Explaining COVID-19 related mortality disparities in American Indians and Alaska Natives.

American Indian and Alaska Native (AI/AN) individuals are more likely to die with COVID-19 than other groups, but there is limited empirical evidence to explain the cause of this inequity. The objective of this study was to determine whether medical comorbidities, area socioeconomic deprivation, or access to treatment can explain the greater COVID-19 related mortality among AI/AN individuals. The design was a retrospective cohort study of harmonized electronic health record data of all inpatients with COVID-19 from 21 United States health systems from February 2020 through January 2022. The mortality of AI/AN inpatients was compared to all Non-Hispanic White (NHW) inpatients and to a matched subsample of NHW inpatients. AI/AN inpatients were more likely to die during their hospitalization (13.2% versus 7.1%; odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.48, 2.65) than their matched NHW counterparts. After adjusting for comorbidities, area social deprivation, and access to treatment, the association between ethnicity and mortality was substantially reduced (OR 1.59, 95% CI 1.15, 2.22). The significant residual relation between AI/AN versus NHW status and mortality indicate that there are other important unmeasured factors that contribute to this inequity. This will be an important direction for future research.

Ethical publishing in 'Indigenous' contexts.

Ethical publishing practices are vital to tobacco control research practice, particularly research involving Indigenous (Indigenous peoples: For the purposes of this Special Communication, we use the term Indigenous people(s) to include self-identified individuals and communities who frequently have historical continuity with precolonial/presettler societies; are strongly linked to the land on which they or their societies reside; and often maintain their own distinct language(s), belief and social-political systems, economies and sciences. The authors humbly acknowledge, respect and value that Indigenous peoples are diverse and constitute many nations, cultures and language groups. Many Indigenous peoples also exist as governments in treaty relations with settler-colonial societies, and all Indigenous peoples have inherent rights under international law. The language and terminology used should reflect the local context(s) and could include, but are not limited to, terms such as Aboriginal, Bagumani, Cherokee, First Peoples, First Nations, Inuit, Iwaidja, Kungarakan, Lakota, Maori, Mѐtis, American Indian, Navajo, Wagadagam, Wiradjuri, Yurok, etc) people. These practices can minimise, correct and address biases that tend to privilege Euro-Western perspectives. Ethical publishing practices can minimise and address harms, such as appropriation and misuse of knowledges; strengthen mechanisms of accountability to Indigenous peoples and communities; ensure that tobacco control research is beneficial and meaningful to Indigenous peoples and communities; and support Indigenous agency, sovereignty and self-determination. To ensure ethical practice in tobacco control, the research methodology and methods must incorporate tangible mechanisms to include and engage those Indigenous peoples that the research concerns, affects and impacts.Tobacco Control is currently missing an ethical research and evaluation publishing protocol to help uphold ethical practice. The supporters of this Special Communication call on Tobacco Control to adopt publication practice that explicitly upholds ethical research and evaluation practices, particularly in Indigenous contexts. We encourage researchers, editors, peer reviewers, funding bodies and those publishing in Tobacco Control to reflect on their conduct and decision-making when working, developing and undertaking research and evaluation of relevance to Indigenous peoples.Tobacco Control and other publishers, funding bodies, institutions and research teams have a fundamental role in ensuring that the right peoples are doing the right work in the right way. We call for Tobacco Control to recognise, value and support ethical principles, processes and practices that underpin high-quality, culturally safe and priority-driven research, evaluation and science that will move us to a future that is commercial tobacco and nicotine free.

A Framework for Promoting Diversity, Equity, and Inclusion in Genetics and Genomics Research.

IMPORTANCE: Research into the genetic and genomic ("genomics") foundations of disease is central to our understanding of disease prevention, early detection, diagnostic accuracy, and therapeutic intervention. Inequitable participation in genomics research by historically excluded populations limits the ability to translate genomic knowledge to achieve health equity and ensure that findings are generalizable to diverse populations. OBSERVATIONS: We propose a novel framework for promoting diversity, equity, and inclusion in genomics research. Building on principles of community-based participatory research and collective impact frameworks, the framework can guide our understanding of the social, cultural, health system, policy, community, and individual contexts in which engagement and genomics research are being done. Our framework highlights the involvement of a multistakeholder team, including the participants and communities to be engaged, to ensure robust methods for recruitment, retention, return of genomic results, quality of engagement, follow-up, and monitoring of participants. CONCLUSIONS AND RELEVANCE: The proposed engagement framework will guide investigators in optimizing equitable representation in research and enhancing the rigor of genomics investigation.

Efficacy and Utilization of Smartphone Applications for Smoking Cessation Among American Indians and Alaska Natives: Results From the iCanQuit Trial.

INTRODUCTION: There is tremendous need for efficacious and accessible interventions for smoking cessation among American Indians and Alaska Natives. We tested the efficacy of an Acceptance and Commitment Therapy (ACT)-based smartphone application (iCanQuit) versus US Clinical Practice Guidelines-based smartphone application (QuitGuide) for smoking cessation among American Indians and Alaska Natives. AIMS AND METHODS: We compared cessation, changes in ACT-based processes, engagement and satisfaction between American Indian and Alaska Native iCanQuit (n = 89) and QuitGuide (n = 80) participants enrolled in the iCanQuit trial. The primary outcome was self-reported, complete-case, 30-day point-prevalence abstinence. Follow-up timepoints were 12, 6, and 3 months. RESULTS: Randomized American Indians and Alaska Natives from 31 US states (70% urban, 30% rural, with 25% of participants residing on tribal land). The outcome data retention rates were 93%, 92%, and 90% at the 12-, 6-, and 3-month follow-ups, respectively, with no differential retention between arms. The 30-day point-prevalence abstinence for iCanQuit versus QuitGuide was 30% versus 18% at 12 months (odds ratio [OR] = 1.96; 95% confidence interval [CI]: 0.90 to 4.26) 25% versus 11% at 6 months (OR = 2.62; 95% CI: 1.06 to 6.45), and 15% versus 6% at 3 months (OR = 2.93; 95% CI: 0.90 to 9.59). Increases in acceptance of internal cues to smoke mediated the effect of treatment on smoking cessation at 12 months. iCanQuit arm participants were also significantly more engaged and satisfied with their assigned application. CONCLUSIONS: In a nationwide sample with high data retention and participant engagement, this is the first study to show that a digital intervention may be efficacious for helping American Indians and Alaska Natives quit smoking. IMPLICATIONS: This is the first study to provide evidence of an efficacious, accessible, and engaging treatment for helping American Indians and Alaska Natives quit smoking. Compared to a US Clinical Practice Guidelines-based smartphone application (QuitGuide), an ACT-based smartphone application (iCanQuit) was more efficacious, engaging, and satisfactory among American Indians and Alaska Natives nationwide. Our results will inform the tailoring of the iCanQuit smartphone application for American Indian and Alaska Native tribal communities and organizations with potential for broad dissemination and high impact.

The First 10 Years: Reflecting on Opportunities and Challenges of the Tobacco Products Scientific Advisory Committee of the United States Food and Drug Administration.

Introduction: Tobacco control policies have helped to reduce the health, social, and economic burden of commercial tobacco use worldwide. Little is known about the long-term impact of regulatory policies and functioning bodies that make recommendations to inform policies. The Tobacco Products Scientific Advisory Committee (TPSAC) of the U.S. Food and Drug Administration (FDA) was formed in 2009 to evaluate the safety, health, and dependence of tobacco products and provide related advice and recommendations to the FDA and the Secretary of Health and Human Services. This article describes the first 10 years of the TPSAC activities and reflects on the impact of their service on regulatory actions.Methods: We reviewed public documents from the 2010-2019 TPSAC meetings to examine the purposes, TPSAC decisions, public health participation in meetings, and concordance of the TPSAC recommendations with regulatory actions. Meeting agendas, transcripts, public testimony, and presentations were reviewed to obtain this information.Results: Since 2010, the TPSAC held 25 public meetings with 178 speakers who provided oral public testimony. Sixty-four percent of meetings were held from 2010 to 2012, when three congressionally mandated reports were due on the topics of menthol cigarettes, harmful and potentially harmful constituents in tobacco products, and dissolvable tobacco products. Forty-four percent of meetings focused on menthol cigarettes, 32% on modified risk tobacco products, 16% on harmful and potentially harmful constituents, 12% on dissolvable tobacco, and 4% on tobacco addiction/dependence. FDA regulatory actions were largely nonconcordant with voting decisions by TPSAC.Conclusions: The TPSAC has evaluated an enormous amount of science during the first 10 years, but their influence on regulatory policies has been limited. The TPSAC roles and functioning should be reevaluated to determine how TPSAC can better fulfill its mandate to inform the FDA's regulatory decision making, which could ultimately reduce the burden of tobacco use in the United States.

Active smoking, secondhand smoke exposure and serum cotinine levels among Cheyenne River Sioux communities in context of a Tribal Public Health Policy.

INTRODUCTION: American Indians and Alaska Natives face disproportionately high rates of smoking and secondhand smoke (SHS) exposure. The Cheyenne River Sioux Tribe (CRST) is among the few Tribal Nations controlling commercial tobacco exposures in public and work places. We had an opportunity to explore effects of the new commercial tobacco-free policy (implemented in 2015) in an environmental health study (2014-2016) that collected information about commercial tobacco use and SHS prevalence and examined predictor variables of serum cotinine concentrations. METHODS: Self-reported survey data were used in quantile regression statistical modelling to explore changes in cotinine levels, based on smoking status, smokeless tobacco consumption and SHS exposure. RESULTS: From enrolled 225 adults, 51% (N=114) were current smokers. Among 88 non-tobacco users, 35 (40%) reported current SHS exposure. Significant differences in cotinine median concentrations were found among participants with and without current SHS exposure. Extremely high cotinine concentrations (~100 times larger than the median) were detected in some non-tobacco users. After implementing the new smoke-free air Tribal policy, cotinine decreased in participants with intermediate (3-15 ng/mL, non-tobacco users with SHS exposure) and high (>15 ng/mL, mainly tobacco users) cotinine levels showing association with an abatement of opportunities for SHS exposure. Significant predictors of cotinine levels were sampling year, current smoking and tobacco chewing. No gender differences were observed in cotinine. CONCLUSIONS: Our results show decrease in cotinine concentrations in CRST participants since implementation of their 'Smoke-Free Clean Air Act' in 2015.

Diné (Navajo) Healer Perspectives on Commercial Tobacco Use in Ceremonial Settings: An Oral Story Project to Promote Smoke-Free Life.

Many American Indian (AI) healers are faced with a dilemma of how to maintain the ceremonial uses of traditional tobacco meant to encourage the restoration and balance of mind, body, and spirit, while discouraging commercial tobacco use and protecting against secondhand smoke exposure in ceremonial settings. To explore this dilemma and offer culturally informed solutions, researchers conducted qualitative interviews with Navajo healers who describe the history and role of commercial tobacco within ceremonial contexts. Healers understand the importance of their role on their community's health and expressed deep concern about the use of commercial tobacco in the ceremonial setting. Healers play an important role in curbing the use of commercial tobacco and limiting the exposure to secondhand smoke in ceremonial settings and beyond. Study implications include the importance of understanding traditional and cultural knowledge and its potential as a pathway to solve contemporary public health issues facing AI communities.

Commercial tobacco and indigenous peoples: a stock take on Framework Convention on Tobacco Control progress.

BACKGROUND: The health status and needs of indigenous populations of Australia, Canada and New Zealand are often compared because of the shared experience of colonisation. One enduring impact has been a disproportionately high rate of commercial tobacco use compared with non-indigenous populations. All three countries have ratified the WHO Framework Convention on Tobacco Control (FCTC), which acknowledges the harm caused to indigenous peoples by tobacco. AIM AND OBJECTIVES: We evaluated and compared reporting on FCTC progress related to indigenous peoples by Australia, Canada and New Zealand as States Parties. The critiqued data included disparities in smoking prevalence between indigenous and non-indigenous peoples; extent of indigenous participation in tobacco control development, implementation and evaluation; and what indigenous commercial tobacco reduction interventions were delivered and evaluated. DATA SOURCES: We searched FCTC: (1) Global Progress Reports for information regarding indigenous peoples in Australia, Canada and New Zealand; and (2) country-specific reports from Australia, Canada and New Zealand between 2007 and 2016. STUDY SELECTION: Two of the authors independently reviewed the FCTC Global and respective Country Reports, identifying where indigenous search terms appeared. DATA EXTRACTION: All data associated with the identified search terms were extracted, and content analysis was applied. RESULTS: It is difficult to determine if or what progress has been made to reduce commercial tobacco use by the three States Parties as part of their commitments under FCTC reporting systems. There is some evidence that progress is being made towards reducing indigenous commercial tobacco use, including the implementation of indigenous-focused initiatives. However, there are significant gaps and inconsistencies in reporting. Strengthening FCTC reporting instruments to include standardised indigenous-specific data will help to realise the FCTC Guiding Principles by holding States Parties to account and building momentum for reducing the high prevalence of commercial tobacco use among indigenous peoples.

Variation in CYP2A6 and nicotine metabolism among two American Indian tribal groups differing in smoking patterns and risk for tobacco-related cancer.

OBJECTIVE: The Northern Plains (NP) and Southwest (SW) American Indian populations differ in their smoking patterns and lung cancer incidence. We aimed to compare CYP2A6 genetic variation and CYP2A6 enzyme activity (representative of the rate of nicotine metabolism) between the two tribal populations as these have previously been associated with differences in smoking, quitting, and lung cancer risk. PARTICIPANTS AND METHODS: American Indians (N=636) were recruited from two different tribal populations (NP in South Dakota, SW in Arizona) as part of a study carried out as part of the Collaborative to Improve Native Cancer Outcomes P50 Project. A questionnaire assessed smoking-related traits and demographics. Participants were genotyped for CYP2A6 genetic variants *1B, *2, *4, *7, *9, *12, *17, and *35. Plasma and/or saliva samples were used to measure nicotine's metabolites cotinine and 3'-hydroxycotinine and determine CYP2A6 activity (3'-hydroxycotinine/cotinine, i.e. the nicotine metabolite ratio, NMR). RESULTS: The overall frequency of genetically reduced nicotine metabolizers, those with CYP2A6 decrease-of-function or loss-of-function alleles, was lower in the NP compared with the SW (P=0.0006). The CYP2A6 genotype was associated with NMR in both tribal groups (NP, P<0.0001; SW, P=0.04). Notably, the rate of nicotine metabolism was higher in NP compared with SW smokers (P=0.03), and in comparison with other ethnic groups in the USA. Of the variables studied, the CYP2A6 genotype was the only variable to significantly independently influence NMR among smokers in both tribal populations (NP, P<0.001; SW, P=0.05). CONCLUSION: Unique CYP2A6 allelic patterns and rates of nicotine metabolism among these American Indian populations suggest different risks for smoking, and tobacco-related disease.

Breathing clean air is Sa'áh Naagháí Bik'eh Hózhóó (SNBH): a culturally centred approach to understanding commercial smoke-free policy among the Diné (Navajo People).

INTRODUCTION: Indigenous worldviews and research approaches are fundamental to make meaning of complex health issues and increase the likelihood of identifying existing cultural protective factors that have contributed to the resilience and survival of Indigenous people worldwide. OBJECTIVE: We describe the process for applying the Diné (Navajo) paradigm of Sa'áh Naagháí Bik'eh Hózhóó (SNBH), a belief system that guides harmonious living, and demonstrate how the application of SNBH enhances understanding of Navajo principles for well-being. Specifically, we juxtapose this analysis with a conventional qualitative analysis to illuminate and interpret Diné perspectives on the health and economic impact of commercial secondhand smoke and smoke-free policy. METHODS: Focus groups were conducted throughout Navajo Nation to assess the appeal and impact of several evidence-based messages regarding the health and economic impact of smoke-free policy. RESULTS: Diné perspectives have shifted away from family and cultural teachings considered protective of a smoke-free life, and struggle to balance the ethical and economics of respect for individual and collective rights to live and work in smoke-free environments. CONCLUSIONS: Indigenous-centred approaches to public health research and policy analysis contribute to understanding the cultural knowledge, practices and beliefs that are protective of the health and well-being of Indigenous people.

Advancing smoke-free policy adoption on the Navajo Nation.

BACKGROUND: Comprehensive smoke-free laws are effective at protecting non-smokers and reducing tobacco use, yet they are not widely adopted by tribal governments. METHODS: A series of smoke-free policy initiatives on the Navajo Nation, beginning in 2008, were reviewed to identify key issues, successes and setbacks. RESULTS: It has been essential that proposed policies acknowledge the Navajo people's spiritual use of nát'oh, a sacred plant used for gift-giving, medicinal purposes and traditional ceremonies, while simultaneously discouraging a secular use of commercial tobacco. Concern that smoke-free policies economically harm tribal casinos has been a major barrier to broad implementation of comprehensive smoke-free laws in Navajo Nation. CONCLUSIONS: It is necessary for tobacco control researchers and advocates to build relationships with tribal leaders and casino management in order to develop the business case that will take comprehensive smoke-free policies to scale throughout tribal lands.

Working to Eliminate Cancer Health Disparities from Tobacco: A Review of the National Cancer Institute's Community Networks Program.

INTRODUCTION: In 2005, the National Cancer Institute funded the Community Networks Program (CNP), which aimed to reduce cancer health disparities in minority racial/ethnic and underserved groups through community-based participatory research, education, and training. The purpose of this study was to describe the CNP model and their tobacco-related work in community-based research, education, and training using a tobacco disparities research framework. METHODS: We conducted a comprehensive review of the CNP tobacco-related activities including publications, published abstracts, research activities, trainee pilot studies, policy-related activities, educational outreach, and reports produced from 2005-2009. Two authors categorized the tobacco-related activities and publications within the framework. RESULTS: Although there was no mandate to address tobacco, the CNPs produced 103 tobacco-related peer-reviewed publications, which reflects the largest proportion (12%) of all CNP cancer-related publications. Selected publications and research activities were most numerous under the framework areas "Psychosocial Research," "Surveillance," "Epidemiology," and "Treatment of Nicotine Addiction." Thirteen CNPs participated in tobacco control policymaking in mainstream efforts that affected their local community and populations, and 24 CNPs conducted 1147 tobacco-related educational outreach activities. CNP activities that aimed to build research and infrastructure capacity included nine tobacco-related pilot projects representing 16% of all CNP cancer-related pilot projects, and 17 publications acknowledging leveraged partnerships with other organizations, a strategy encouraged by the CNP. CONCLUSIONS: The CNP is a promising academic-community model for working to eliminate tobacco-related health disparities. Future efforts may address scientific gaps, consider collaboration across groups, assess the extent of operationalizing community-based participatory research, and improve common tracking measures.

Disparities in Smoking-Related Mortality Among American Indians/Alaska Natives.

INTRODUCTION: Smoking-related disparities continue to be a public health problem among American Indian/Alaska Native (AI/AN) population groups and data documenting the health burden of smoking in this population are sparse. The purpose of this study was to assess mortality attributable to cigarette smoking among AI/AN adults relative to non-Hispanic white adults (whites) by calculating and comparing smoking-attributable fractions and mortality. METHODS: Smoking-attributable fractions and mortality among AI/ANs (n=1.63 million AI/ANs) and whites were calculated for people living in 637 Indian Health Service Contract Health Service Delivery Area counties in the U.S., from mortality data collected during 2001-2009. Differences in smoking-attributable mortality between AI/ANs and whites for five major causes of smoking-related deaths were examined. All data analyses were carried out in 2013-2014. RESULTS: Overall, from 2001 to 2009, age-adjusted death rates, smoking-attributable fractions, and smoking-attributable mortality for all-cause mortality were higher among AI/ANs than among whites for adult men and women aged ≥35 years. Smoking caused 21% of ischemic heart disease, 15% of other heart disease, and 17% of stroke deaths in AI/AN men, compared with 15%, 10%, and 9%, respectively, for white men. Among AI/AN women, smoking caused 18% of ischemic heart disease deaths, 13% of other heart diseases deaths, and 20% of stroke deaths, compared with 9%, 7%, and 10%, respectively, among white women. CONCLUSIONS: These findings underscore the need for comprehensive tobacco control and prevention efforts that can effectively reach and impact the AI/AN population to prevent and reduce smoking.

Religio-Spiritual Participation in Two American Indian Populations.

Following a previous investigation of religio-spiritual beliefs in American Indians, this article examined prevalence and correlates of religio-spiritual participation in two tribes in the Southwest and Northern Plains (N = 3,084). Analysis suggested a "religious profile" characterized by strong participation across three traditions: aboriginal, Christian, and Native American Church. However, sociodemographic variables that have reliably predicted participation in the general American population, notably gender and age, frequently failed to achieve significance in multivariate analyses for each tradition. Religio-spiritual participation was strongly and significantly related to belief salience for all traditions. Findings suggest that correlates of religious participation may be unique among American Indians, consistent with their distinctive religious profile. Results promise to inform researchers' efforts to understand and theorize about religio-spiritual behavior. They also provide tribal communities with practical information that might assist them in harnessing social networks to confront collective challenges through community-based participatory research collaborations.

Patterns of cigarette smoking initiation in two culturally distinct American Indian tribes.

OBJECTIVES: To better understand patterns of initiation among American Indians we examined age-related patterns of smoking initiation during adolescence and young adulthood in 2 American Indian tribes. METHODS: We used log-rank comparison and a Cox proportional hazard regression model to analyze data from a population-based study of Southwest and Northern Plains American Indians aged 18 to 95 years who initiated smoking by age 18 years or younger. RESULTS: The cumulative incidence of smoking initiation was much higher among the Northern Plains Indians (47%) than among the Southwest Indians (28%; P < .01). In the Southwest, men were more likely than women to initiate smoking at a younger age (P < .01); there was no such difference in the Northern Plains sample. Northern Plains men and women in more recent birth cohorts initiated smoking at an earlier age than did those born in older birth cohorts. Southwest men and women differed in the pattern of smoking initiation across birth cohorts as evidenced by the significant test for interaction (P = .01). CONCLUSION: Our findings underscore the need to implement tobacco prevention and control measures within American Indian communities.