Identification of Sociodemographic, Clinical, and Genetic Factors to Aid Alaska Native and American Indian People to Successfully Quit Smoking.

INTRODUCTION: Alaska Native and American Indian (ANAI) people have a smoking prevalence of 23%. Nicotine metabolite ratio (NMR) and genetic testing may enable tailored selection of tobacco cessation medication. AIMS AND METHODS: The purpose of this study was to evaluate the relative contributions of NMR, cessation medication, demographics, and tobacco use history to cessation. Participants were recruited into an observational cohort study consisting of a baseline visit prior to their quit date and 6-week follow-up. Demographic and tobacco use surveys and blood, urine, and breath samples were collected at each visit. Electronic health records were queried for cessation medications. NMR was categorized into slow or normal nicotine metabolism phenotypes (<0.31 and ≥ 0.31, respectively). The main outcome was cessation at 6 weeks. Analyses consisted of descriptive statistics, medication and phenotype concordance, and estimates of relative risk (RR) of quitting. RESULTS: We enrolled 151 ANAI adults who smoked cigarettes daily. Two-thirds had normal nicotine metabolism phenotype. Retrospective medication and phenotype concordance was 39%. The overall quit rate was 25%. No demographic factors or tobacco use history were associated with quit success. Varenicline and bupropion increased the likelihood of quitting (RR = 2.93 [1.42, 6.03] and RR = 2.52 [1.12, 5.64], respectively) compared to nicotine replacement therapy. Non-optimal medication and phenotype concordance decreased likelihood of quit success (RR = 0.44 [0.22, 0.91]) compared to optimal concordance. CONCLUSIONS: This exploratory study found associations between quit success and tobacco cessation medication as well as medication and phenotype concordance. Additional research is needed to assess use of NMR for treatment selection among ANAI people. IMPLICATIONS: These results broadly support additional community-engaged research to improve medication and phenotype concordance in tribal health settings. Such future research on implementing meditcation and phenotype concordance holds promise to improve expectations, quit success, and health outcomes amongst individuals attempting to quit smoking.

Exploring barriers and facilitators to pharmacist-provided diabetes self-management education and support.

BACKGROUND: Pharmacists have the necessary clinical experience and medication knowledge to effectively provide diabetes self-management education and support (DSMES); however, barriers exist to DSMES implementation by community pharmacists. OBJECTIVE: The aim of this study is to explore DSMES from the community pharmacists' perspectives, identify barriers and facilitators to pharmacist DSMES implementation, and guide development of pharmacist-provided DSMES programs in Idaho. METHODS: Implementation climate, the theoretical framework for this project, is focused on how community pharmacists in Idaho perceive they will be supported by patients, health care providers, and insurers in DSMES implementation. Pharmacist investigators with qualitative research experience conducted semistructured interviews with 6 licensed community pharmacists from Idaho via Zoom between March and June 2020. Recordings were transcribed verbatim and analyzed using HyperRESEARCH 4.5.1. Themes, patterns, and dominant concepts that emerged from respondents' about DSMES were explored, labeled, and categorized into modifiable and nonmodifiable barriers and facilitators. This study was granted expedited approval by the Idaho State University Investigational Review Board. RESULTS: Relevant themes included current scope of practice, barriers, and facilitators. Subthemes related to the current scope of pharmacy practice included unclear roles and responsibilities and legislative constraints to practice. For barriers, subthemes included cost of set-up, billing and coding education, and the sustainability of services based on current reimbursement models. For facilitators, subthemes included the need for additional collaborations (external and internal), technology access, and trained pharmacy staff. CONCLUSION: Pharmacists are underutilized health care providers, capable of providing DSMES services if provided the necessary resources. This work identifies barriers and facilitators to pharmacist-led DSMES that can be considered by others when implementing DSMES or other disease management services.

Pandemic response in Alaska: Preparing pharmacists to lead vaccination efforts.

BACKGROUND: Despite the established efficacy of vaccines, many Alaskans choose not to be vaccinated, citing safety and efficacy concerns. Vaccine hesitancy, consistently ranked among the top 10, is one of most addressable global health threats. The main objective of this paper is to provide an overview of the steps taken by our team to help identify and address vaccine hesitancy by identifying unmet training needs and engaging pharmacists, pharmacy interns, and technicians in the development of tailored vaccine hesitancy education to improve vaccine confidence and vaccination rates among all Alaskans. METHODS: To determine the unmet training needs that contributed to vaccine hesitancy, an assessment survey was developed and administered to pharmacists across the state. RESULTS: An expert panel, composed of pharmacists across the state, was convened to review survey results and to establish a scalable health care provider training program. Adult-learning strategies and real-world examples were used to address pharmacist identified factors contributing to vaccine hesitancy and provide more tailored training to pharmacists and technicians in Alaska to help address factors contributing to vaccine hesitancy in patients that may be extending the pandemic. CONCLUSION: Pharmacy professionals are well positioned to respond to emerging threats, but more training and practice opportunities are required to get comfortable addressing vaccine hesitancy with established communication strategies.

Using National Survey Data: A Cross-Sectional Analysis of Surveys with Questions on Chronic Diseases and Social Determinants of Health.

Surveys are a common tool utilized by organizations and researchers to collect data and evaluate various populations. This project aimed to consolidate a list of national health surveys to make the data source identification process easier when utilizing survey data. A cross-sectional analysis of currently available national survey data was conducted using information from the Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services website. Surveys were assessed for inclusion criteria, and then data on diagnosis of chronic diseases and social determinants of health (SDoH) were extracted from included surveys. A total of 39 data sources were identified. After screening, 16 surveys met inclusion criteria and were included in the extraction process. This project identified 16 national health surveys containing questions related to chronic disease(s) and SDoH, which can be used to answer clinical, educational, and research questions. National surveys presented cover a broad range of topics, and these surveys may meet a variety of user needs.

The Brassica mature pollen and stigma proteomes: preparing to meet.

Successful pollination in Brassica brings together the mature pollen grain and stigma papilla, initiating an intricate series of molecular processes meant to eventually enable sperm cell delivery for fertilization and reproduction. At maturity, the pollen and stigma cells have acquired proteomes, comprising the primary molecular effectors required upon their meeting. Knowledge of the roles and global composition of these proteomes in Brassica species is largely lacking. To address this gap, gel-free shotgun proteomics was performed on the mature pollen and stigma of Brassica carinata, a representative of the Brassica family and its many crop species (e.g. Brassica napus, Brassica oleracea and Brassica rapa) that holds considerable potential as a bio-industrial crop. A total of 5608 and 7703 B. carinata mature pollen and stigma proteins were identified, respectively. The pollen and stigma proteomes were found to reflect not only their many common functional and developmental objectives, but also the important differences underlying their cellular specialization. Isobaric tag for relative and absolute quantification (iTRAQ) was exploited in the first analysis of a developing Brassicaceae stigma, and revealed 251 B. carinata proteins that were differentially abundant during stigma maturation, providing insight into proteins involved in the initial phases of pollination. Corresponding pollen and stigma transcriptomes were also generated, highlighting functional divergences between the proteome and transcriptome during different stages of pollen-stigma interaction. This study illustrates the investigative potential of combining the most comprehensive Brassicaceae pollen and stigma proteomes to date with iTRAQ and transcriptome data to provide a unique global perspective of pollen and stigma development and interaction.

Expansion of community pharmacies' role in public vaccine delivery to children: Opportunities and need.

Despite the positive impact pharmacists have had on access to vaccines, only a limited number of community pharmacists and pharmacies are able to participate in most federal- and state-supported vaccine programs. In this commentary we (1) review vaccination services currently provided by community pharmacists in the United States, (2) highlight regulatory, reimbursement, and role-based barriers to community pharmacists' participation in the vaccines for children (VFC) program, a cornerstone program to support vaccinations of children in the United States, and (3) suggest changes to support and improve VFC participation for all health care providers. For the purposes of this commentary, community pharmacies are defined as retail pharmacies not associated with a health care system, hospital, or clinic.

Developing sustainable workflows for community pharmacy-based SARS-CoV-2 testing.

BACKGROUND: The coronavirus disease Rapid Antigen Testing Expansion Program (Program) employed a drive-thru model to maximize pharmacy staff and the public's safety. OBJECTIVES: To quickly design, implement, and disseminate a pharmacy-based point-of-care testing program during a public health crisis. PRACTICE DESCRIPTION: Community pharmacies in Idaho were engaged in the state's public health efforts to boost severe acute respiratory syndrome coronavirus 2 testing statewide. Geographic location was a major recruitment factor. Two recruitment periods were held to extend the Program's reach into more remote underserved communities. PRACTICE INNOVATION: Program and pharmacy staff developed workflows and materials in an iterative process. Pharmacies received testing supplies. Program staff created e-Care plans for documentation and reimbursement and designed a Web portal for state reporting of positive rapid antigen test results. EVALUATION METHODS: Testing data (pharmacy location, patient insurance status, test type and results, number of submitted Medicaid claims) were captured in an online form. RESULTS: From September to December 2020, 13 pharmacies opted into a drive-thru, rapid antigen point-of-care testing and nasal swab for offsite testing program. A total of 2425 tests were performed. Approximately 29.4% of point-of-care tests were positive, and 70.6% required backup polymerase chain reaction confirmatory analysis. Patient insurance breakdown was 72.1% private, 8% Medicare, 11.4% Medicaid, and 8.5% uninsured. On average, pharmacies tested patients an average of 2.3 hours/day and 2.6 days/week. As a group, they provided 77.5 hours of testing per week statewide. Program pharmacies accounted for an average of 5.1% of testing across the entire state at the end of December 2020. CONCLUSION: Independent community-based pharmacies should be considered as partners in public health initiatives.

Preoperative anemia management program reduces blood transfusion in elective cardiac surgical patients, improving outcomes and decreasing hospital length of stay.

BACKGROUND: Anemia is an independent risk factor for hospitalization, readmission, prolonged length of stay (LOS), diminished quality of life, and mortality. A multidisciplinary program was implemented to manage anemia preoperatively as a patient blood management (PBM) initiative. METHODS AND MATERIALS: From March 2016 to August 2018, 240 patients were screened for anemia during their preoperative cardiovascular visit. About 52/240 (22%) were found to be anemic and met out inclusion criteria. Also, 45/52 (87%) had iron deficiency anemia and 7 (13%) had anemia without iron deficiency. A similar historical cohort of patients undergoing elective cardiovascular surgery with hemoglobin (Hb) < 12 g/dl from September 2014 to February /2016 (n = 52) served as control group. The primary outcome was perioperative red blood cell (RBC) transfusion. Secondary outcomes were date-of-surgery Hb, intensive care unit (ICU) and hospital LOS, complication rates, and transfusion cost. RESULTS: The two most common treatments were IV iron ± folate (n = 36/45; 80%) and oral iron (n = 9/45; 20%). As compared to historical patients, study patients had significantly higher day-of-surgery Hb (10.6 ± 1.4 vs. 9.8 ± 1.3 g/dl, p < .001), lower utilization of RBC transfusion (0.86 ± 1.4 vs. 2.78 ± 2.4, p < .001), fewer days in the ICU (2.1 ± 2.0 vs. 4.0 ± 3.5, p = .002), and shorter total LOS (6.9 ± 4.8 vs. 12.9 ± 6.8, p < .0001). Study patients also showed lower overall complication rates (p < .0001). Analysis of RBC acquisition cost and transfusion cost also showed significant saving of 69% ($293 vs. $945 and $656 vs. $2116, respectively). CONCLUSION: When corrected for type of procedures and surgeon, our pilot anemia program in elective cardiovascular surgeries showed higher day-of-surgery Hb and significant reduction in RBC transfusion rates, ICU and hospital LOS, and overall complication rates.

Pharmacists' Willingness to Provide Coronavirus Disease (COVID-19) Services and the Needs to Support COVID-19 Testing, Management, and Prevention.

The need for increased testing is pivotal in the response to the coronavirus disease (COVID-19) pandemic. Recently, through the Public Readiness and Emergency Preparedness (PREP) Act, pharmacists were given the ability to order and administer COVID-19 tests, giving them a better opportunity to engage in the pandemic response across the nation as well as in Idaho. This survey sought to determine Idaho pharmacists' willingness to provide different COVID-19 related services, assess needed resources to provide such services, and identify and prioritize other unmet community needs. We conducted a nine-question, cross-sectional survey distributed to pharmacists with addresses located in Idaho. All questions in the survey were optional and focused on pharmacist's willingness to provide services, what resources and additional training they would need, difficulty with 90-day prescriptions, and solicited additional feedback using an open-ended question. A total of 229 responses were received, representing all areas of pharmacy practice, with approximately half from community settings. The majority of respondents (70%) were willing to provide COVID-19 testing. Adequate staffing, changes to workflow, and the need for billing and clear reimbursement mechanisms were most frequently cited as barriers to contributing to the COVID-19 response. In summary, we found that pharmacists are very willing to help during this crisis, but their involvement may be better facilitated with the removal of barriers.

Women as first authors in key pharmacy journals: Analysis by publication type.

BACKGROUND: Numerous national and international studies have explored the issue of gender disparity in health science-publication rates. However, few have examined publication type (e.g., reviews and original research) and authorship order, which are 2 key factors in contribution recognition and the work's visibility and application. OBJECTIVE: The objective of this work was to determine the changes in the distribution of women as first authors by publication type over time in pharmacy practice journals. METHODS: This was a bibliometric data analysis of pharmacy practice publications from January 2007 through December 2017. We used data from the U.S. Social Security Administration, and the multilingual Genderize application program interface (Genderize.io) to identify the authors' potential gender. To determine the publication type, we used the Web of Science article list (Clarivate Analytics, Philadelphia, PA). The Cochran-Armitage trend test was used to determine the differences over time. RESULTS: Articles published from January 2007 through December 2017 in 8 pharmacy practice journals were reviewed (N = 14,658 articles): research articles (63.8%), reviews (17.0%), editorial material (11.1%), and letters (8.1%). There was a statistically significant increase in the number of first-authored articles and reviews by women (45.1% to 55.4% and 39.2% to 56.1%, respectively). There was not a significant increase in the proportion of women as first authors in editorials or letters over the study period. CONCLUSION: Despite increases in research and reviews with women as first authors, there is still a need for increased representation of women in opinion-based publications such as editorials.

Reimbursement for pharmacist-provided health care services: A multistate review.

OBJECTIVE(S): To better understand individual state approaches to reimbursement for pharmacist-provided health care services, we sought to (1) review existing statutes and regulations on pharmacist reimbursement from select states (Alaska, California, Idaho, New Mexico, Oregon, and Washington) and (2) suggest approaches to changing state statutes and regulations to allow for reimbursement. METHODS: We reviewed approaches taken by 4 states that currently allow for direct reimbursement of pharmacist-provided health services and 2 states that are in process. Washington requires commercial health plans to credential and privilege pharmacists as health care providers deeming reimbursement and coverage disparities among providers as compensation discrimination. RESULTS: Oregon does not require insurers to provide payment but requires pharmacists to contract and credential with each individual insurer, without the mandate for payment. In California, pharmacists receive 85% of the established fee schedule that physicians receive for equivalent services, and payment is issued to the pharmacy, not the individual pharmacist. California and New Mexico both only allow specified pharmacies or pharmacists to bill (advanced credentials or a tiered licensing model). In Alaska, scope and payor regulations align to allow compensation for covered services; however, insurance credentialing portals are not configured to enroll pharmacists as billing providers. In May 2020, pharmacists were added as nonphysician ordering, referring, and prescribing providers in the Idaho Medicaid basic plan regulations, and licensed pharmacists with national provider identification numbers were auto-enrolled. CONCLUSION: The states we reviewed took different approaches on the basis of their established statutes and regulations (pharmacy, public and private insurance), resulting in variability in compensated services and reimbursement. An intentional alignment of statutes, regulations, and scope of practice is required to support reimbursement and sustainability of services.

Alaska pharmacists: First responders to the pandemic in the last frontier.

BACKGROUND: Pharmacists are among the nation's most accessible and underused health professionals. Within their scope of practice, pharmacists can prescribe and administer vaccines, conduct point-of-care testing, and address drug shortages through therapeutic substitutions. OBJECTIVES: To better use pharmacists as first responders to coronavirus disease 2019 (COVID-19), we conducted a needs and capacity assessment to (1) determine individual commitment to provide COVID-19 testing and management services, (2) identify resources required to provide these services, and (3) help prioritize unmet community needs that could be addressed by pharmacists. METHODS: In March 2020, pharmacists and student pharmacists within the Alaska Pharmacist Association worked to tailor, administer, and evaluate results from a 10-question survey, including demographics (respondent name, ZIP Code, cell phone, and alternate e-mail). The survey was developed on the basis of published COVID-19 guidelines, Centers for Disease Control and Prevention COVID-19 screening and management guidelines, National Association of Boards of Pharmacy guidance, and joint policy recommendation from pharmacy organizations. RESULTS: Pharmacies are located in the areas of greatest COVID-19 need in Alaska. Pharmacists are willing and interested in providing support. Approximately 63% of the pharmacists who completed the survey indicated that they were interested in providing COVID-19 nasal testing, 60% were interested in conducting COVID-19 antibody testing, and 93% were interested in prescribing and administering immunizations for COVID-19, as available. When asked about resources needed to enable pharmacists to prescribe antiviral therapy, 37% of the pharmacists indicated they needed additional education or training, and 39% required access to technology to bill and document provided services. CONCLUSION: The primary barrier to pharmacists augmenting the current COVID-19 response is an inability to cover the costs of providing these health services. Pharmacists in Alaska are ready to meet COVID-19-related clinical needs if public and private insurers and legislators can help address the barriers to service sustainability.

Assessing Pharmacists' Views and Barriers to Providing and Billing for Pharmacist-Provided Health Care Services.

Background: The role of Idaho and Alaska pharmacists in providing health care services has steadily broadened over recent years. With many new pharmacist-provided health care service possibilities, this study assessed the impact of these advancements on community pharmacies. Objective: The objective of this study was to identify current pharmacist-provided health care services and pharmacist-perceived barriers to providing and billing for these services in Idaho and Alaska community pharmacies. Methods: A questionnaire was developed focusing on 2 areas: providing services and billing for services. Pharmacy students on experiential rotations administered the questionnaires to pharmacists at their rotation sites. Pharmacists at community pharmacy practice sites in Idaho and Alaska completed the questionnaire in an interview format conducted by students. Likert-type scale data were analyzed using descriptive statistics. Because the study did not include a comparator group, no power calculation was conducted. All open-response answers were analyzed independently by 2 researchers and discrepancies in coding open-ended questions were resolved by discussion with a group of 4 researchers. Results: Most pharmacists reported that they already provide non-dispensing services, desired to implement new services, and had confidence in their team's ability to handle new services. Time and resources were the most cited barriers to providing new services; compensation, company support, and education were the most cited barriers to billing for services. Conclusions: Community pharmacists already provide non-dispensing services and many are looking to provide more services, but barriers of time, resources, compensation, company support, and education will need to be overcome to move forward.

Pharmacogenomics of Nicotine Metabolism: Novel CYP2A6 and CYP2B6 Genetic Variation Patterns in Alaska Native and American Indian Populations.

INTRODUCTION: Alaska Native and American Indian (AN/AI) populations have higher tobacco use prevalence than other ethnic/racial groups. Pharmacogenetic testing to tailor tobacco cessation treatment may improve cessation rates. This study characterized polymorphic variations among AN/AI people in genes associated with metabolism of nicotine and drugs used for tobacco cessation. METHODS: Recruitment of AN/AI individuals represented six subgroups, five geographic subgroups throughout Alaska and a subgroup comprised of AIs from the lower 48 states living in Alaska. We sequenced the CYP2A6 and CYP2B6 genes to identify known and novel gain, reduced, and loss-of-function alleles, including structural variation (eg, gene deletions, duplications, and hybridizations). RESULTS: Variant allele frequencies differed substantially between AN/AI subgroups. The gene deletion CYP2A6*4 and reduced function CYP2A6*9 alleles were found at high frequency in Northern/Western subgroups and in Lower 48/Interior subgroups, respectively. The reduced function CYP2B6*6 allele was observed in all subgroups and a novel, predicted reduced function CYP2B6 variant was found at relatively high frequency in the Southeastern subgroup. CONCLUSIONS: Diverse CYP2A6 and CYP2B6 variation among the subgroups highlight the need for comprehensive pharmacogenetic testing to guide tobacco cessation therapy for AN/AI populations. IMPLICATIONS: Nicotine metabolism is largely determined by CYP2A6 genotype, and variation in CYP2A6 activity has altered the treatment success in other populations. These findings suggest pharmacogenetic-guided smoking cessation drug treatment could provide benefit to this unique population seeking tobacco cessation therapy.

Pharmacist medical provider status in Alaska, the last frontier.

Alaska law and health care policies, incidentally, designate pharmacists as billable medical providers when providing health care services. However, state and commercial provider enrollment and claims processing systems are not configured to enroll and accept claims from pharmacists. Alaska law does not protect pharmacists from unfair discriminatory practices by payors despite such protections being afforded in federal regulation. Additional advocacy and legislation are needed to fully implement pharmacists as billing medical providers within traditional payor models. Health care services provided by pharmacists can help alleviate unmet patient health care needs in the community and primary care settings of Alaska. The identified barriers will continue to limit the ability of pharmacists in Alaska to sustainably provide lifesaving, scope-permitted, and otherwise covered services to those in greatest need.

Differences in service utilization at an urban tribal health organization before and after Alzheimer's disease or related dementia diagnosis: A cohort study.

INTRODUCTION: The prevalence, mortality, and healthcare impact of Alaska Native and American Indian (ANAI) people with Alzheimer's disease and related dementias (ADRD) are unknown. METHODS: We conducted a cohort study of electronic health record data that compared healthcare service utilization in patients with and without an ADRD diagnosis. Zero-inflated negative binomial regression with robust standard errors was used to estimate utilization rates. RESULTS: Compared with patients without ADRD, utilization rates were similar before but higher after ADRD diagnosis. For those with diagnosed ADRD, utilization increased gradually over time with sharp upward change during the year of diagnosis. DISCUSSION: This is the only study quantifying changes in healthcare service utilization before and after ADRD diagnosis among ANAI people, which is crucial for tailoring geriatric care for ANAI populations.

Text message reminders increased colorectal cancer screening in a randomized trial with Alaska Native and American Indian people.

BACKGROUND: Alaska Native and American Indian people (AN/AIs) have a high incidence of colorectal cancer (CRC) and CRC-related mortality. Screening can prevent death from CRC, but screening rates are low in racially and ethnically diverse populations. The authors conducted a randomized controlled trial using text messaging to increase CRC screening among unscreened AN/AIs in a tribal health care system in Anchorage, Alaska. METHODS: The intervention entailed up to 3 text messages sent 1 month apart. The authors randomized 2386 AN/AIs aged 40 to 75 years who were eligible for CRC screening to the intervention or usual-care control conditions. Screening status was ascertained from electronic health records 3 months and 6 months after the last text message. Hazard ratios (HRs) were estimated to evaluate the effectiveness of the intervention, stratified by age and sex. RESULTS: The intervention increased CRC screening for AN/AIs aged 50 to 75 years (HR, 1.42; 95% confidence interval [95% CI], 0.97-2.09) and aged 40 to 49 years (HR, 1.24; 95% CI, 0.95-1.62). Within both age groups, the HRs were higher for women (HR, 1.69 [95% CI, 1.02-2.80] and HR, 1.37 [95% CI, 1.01-1.88]) compared with men (HR, 1.09 [95% CI, 0.59-1.99] and HR, 0.90 [95% CI, 0.54-1.53]). Interaction analysis yielded P values of .55 and .09, respectively, for age and sex. CONCLUSIONS: A simple text messaging intervention was found to increase CRC screening rates in AN/AIs, a group with high CRC morbidity and mortality. Text messaging may be a cost-effective means of reducing CRC screening disparities in AN/AIs and other populations. Cancer 2017;123:1382-1389. © 2016 American Cancer Society.

Application of the PEN-3 Model to Tobacco Initiation, Use, and Cessation Among American Indian and Alaska Native Adults.

American Indian (AI) and Alaska Native (AN) communities confront some of the highest rates of tobacco use and its sequelae. As part of a formative research project investigating stakeholder understandings, preferences, and needs surrounding the use of pharmacogenetics toward tobacco cessation treatment, we sought to characterize sociocultural issues related to tobacco use and cessation. We used the PEN-3 cultural model to frame the research question and analysis of stakeholder interviews with 20 AI/AN patients, 12 health care providers, and 9 tribal leaders. Our study found high knowledge levels of the negative health effects of tobacco use; however, most patient participants ascribed negative health effects only to regular, heavy tobacco use and not to light use, which is more common in the population. The majority of patient participants did not endorse use of tobacco cessation treatment despite evidence of efficacy among AI/AN adults. Health promotion messaging to target low-tobacco consuming AI/AN people is needed. Additionally, messaging to promote tobacco cessation treatment using successful AI/AN former tobacco users to improve community perception of tobacco cessation treatment is recommended.

"They are Us-We are Them": Transformative learning through nursing education leadership.

Stigmatization towards persons with mental illnesses is a major quality of care concern. Unfortunately, nurses are no less implicated than other health professions. This article reports the results of an evaluation of a learning intervention for psychiatric nursing students in partnership between Brandon University and the Mental Health Commission of Canada. We describe this intervention as an example of transformational learning through nursing education leadership and suggest its use as a promising model for cultural change in healthcare practice. Leaders and managers are encouraged to explore how such a model may be adaptable or implementable for their own organizations and departments.