection classes were identified: high, moderate, low, and declining protection. Abstinence at baseline was associated with an increased odds of membership in the high protection class compared to the moderate and low protection classes. Students with consistent and high school protection throughout middle school were significantly less likely to report past month cannabis use at follow-up 2 compared to other classes. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Maintaining a high level of school protection throughout middle school substantially lowers the odds of cannabis use among AI adolescents. CONCLUSIONS: Interventions to promote school-related protective factors in this population are essential and should be designed and tested.

Nicotine use among reservation-area American Indian adolescents compared with a national sample.

BACKGROUND: Past research has found significant nicotine use disparities for reservation-area American Indian adolescents when compared to national levels. However, adolescent nicotine use has changed markedly, with reduced smoking and rapid increases in nicotine vaping. This study presents 2021-2022 prevalence estimates of tobacco product use, perceived harm and availability for reservation-area American Indian youth, with comparisons to the Monitoring the Future (MTF) national study. METHODS: Participants were 8th, 10th and 12th grade students. American Indian data were 33 reservation-area schools in 2021-2022 (n=2420); MTF data were 308 schools in Spring 2022 (n=31,438). Measures were lifetime, 30-day cigarette smoking, smokeless tobacco use, and nicotine vaping; past-year nicotine vaping; daily smoking; perceived harmfulness and availability of these tobacco products. Prevalence and 95% confidence intervals were computed by grade. RESULTS: Estimated prevalence of lifetime, monthly and daily cigarette smoking among American Indian 8th and 10th graders was higher than national levels. Nicotine vaping prevalence was similar between samples. American Indian students were less likely to report tobacco product use poses great risk, but also less likely to report tobacco products are easily available. CONCLUSIONS: Although estimated smoking prevalence among American Indian 8th and 10th graders was higher than national levels, prevalence appears lower than reported in earlier studies, suggesting declining disparities. Prevalence of nicotine vaping among reservation-area American Indian adolescents generally mirrors the national population; however, a lower percentage reported regular nicotine vaping poses a serious risk. This discrepancy suggests a need for prevention and intervention efforts culturally tailored for this population.

Outcome expectancies, descriptive norms, and alcohol use: American Indian and white adolescents.

This study examined the relationships between adolescent alcohol use and outcome expectancies and descriptive norms for a sample of American Indian and white youth living on or near reservations. Three outcome expectancies proposed by the theory of normative social behavior (perceived benefits to self, perceived benefits to others, and anticipatory socialization) were examined. Survey data were collected from high school students in the 2009-2010, 2010-2011, and 2011-2012 school years. Stronger descriptive norms for use and higher perceived benefits to self from use were associated with alcohol use in the last month, drunkenness in the last month, and binge drinking. Perceived benefits to self also moderated the relationship between descriptive norms and both alcohol use in the last month and binge drinking, and the effect of descriptive norms on use became more robust as perceived benefits to self increased. Outcome expectancies of perceived benefits to others and anticipatory socialization did not moderate the relationship between norms and alcohol use. Implications for prevention are discussed.

The normative environment for drug use: comparisons among American Indian and white adolescents.

The current study examined the influence of descriptive norms, injunctive norms, perceived outcome expectancies, and ethnicity on marijuana and inhalant use among 2334 American Indian (AI) and White high school students who lived on or near reservations in the United States. Hierarchical multiple regression analyses were conducted with survey data collected during the 2009-2010 and 2010-2011 school years. Results suggest differences between ethnicities in the influence of the normative environment and outcome expectancies on both marijuana and inhalant use. Study limitations are noted, and future research is suggested.

Protective factors in the relationship between perceived discrimination and risky drinking among American Indian adolescents.

INTRODUCTION: The relationship between perceived discrimination and risky drinking among American Indian (AI) youth is understudied, and the potential protective factors that may buffer this association are unknown. Therefore, the objective of this study was to examine protective factors across individual, family, school, peer, and cultural domains of the social ecology that might attenuate the relationship between perceived discrimination and risky drinking among AI adolescents. METHOD: Data were from the Substance Use Among American Indian Youth Study (Swaim and Stanley, 2018, 2021). AI youth who have used alcohol in their lifetime (n = 2516 within 62 schools) had an average age of 15.16 years (SD = 1.75) and 55.5% were female. Five sets of linear regressions were conducted. Risky drinking was regressed on demographic variables, alcohol use frequency, perceived discrimination, one protective factor (religiosity, parental monitoring, peer disapproval of alcohol use, school engagement, and ethnic identity), and one two-way interaction between perceived discrimination and the protective factor. RESULTS: Prevalence of risky drinking among lifetime drinkers was 40.1%. There were positive associations between perceived discrimination and risky drinking in all models (Bs range from.20 to.23; p <.001). Parental monitoring had a negative association with risky drinking (B = -0.255, p <.001). Religiosity was the only statistically significant moderator (B = -0.08, p = 0.01), indicating that religiosity weakened the relation between perceived discrimination and risky drinking. CONCLUSIONS: Religiosity may represent an important protective factor that could help guide efforts to prevent risky drinking in the face of discrimination among AI adolescents.