Perception of Barriers to and Factors Associated with HPV Vaccination Among Parents of American Indian Adolescents in the Cherokee Nation.

The purpose of this study was to understand the perceptions of HPV vaccination barriers and factors among parents or guardians of American Indian adolescents in the Cherokee Nation. Fifty-four parents of American Indian adolescents in the Cherokee Nation participated in one of eleven focus group discussions from June to August 2019. Discussions were recorded, transcribed, coded, and analyzed for themes. Protection against cancer was the primary parent-reported reason for vaccinating their children against HPV. The lack of information and safety concerns about the HPV vaccine were the main reasons for non-vaccination. To increase HPV vaccine uptake, parents strongly supported offering vaccinations in school. Furthermore, increased healthcare provider-initiated discussion can ease parental concerns about HPV vaccine safety and improve coverage.

Investigating Cannabis-Use Among Students Attending High Schools Within the Cherokee Nation Reservation 2017 and 2019.

Oklahoma's medical cannabis is some of the least restrictive in the US. Previous research suggests that American Indian/Alaska Native (AIAN) have higher rates of cannabis use than other racial or ethnic groups. The goals of this paper are, first, to look at cannabis use among high school students living on the Cherokee Nation Reservation before (2017) and after (2019) medical cannabis because legal in Oklahoma (2018) utilizing the Cherokee Nation Youth Risk Behavior Survey (CNYRBS). Second, to describe the socio-demographic characteristics of youth using cannabis in the Cherokee Nation Reservation. Data were retrieved from the 2017 and 2019 CNYRBS. The data for this study included 1,216 high school students who completed the 2017 and 1,476 who completed the 2019 CNYRBS. After removal of incomplete records, there were 2,602 students whose data was analyzed in this study. Data were weighted to be representative of public-school students attending grades 9-12 within Cherokee Nation Reservation. Despite the legalization of medical cannabis in Oklahoma in 2018, there was no change in cannabis use among youth between 2017 and 2019. There were variations in cannabis use based on demographic factors and other substance uses. AIAN individuals had higher odds of current cannabis use compared to non-Hispanic White students, but there were no differences based on ethnicity. Additionally, the use of cigarettes, e-cigarettes, alcohol, and illegal drugs were associated with increased odds of cannabis use among both current and former users compared to those who had never used it. There was no spike in use among youth at least immediately after the legalization of cannabis in the Cherokee Nation Reservation. There were socio-demographic as well as substance use disparities in the use of cannabis.

Investigating Tobacco Product Use Behavior Among Students Attending High Schools Within the Cherokee Nation Reservation.

Tobacco use is the leading cause of death in the United States and youth prevention is key to reducing tobacco use. American Indian/Alaska Native (AI/AN) individuals have a higher prevalence of tobacco use compared to other populations. This paper aims to evaluate the prevalence of tobacco products among youth within the Cherokee Nation reservation. Data from the 2019 Cherokee Nation Youth Risk Behavior Survey (YRBS) was used to analyze the prevalence of tobacco use (cigarettes, smokeless tobacco, electronic cigarettes, cigars, and ≥ 2 products) among students within Cherokee Nation. Weighted frequency and percentages were obtained for variables and 95% confidence intervals were computed using Taylor linearization variance estimators. Binary associations between variables were examined using the Rao-Scott Chi-square test. There were 1475 high students who participated in the 2019 Cherokee Nation YRBS. Males were more likely to report the use of smokeless tobacco and ≥ 2 products than females. Twelfth graders had a higher prevalence of reported e-cigarette use compared to lower grades. AI/AN students had a higher prevalence of current use of cigarettes and ≥ 2 products compared to other groups. The use of marijuana and alcohol was positively associated with the use of all tobacco products. Depression was also positively associated with the use of all products excluding smokeless tobacco. Grade, age, depression, and current use of other tobacco products, marijuana, and alcohol were associated with greater electronic cigarette intensity levels. Using the results, tribal and local organizations can promote evidence-based interventions that focus on reducing tobacco use among youth.

Pregnant Smokers' Intention to Switch From Cigarettes to E-Cigarettes: A Reasoned Action Approach.

INTRODUCTION: This study used the reasoned action approach (RAA) to examine 1) factors associated with pregnant smokers' intention to switch from cigarettes to e-cigarettes and 2) the influence that intention to switch had on future expectations to resume cigarette use postpartum. METHODS: U.S. pregnant women (N = 267) who reported past 30-day use of cigarettes completed an online cross-sectional survey between November and December 2019. A 30-item scale measured RAA constructs (intention, instrumental attitudes, experiential attitudes, injunctive norms, descriptive norms, perceived autonomy, and perceived capacity). A confirmatory factor analysis confirmed and structural equation modeling tested the RAA constructs' association with intention to switch and the relationship between intention to switch and future expectations to resume smoking after pregnancy. RESULTS: The confirmatory factor analysis confirmed the seven-factor measurement model. Structural equation modeling found instrumental attitudes (ß = 0.43; p < .001) and descriptive norms (ß = 0.53; p < .001) were associated with intention to switch from cigarettes to e-cigarettes. However, there were differences between the constructs' relationships with intention between those who did and did not use e-cigarettes in the past 30 days. Intention to switch was inversely related with future expectations to resume smoking postpartum (ß = -0.13; p < .001). CONCLUSIONS: This study examined multiple facets of behavioral decision-making that may influence pregnant smokers' intention to switch to e-cigarettes during pregnancy. In this sample, pregnant people who believed switching from cigarettes to e-cigarettes was important and that other smokers commonly switched during pregnancy reported greater intention to switch. Novel theories, such as the RAA, may provide an optimal lens to understand pregnant smokers' behavioral decision-making process as they consider switching from cigarettes to e-cigarettes.

Impact of e-cigarette use among a cohort of American Indian cigarette smokers: associations with cigarette smoking cessation and cigarette consumption.

INTRODUCTION: Despite American Indian/Alaska Native (AI/AN) people having the highest prevalence of cigarette smoking nationwide, few studies have evaluated e-cigarette use among AI/AN adults who smoke. The primary objective of this observational pilot cohort study was to determine if e-cigarette use is associated with cigarette smoking cessation or reduction among adult AI individuals who smoke. METHODS: In 2016, we collected baseline survey and biomarker data among AI adults who smoke. The survey included questions about cigarette consumption and use of e-cigarettes and biomarkers, such as salivary cotinine markers and exhaled carbon monoxide. After 18 months, we repeated data collection, and asked about changes in cigarette smoking status and cigarettes per day (CPD). Comparisons between groups were performed using the χ2 test, Fisher's exact test or Wilcoxon rank-sum test. RESULTS: Of 375 baseline participants, 214 (57.07%) returned for follow-up and were included in analyses. Of these, 20 (9.3%) reported having stopped cigarette smoking and had biochemical verification of cigarette smoking abstinence. Among those who quit smoking, 15% were baseline e-cigarette users; while among those who continued to smoke at follow-up, about 11% were baseline e-cigarette users. This difference was not statistically significant (p=0.48). Among all those who continued to smoke at follow-up, there was no overall decrease in CPD, nor a significant difference in change in CPD between baseline e-cigarette users and non-users (p=0.98). CONCLUSIONS: E-cigarette use at baseline was not associated with smoking cessation or a change in CPD in this cohort of AI adults who smoke after an 18-month follow-up period.

Use of Potentially Reduced Exposure Tobacco Products Among American Indian Smokeless Tobacco Users: Associations With Cessation Behaviors and Cotinine Levels.

OBJECTIVES: American Indian/Alaska Native (AI/AN) adults use smokeless tobacco products (eg, chewing and dip tobacco) more often than other racial/ethnic groups do. Although US adults increasingly use potentially reduced exposure tobacco products (PREPs), such as electronic cigarettes and snus, no studies have examined the use of PREPs among AI/AN smokeless tobacco users. We examined associations between current PREPs use and smokeless tobacco-related measures, including cessation attempts and cotinine levels, in a sample of American Indian adults who currently use smokeless tobacco. METHODS: We collected survey and tobacco biomarker data from 299 adult American Indian smokeless tobacco users at Cherokee Nation health care facilities and events in 2016 and 2017. We used multivariable analyses to determine associations between current PREPs use and smokeless tobacco-related characteristics. RESULTS: Current PREPs users were younger, less likely to be married or living with a partner, less likely to report a chronic medical condition, and more likely to report other tobacco use than PREPs nonusers. Among participants with annual household incomes ≤$30 000, current PREPs users were less likely than PREPs nonusers to report a definite desire to quit smokeless tobacco (P = .02). PREPs use was not associated with planning to quit smokeless tobacco, past 12-month smokeless tobacco quit attempts, amount of smokeless tobacco used per week, cotinine levels, or scores on the Fagerström Test for Nicotine Dependence-Smokeless Tobacco. CONCLUSIONS: Our study suggests that American Indian smokeless tobacco users may not be using PREPs as a smokeless tobacco cessation aid. Future studies should take this finding into consideration when evaluating the role of PREPs use in smokeless tobacco cessation and in total tobacco cessation in this population.

Vaping patterns, nicotine dependence and reasons for vaping among American Indian dual users of cigarettes and electronic cigarettes.

BACKGROUND: The American Cancer Society discourages the dual use of electronic cigarettes (ECs) and cigarettes because such use has not resulted in reduced exposures to the harmful effects of smoking. American Indian (AI) people have the highest prevalence of smoking and of EC use in the United States, but very little is known about dual EC and cigarette use in AI communities. METHODS: In 2016, 375 adult AI in Oklahoma who smoked cigarettes completed a survey about EC use (vaping). We describe vaping patterns, nicotine dependence, and reasons for EC use among the subset of 44 (12%) current dual EC users. To differentiate habitual EC users from occasional or merely curious users, we defined dual use as using ECs on some days or every day in the past 30 days. RESULTS: About one-third of dual users vaped ten or more times daily. About two-thirds used a tank product. Eleven percent used ECs without nicotine and another 9% were unsure of the nicotine content. A minority (40%) enjoyed vaping more than smoking, and most (76%) would smoke first on days they did both. Thirty-one percent vaped within 5 min of waking and another 24% within 30 min. Although the two-item heaviness of use index did not differ significantly between smoking and vaping, the ten-item Penn State Dependence Index (PSDI) suggested greater dependence on smoking than vaping (11.02 vs. 6.42, respectively; p < .0001). The most common reasons for vaping were to reduce smoking (79%), enjoyment of flavors (78%), and ability to vape where smoking is not allowed (73%). Perceptions of less harm to others (69%) or to self were the next most common (65%). Fewer than half used ECs to reduce stress, for affordability, or because others used them. CONCLUSIONS: Nearly 20% of dual users used ECs either without nicotine or without knowing if the product contained nicotine. The PSDI indicated greater dependence on smoking than vaping. Reasons for vaping were nearly equal between smoking reduction and enjoying flavors. Understanding patterns of dual use will inform future efforts to address nicotine dependence for AI communities with high prevalence of smoking.

Dual Versus Never Use of E-Cigarettes Among American Indians Who Smoke.

INTRODUCTION: Many American Indian communities have a high prevalence of smoking and e-cigarette use, but factors associated with their dual use are rarely studied. METHODS: In 2016, a total of 375 American Indian adults who smoke completed paper surveys regarding cigarette and e-cigarette use and provided saliva for cotinine levels. In 2018, cross-sectional analyses were performed, comparing dual users (12%), defined as using e-cigarettes on some or every day for the past 30 days, with never users of e-cigarettes (37%). RESULTS: Compared with never users, dual users were younger, more often reported history of depression (56% and 29%, respectively; p<0.01) and family history of smoking-related disease (77% and 59%, respectively; p<0.05), had lower harm perceptions of e-cigarettes (27% and 47%, respectively; p<0.01) or vapor (14% and 35%, respectively; p<0.01), and more often perceived e-cigarettes as cessation aids (75% and 16%, respectively; p<0.01) and as less harmful than cigarettes (70% and 17%, respectively; p<0.01). Dual users were less often uncertain/unknowing about e-cigarette benefits or harms (p<0.01) and more often reported likelihood to quit smoking (49% and 24%, respectively; p<0.01) and prior attempt to quit smoking, ever (89% and 67%, respectively; p<0.01) or in the past year (55% and 32%, respectively; p=0.01). Cigarette consumption and cotinine levels did not differ between groups. Dual users more often tried other nicotine products (p<0.02) and more often lived with a vaping partner/spouse (45% and 6%, respectively; p<0.01). CONCLUSIONS: Dual users perceived e-cigarettes as less harmful than cigarettes and more as cessation aids than cigarette-only users did, but cigarette consumption did not differ between groups. Whether e-cigarettes will reduce smoking-related disparities among American Indian people remains undetermined.

Perceptions of Smoking and Vaping on Weight Control Among Adult American Indians Who Smoke.

Interest in electronic cigarette (EC) use, or vaping, to help control weight is increasing. Many American Indian (AI) populations have a high prevalence of smoking, obesity, and EC use, but their perceptions of EC use for weight control are unknown. In Oklahoma in 2016, 375 AI adults who smoke completed a survey including perceptions about smoking and EC effects on weight control. Only 24% believed that smoking helps control weight, and 8% believed that vaping helps control weight. Perceptions differed by EC use, with ever users more often than never users perceiving that smoking (30% vs 12%, respectively; p < .01) and vaping (10% vs 5%; p = .04) help to control weight. Sex, age group (18-44 years vs 45 + years), education (high school graduate/equivalent vs less than high school), smoking cessation attempt in past year, and likelihood to quit in 6 months were not associated with weight control perceptions for either smoking or vaping. Uncertainty regarding EC effects on weight control was less common among EC ever users compared to never users (41% vs 53%, respectively; p = .04). Most people who did not believe or were uncertain that smoking controls weight also did not believe or were uncertain that vaping controls weight. However, only a minority (29%) of people who believed smoking controls weight also believed that vaping controls weight. Among adult AI who smoke, both smoking and vaping were infrequently perceived as helping to control weight, but such perceptions were reported more frequently among those who ever used ECs.

E-cigarettes and Tobacco Exposure Biomarkers among American Indian Smokers.

Objective We assessed associations between electronic cigarette (e-cigarette) use and smoking-related measures among American Indians (AIs) who smoke. MethodsWe collected baseline survey and smoking biomarker data in a cohort of 375 adult AI smokers at a Cherokee Nation healthcare facility in Oklahoma. We used multivariate logistic and linear regression analyses to determine associations between e-cigarette use and smoking-related characteristics, including biomarkers. ResultsCurrent e-cigarette users were more likely than never users to report a quit attempt in the past 12 months (current vs never adjusted odds ratio (AOR) = 2.24 [95% CI 1.20-4.16]). Current and past e-cigarette users were more likely than never users to report a likelihood to quit smoking (current vs never AOR = 2.97 [95% CI 1.34-6.56]; past vs never AOR = 1.77 [95% CI 1.08-2.91]). E-cigarette use was not significantly associated with confidence to quit smoking, cigarette packs smoked per day, or cotinine levels. ConclusionsE-cigarette use was associated with previous and future quit attempts, but not with reductions in cigarette smoking or confidence in quitting. This suggests that many dual users might benefit from the addition of evidence-based smoking cessation treatments.

Predictors of intimate partner problem-related suicides among suicide decedents in Kentucky.

BACKGROUND: Suicide is the 10th leading cause of death in the United States. Furthermore, intimate partner problems are amid the top precipitating circumstances among suicide decedents. The aim of this study was to determine circumstantial associations of intimate partner problem-related suicides in suicide decedents in Kentucky. METHODS: All suicides that were reported to the Kentucky Violent Death Reporting System between 2005 and 2012 were eligible for this study. Multiple logistic regression was used to explore predictors (precipitating health-related problems, life stressors, and criminal/legal issues) of intimate partner problem-related suicides. RESULTS: Of the 4,754 suicides, included in this study, approximately 17% had intimate partner problems prior to suicide. In the adjusted analysis, mental health issues, alcohol problems, history of suicides attempts, suicides precipitated by another crime, and other legal problems increased the odds of having an intimate partner-related suicide. However, having physical health problems, prior to the suicide, decreased the odds of intimate partner-related suicide. CONCLUSIONS: These results provide insight for the development of suicide interventions for individuals with intimate partner problems by targeting risk factors that are prevalent among this population. Moreover, these results may help marriage/relationship and/or family/divorce court representatives identify individuals with intimate partner problems more at risk for suicide and alleviate the influence these suicide risk factors have on individuals experiencing Intimate partner problems.