Tribal Tobacco Use Project II: Planning, Implementation, and Dissemination Using Culturally Relevant Data Collection among American Indian Communities.

American Indians have substantially higher commercial tobacco-related cancer rates when compared to the general population. To effectively combat commercial tobacco-related cancer, it is important that tribal nations obtain current and accurate community-specific data on commercial tobacco use and exposure-related attitudes and behaviors. With the goal to collect, synthesize, and disseminate data on tobacco use, including the role traditional tobacco plays among American Indian people, the American Indian Cancer Foundation (AICAF) and various stakeholders developed and implemented the Tribal Tobacco Use Project II (TTUP II) during 2018-2021. Building upon its predecessor, the Tribal Tobacco Use Project I (TTUP I), TTUP II used principles of community-based participatory research and culturally appropriate methods, such as Reality-Based Research, in partnership with tribal nations. We describe the TTUP II rationale, methods for participant recruitment and data collection, emphasizing the importance of using culturally relevant survey items to disentangle commercial tobacco use from traditional tobacco use. American Indian traditional tobacco is viewed as medicine in these communities with a unique socio-cultural context that must be addressed when engaging in commercial tobacco control efforts in American Indian communities. This approach may be useful to other tribal nations who are interested in conducting culturally relevant tobacco surveillance efforts.

Stroke Incidence and Survival in American Indians, Blacks, and Whites: The Strong Heart Study and Atherosclerosis Risk in Communities Study.

Background American Indians ( AIs ) have high stroke morbidity and mortality. We compared stroke incidence and mortality in AI s, blacks, and whites. Methods and Results Pooled data from 2 cardiovascular disease cohort studies included 3182 AI s from the SHS (Strong Heart Study), aged 45 to 74 years at baseline (1988-1990) and 3765 blacks and 10 413 whites from the ARIC (Atherosclerosis Risk in Communities) Study, aged 45 to 64 years at baseline (1987-1989). Stroke surveillance was based on self-report, hospital records, and death certificates. We estimated hazard ratios for incident stroke (ischemic and hemorrhagic combined) through 2008, stratified by sex and birth-year tertile, and relative risk for poststroke mortality. Incident strokes numbered 282 for AI s, 416 for blacks, and 613 for whites. For women and men, stroke incidence among AI s was similar to or lower than blacks and higher than whites. Covariate adjustment resulted in lower hazard ratios for most comparisons, but results for these models were not always statistically significant. After covariate adjustment, AI women and men had higher 30-day poststroke mortality than blacks (relative risk=2.1 [95% CI=1.0, 3.2] and 2.2 [95% CI=1.3, 3.1], respectively), and whites (relative risk=1.6 [95% CI=0.8, 2.5] and 1.7 [95% CI=1.1, 2.4]), and higher 1-year mortality (relative risk range=1.3-1.5 for all comparisons). Conclusions Stroke incidence in AI s was lower than for blacks and higher than for whites; differences were larger for blacks and smaller for whites after covariate adjustment. Poststroke mortality was higher in AI s than blacks and whites.

Feasibility of a Systems Approach to Treat Commercial Tobacco Dependence within American Indian Health Clinics.

American Indians and Alaska Natives (AI/ANs) have the highest smoking prevalence, smoking-related disease, and mortality rates of any racial or ethnic group. Three AI health clinics in Minnesota implemented an evidence-based tobacco dependence treatment intervention that included provider education and customized clinical system tools. A baseline assessment of each clinic facility guided the focus of the intervention and tailored the clinical system tools. Clinic staff were assessed with pre/post-training evaluations and annual assessments. Results indicated self-reported improvements in the rate of identifying smoking status (57% to 89%), documenting smoking status (from 60% to 80%), and providing evidence-based treatments such as pharmacotherapy (from 36% to 78%).

Trajectories of Cigarette Smoking From Teens to Young Adulthood: 2000 to 2013.

PURPOSE: To identify trajectories of smoking behaviors of a cohort of youth followed through young adulthood from 2000 to 2013. DESIGN: The Minnesota Adolescent Community Cohort study, a population-based cohort study. SETTING: Nationwide, originating in the Midwestern United States. PARTICIPANTS: Cohort of youth surveyed for 14 years beginning at ages 12 to 16 (N = 4241 at baseline; 59% recruitment rate). MEASURES: Main variable of interest was the number of days smoked in the past 30 days. Also included time-varying and time-invariant covariates. ANALYSIS: We utilized growth mixture modeling to group individuals into trajectories over time. RESULTS: We identified 5 distinct trajectories: nonsmokers (59.5%), early-onset regular smokers (14.2%), occasional smokers (11.5%), late-onset regular smokers (9.4%), and quitters (5.3%). Adjusted models showed that early- and late-onset regular smokers (compared to nonsmokers) had lower odds of attending or graduating from a 4-year college ( P < .05). Participants in all smoking classes compared to nonsmokers had greater odds of having more close friends who smoked ( P < .05). CONCLUSION: Our results show that individuals in their teens through young adulthood can be classified into 5 smoking trajectories. More people in this age range remained abstainers than found in most previous studies; however, a sizable group was identified as regular smokers by the time they reached young adulthood. Interventions targeted at teens, including those that address social and environmental influences, are clearly still needed to prevent escalation of smoking as they move toward young adulthood.

Sources and Number of Coupons for Cigarettes and Snus Received by a Cohort of Young Adults.

PURPOSE: To examine the sources of tobacco coupons and their influence on susceptibility to snus use. DESIGN: Cohort study. SETTING: Minnesota Adolescent Community Cohort Study. SUBJECTS: A population-based sample of US Midwest young adults in 2011 to 2012 and 2012 to 2013 (aged 22-28; n = 2384). MEASURES: Exposure to coupons for various tobacco products through various sources in the past 6 months, susceptibility to snus use. ANALYSIS: Multiple logistic regressions. RESULTS: During the 6 months prior to 2012 to 2013 survey, 11% of the sample received coupons for cigarettes, 5% received coupons for snus, 3% received coupons for other smokeless tobacco products, and <1% received coupons for little cigars. Direct mail was the most commonly cited source of cigarette and snus coupons. Tobacco product packaging provided the highest number of tobacco coupons for current and former smokers. Participants without a 4-year college education (compared to those who had a 4-year college education) were more likely to have received coupons for cigarettes and snus and received more coupons for both products ( P < .05). Racial/ethnic minority young adults (vs non-Hispanic white) received more cigarette and snus coupons ( P < .05). Receiving snus coupons was positively associated with susceptibility to snus use ( P < .05). CONCLUSION: Tobacco companies are successful in reaching young adults using coupons for various tobacco products. Snus coupons may influence snus use, similar to how cigarette coupons influence smoking.

Barriers to Quitting Smoking Among Young Adults: The Role of Socioeconomic Status.

PURPOSE: The aims of this analysis were to explore how self-reported barriers to quitting vary by socioeconomic status (SES) among young-adult smokers and to assess their relationship to quitting. DESIGN: This analysis uses 2 waves of telephone-survey data from the Minnesota Adolescent Community Cohort study. SETTING: Midwestern United States. PARTICIPANTS: Participants (n = 419) were smokers aged 17 to 24 years. MEASURES: Socioeconomic status was estimated using the highest level of education completed by the participants' parents. Demographics, smoking behavior, and perceived barriers to quitting were collected via survey questions. ANALYSIS: Differences in barriers by SES were assessed using prevalence ratios (PRs). Relative risks were calculated to assess the association between barriers and quitting status 1 year later, testing for effect modification by SES. RESULTS: Compared to the high SES group (n = 314), the low SES group (n = 105) was more likely to report several barriers to quitting; however, only the risk of gaining weight was significantly more common (PR: 1.38 [1.05-1.83]). There were no significant associations between barriers and quitting status 1 year later, but the number of cigarettes per day was consistently related to the likelihood of quitting 1 year later, regardless of SES. CONCLUSION: Despite the limited generalizability to racially diverse populations and different geographic locations, the results suggest perceived barriers may not differ by SES or predict quitting among young adults; however, nicotine dependence may play an important role.

Trends in self-efficacy to quit and smoking urges among homeless smokers participating in a smoking cessation RCT.

INTRODUCTION: In the U.S., approximately 73% of homeless adults smoke cigarettes and they experience difficulty quitting. Homeless smokers report low self-efficacy to quit and that smoking urges are a barrier to quitting. Self-efficacy to quit and smoking urges are dynamic and change throughout smoking cessation treatment. This study examines changes in self-efficacy to quit and smoking urges throughout a smoking cessation intervention among the homeless and identifies predictors of change in these characteristics. METHODS: Homeless smokers (n=430) participating in a smoking cessation randomized controlled trial in the U.S. completed surveys at baseline, and weeks 1, 2, 4, 6, 8, and 26 on demographic and smoking characteristics (i.e., confidence to quit, self-efficacy to refrain from smoking, and smoking urges). A growth curve analysis was conducted by modeling change in the smoking characteristics over time and examining the variability in the change in smoking characteristics by demographic characteristics and treatment group. RESULTS: Among the full sample, self-efficacy to refrain from smoking increased linearly over time, confidence to quit increased until the midpoint of treatment but subsequently decreased, and smoking urges decreased until the midpoint of treatment but subsequently increased. There were race differences in these trajectories. Racial minorities experienced significantly greater increases in self-efficacy to refrain from smoking than Whites and Blacks had higher confidence to quit than Whites. CONCLUSIONS: White participants experienced less increase in self-efficacy to refrain from smoking and lower confidence to quit and therefore may be a good target for efforts to increase self-efficacy to quit as part of homeless-targeted smoking cessation interventions. Sustaining high confidence to quit and low smoking urges throughout treatment could be key to promoting higher cessation rates among the homeless.

Trends in Awareness, Use of, and Beliefs About Electronic Cigarette and Snus Among a Longitudinal Cohort of US Midwest Young Adults.

Introduction: Few longitudinal studies have examined how awareness, use of, and beliefs about electronic cigarettes (e-cigarettes) and snus change over time. We assessed these trends in a cohort of young adults from the US Midwest. Methods: Data were from the Minnesota Adolescent Community Cohort (MACC) Study, collected annually during 2010-2013 when participants were 21-29 years old (n = 2622). Participants were asked if they had heard of and ever used e-cigarettes and snus, and the number of days they used these products in the past 30 days. Beliefs about whether these products are less harmful than cigarettes, less addictive than cigarettes, and could help people quit smoking were assessed. Repeated measures multiple linear and logistic regression models, adjusting for demographics, peer smoking and smoking status, were used to assess trends. Results: Compared to 2010-2011, participants in 2012-2013 were five times more likely to be aware of e-cigarettes, report ever used them, and report using them in the past 30-days. Increases in e-cigarette use were observed in all smoking status. Participants were also increasingly likely to believe that e-cigarettes are less harmful than combustible cigarettes and could help people quit smoking. There was only a modest increase in awareness of and ever using snus, as well as believing snus is less harmful than combustible cigarettes. These trends did not differ by smoking status. Conclusions: The increasingly favorable beliefs about e-cigarettes may explain the increasing prevalence of their use particularly among young adults, both among smokers and nonsmokers. Implications: Awareness and use of e-cigarettes have increased substantially over the past few years, and positive beliefs of e-cigarettes have also become more prevalent among young adults. Meanwhile, little changes in awareness, use of, and beliefs about snus among young adults. Given the potential of these products to have both positive and negative impact on public health depending on who use them and how they are used, strategically communicating the risks associated with e-cigarettes and snus use may help minimize the burden of tobacco use at the population level.

Cessation-related weight concern among homeless male and female smokers.

Concern about post-cessation weight gain is a barrier to making attempts to quit smoking; however, its effect on smoking cessation is unclear. In this study we examine cessation-related weight concern among the homeless, which hasn't been studied. Homeless males (n = 320) and females (n = 110) participating in a smoking cessation RCT in the Twin Cities, Minnesota from 2009 to 2011 completed surveys on cessation-related weight concern, smoking status, and components from the Behavioral Model for Vulnerable Populations. Generalized estimating equations were used to examine baseline predictors of cessation-related weight concern at baseline, the end of treatment, and 26-weeks follow-up. Logistic regression models were used to examine the relationship between cessation-related weight concern and smoking status at the end of treatment and follow-up. Females had higher cessation-related weight concern than males. Among males, older age, Black race, higher BMI, depression, and having health insurance were associated with higher cessation-related weight concern. Among females, nicotine dependence, greater cigarette consumption, indicating quitting is more important, older age of smoking initiation, and less support to quit from family were associated with higher cessation-related weight concern. In multivariate analyses, cessation-related weight concern decreased over time among females. Cessation-related weight concern wasn't associated with smoking cessation. Although several types of characteristics predicted cessation-related weight concern among males, only smoking characteristics predicted cessation-related weight concern among females. Given the small proportion of quitters in this study (8% of males and 5% of females), further research on the impact of cessation-related weight concern on smoking cessation among the homeless is warranted.

Cultural Contributors to Smoking Susceptibility Outcomes Among Latino Youth: The Padres Informados/Jovenes Preparados Participatory Trial.

Padres Informados/Jovenes Preparados is a community-based participatory, family-focused tobacco prevention intervention for immigrant Latino families of adolescents. We conducted a participatory randomized controlled trial including 352 Latino families. Parents and youth in the intervention condition engaged in eight family skill building sessions. Participants completed baseline and 6-month postintervention surveys assessing smoking susceptibility and contextual factors. While the intervention did not affect smoking susceptibility overall, it resulted in lower smoking susceptibility among youth in families with less adherence to traditional Latino cultural values. This family cultural orientation is a key consideration for tobacco prevention interventions focused on Latino youth.

Influences and Practices in Colorectal Cancer Screening Among Health Care Providers Serving Northern Plains American Indians, 2011-2012.

INTRODUCTION: The epidemiology of colorectal cancer, including incidence, mortality, age of onset, stage of diagnosis, and screening, varies regionally among American Indians. The objective of the Improving Northern Plains American Indian Colorectal Cancer Screening study was to improve understanding of colorectal cancer screening among health care providers serving Northern Plains American Indians. METHODS: Data were collected, in person, from a sample of 145 health care providers at 27 health clinics across the Northern Plains from May 2011 through September 2012. Participants completed a 32-question, self-administered assessment designed to assess provider practices, screening perceptions, and knowledge. RESULTS: The proportion of providers who ordered or performed at least 1 colorectal cancer screening test for an asymptomatic, average-risk patient in the previous month was 95.9% (139 of 145). Of these 139 providers, 97.1% ordered colonoscopies, 12.9% ordered flexible sigmoidoscopies, 73.4% ordered 3-card, guaiac-based, fecal occult blood tests, and 21.6% ordered fecal immunochemical tests. Nearly two-thirds (64.7%) reported performing in-office guaiac-based fecal occult blood tests using digital rectal examination specimens. Providers who reported receiving a formal update on colorectal cancer screening during the previous 24 months were more likely to screen using digital rectal exam specimens than providers who had received a formal update on colorectal cancer screening more than 24 months prior (73.9% vs 56.9%, respectively, χ2 = 4.29, P = .04). CONCLUSION: Despite recommendations cautioning against the use of digital rectal examination specimens for colorectal cancer screening, the practice is common among providers serving Northern Plains American Indian populations. Accurate up-to-date, ongoing education for patients, the community, and health care providers is needed.

Cigarette Smoking Among Urban American Indian Adults - Hennepin and Ramsey Counties, Minnesota, 2011.

In 2013, it was estimated that the prevalence of cigarette smoking among American Indians was 36.5%, the highest of all racial/ethnic groups in the continental United States (1). Among American Indians, considerable cultural and geographic variation in cigarette smoking exists. Smoking prevalence among American Indians is lowest in the Southwest and highest in the Upper Midwest/Northern Plains (2). Little information is available about tobacco use among urban American Indians, who might not have ever lived on a reservation or be enrolled in or affiliated with a tribe. In Minnesota, a significant proportion of American Indians reside in urban areas. Among Minnesota's residents who identify as American Indian alone or in combination with another race, 30% live in Hennepin County and Ramsey County, which encompass Minneapolis and St. Paul, respectively (collectively known as the Twin Cities). The predominant tribes (Ojibwe [Chippewa] and Dakota/Lakota/Nakota [Sioux]) traditionally have used locally grown tobacco (Nicotiana rustica), red willow, and other plants for religious ceremonies, although nonceremonial tobacco is often substituted for traditional plants. To assess prevalence of cigarette smoking among this population, it is important to distinguish ceremonial tobacco use (smoked or used in other ways) from nonceremonial tobacco use. To obtain estimates of cigarette smoking prevalence among American Indians in Hennepin and Ramsey counties, the American Indian Adult Tobacco Survey was administered to 964 American Indian residents in 2011, using respondent-driven sampling. Among all participants, 59% were current smokers, 19% were former smokers, and 22% had never smoked. Approximately 40% of employed participants reported that someone smoked in their workplace area during the preceding week. High prevalences of cigarette smoking and secondhand smoke exposure among urban American Indians in Minnesota underscores the need for a comprehensive and culturally appropriate approach to reducing nonceremonial tobacco use.

Social and Environmental Factors Related to Smoking Cessation among Mothers: Findings from the Geographic Research on Wellbeing (GROW) Study.

OBJECTIVES: The current study examined associations between race/ethnicity and psychosocial/environmental factors with current smoking status, and whether psychosocial/environmental factors accounted for racial differences in smoking status in a population-based sample of mothers in California. METHODS: Cross-sectional data from 542 women with a history of smoking were used. Analyses adjusted for age, partner status, and educational attainment. RESULTS: In models adjusted for sociodemographics, black women had significantly lower odds, and Latina immigrants had significantly higher odds of being a former smoker compared to white women. Persons smoking in the home, having a majority of friends who smoke, having perceptions of their neighborhood as being somewhat or very unsafe, and experiencing food insecurity were associated with decreased odds of being a former smoker. When these variables were entered into a single model, only being a Latina immigrant and having a majority of friends who smoke were significantly associated with smoking status. CONCLUSIONS: Black women demonstrated a notable disparity compared with white women in smoking status, accounted for by psychosocial/environmental factors. Immigrant Latinas demonstrated notable success in ever quitting smoking. Social networks may be important barriers to smoking cessation among women.

Economic Impact of Tobacco Price Increases Through Taxation: A Community Guide Systematic Review.

CONTEXT: Tobacco use is a leading cause of preventable death in the U.S. and around the world. Increasing tobacco price through higher taxes is an effective intervention both to reduce tobacco use in the population and generate government revenues. The goal of this paper is to review evidence on the economic impact of tobacco price increases through taxation with a focus on the likely healthcare cost savings and improvements in employee productivity. EVIDENCE ACQUISITION: The search covered studies published in English from January 2000 to July 2012 and included evaluations of national, state, and local policies to increase the price of any type of tobacco product by raising taxes in high-income countries. Economic review methods developed for The Guide to Community Preventive Services were used to screen and abstract included studies. Economic impact estimates were standardized to summarize the available evidence. Analyses were conducted in 2012. EVIDENCE SYNTHESIS: The review included eight modeling studies, with seven providing estimates of the impact on healthcare costs and three providing estimates of the value of productivity gains. Only one study provided an estimate of intervention costs. The economic merit of tobacco product price increases through taxation was determined from the overall body of evidence on per capita annual cost savings from a conservative 20% price increase. CONCLUSIONS: The evidence indicates that interventions that raise the unit price of tobacco products through taxes generate substantial healthcare cost savings and can generate additional gains from improved productivity in the workplace.

Snus use and smoking behaviors: preliminary findings from a prospective cohort study among US Midwest young adults.

The effect of snus use on smoking behaviors among US young adults is largely unknown. Data from the Minnesota Adolescent Community Cohort Study collected in 2010 to 2011 and 2011 to 2012 (participants aged 20-28 years) showed that young adult nonsmokers who had tried snus were subsequently more likely than those who had not tried snus to become current smokers (n = 1696; adjusted odds ratio = 1.79; 95% confidence interval = 1.01, 3.14). Snus use was not associated with subsequent smoking cessation or reduction among young adult current smokers (n = 488; P > .46).

Frequency and characteristics associated with exposure to tobacco direct mail marketing and its prospective effect on smoking behaviors among young adults from the US Midwest.

OBJECTIVES: We examined the exposure to tobacco direct mail marketing and its effect on subsequent smoking behaviors in a US Midwest regional cohort of young adults. METHODS: Data were collected from 2622 young adults (mean age = 24 years) in 2010 to 2011 (baseline) and 2011 to 2012 (follow-up). We collected information on demographics, tobacco use, and exposure to tobacco direct mail materials in the previous 6 months at baseline. Smoking behaviors were reassessed at follow-up. We investigated the characteristics associated with receiving these materials at baseline, and the associations between receiving cigarette coupons in the mail at baseline and smoking behaviors at follow-up. RESULTS: Thirteen percent of participants reported receiving tobacco direct mail materials in the previous 6 months. Receipt of these materials was associated with age, education, and tobacco use (P < .05). Among those who received these materials, 77% and 56% reported receiving coupons for cigarettes and other tobacco products, respectively. Among baseline nonsmokers and ex-smokers, receiving coupons was associated with becoming current smokers at follow-up (P < .05). Among baseline current smokers, receiving coupons was associated with lower likelihood of smoking cessation at follow-up (P < .05). CONCLUSIONS: Tobacco direct mail marketing promoted and sustained smoking behaviors among US Midwest young adults. Regulating this marketing strategy might reduce the prevalence of smoking in this population.

Latent classes of young adults based on use of multiple types of tobacco and nicotine products.

INTRODUCTION: New tobacco and nicotine products such as snus, hookah, and electronic cigarettes have risen in popularity in recent years. Use of these products among young adults is of particular interest given that experimentation with new products is common in young adulthood. METHODS: We conducted latent class analysis among a population-based sample of young adults to identify separate classes based on use of 6 types of tobacco or nicotine products: snus, hookah, electronic cigarettes, cigarillos, snuff, and cigarettes. We then examined how identified classes differed on demographic characteristics and marijuana and alcohol use. RESULTS: We identified 5 classes: the largest group (60%) was characterized as reporting no or limited use of any of the products, while the smallest group (7%) was characterized by use of many types of products (poly-users). Of the 3 middle classes, 2 were the same size (10%) and were characterized by primarily using 2 of the products: one class used snus and snuff, and the other used cigarillos and hookah; the third class (13%) was characterized by primarily cigarette smoking. Numerous differences were seen across classes, including the poly-users being less likely to be college students/graduates and more likely to be male and use marijuana and alcohol. CONCLUSIONS: We found that young adults can be grouped into 5 subgroups based on types of tobacco/nicotine products they do and do not use. A poly-use group that uses all types of tobacco products is concerning, particularly given high levels of marijuana and alcohol use reported in this group.

Do Sources of Cigarettes Among Adolescents Vary by Age Over Time?

Trends in sources of cigarettes among adolescents were assessed using data from a teen cohort (2000-2006). Five sources-bought from store, got from other teen, stole from others, bought from others, and got from an adult-were measured over time by age. The most common source among all ages was other teens. Fewer teens bought cigarettes from stores, with a downward trend for all ages. Among all ages there was an upward trend in stealing with younger teens more likely to steal cigarettes. In addition to targeting cigarette sales, interventions are needed to target other youth cigarette sources.

Transitions in smoking behavior during emerging adulthood: a longitudinal analysis of the effect of home smoking bans.

OBJECTIVES: We studied the effect of home smoking bans on transitions in smoking behavior during emerging adulthood. METHODS: We used latent transition analysis to examine movement between stages of smoking from late adolescence (ages 16-18 years) to young adulthood (ages 18-20 years) and the effect of a home smoking ban on these transitions. We used data from the Minnesota Adolescent Community Cohort study collected in 2004 to 2006. RESULTS: Overall, we identified 4 stages of smoking: (1) never smokers, (2) experimental smokers, (3) light smokers, and (4) daily smokers. Transition probabilities varied by stage. Young adults with a home ban during late adolescence were less likely to be smokers and less likely to progress to higher use later. Furthermore, the protective effect of a home smoking ban on the prevalence of smoking behavior was evident even in the presence of parental smoking. However, this effect was less clear on transitions over time. CONCLUSIONS: In addition to protecting family members from exposure to secondhand smoke, home smoking bans appear to have the additional benefit of reducing initiation and escalation of smoking behavior among young adults.