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, Māori, 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.

Commercial Tobacco Retailing in Tribal Jurisdictions: A Field Study

Objectives: Our objective was to provide data contrasting commercial tobacco retailing in Tribal versus non-Tribal jurisdictions, in 3 states. These data may be relevant for US Food and Drug Administration regulation of Tribal retailing. Methods: With Tribal permission, observations were made on commercial tobacco advertising, product variety, pricing, and retail concept for stores within and just outside Tribal jurisdictions in areas of Arizona (AZ), California (CA), and Oklahoma (OK). Results: A total of 87 Tribal (20 AZ, 53 CA, 14 OK) and 67 (10, 43, 14) non-Tribal retailer visits were completed. There was substantial variation across tribes, with sales in AZ and most CA Tribal jurisdictions handled at convenience stores, whereas OK Tribal retailing was done mostly in specialized tobacco-specialty shops. Electronic cigarettes were ubiquitous across Tribal and non-Tribal outlets. Advertising and breadth of cigarette offerings was most extensive in the tobacco specialty retailers of Tribal OK. Surprisingly, Tribally manufactured cigarettes were found only at some CA Tribal retailers. Conclusions: Some Tribal commercial tobacco outlets actually price above their non-Tribal competitors and there is substantial variation in retailing strategy across Tribal jurisdictions. Tribal governments can continue to evaluate and reform commercial tobacco retailing so as to improve Tribal health.

Genetics of Smoking Behaviors in American Indians

BACKGROUND

The smoking behavior of American Indians (AI) differs from that of non-Hispanic whites (NHW). Typically light smokers, cessation interventions in AIs are generally less effective. To develop more effective cessation programs for AIs, clinicians, researchers, and public health workers need a better understanding of the genetic factors involved in their smoking behavior. Our aim was to assess whether SNPs associated with smoking behavior in NHWs are also associated with smoking in AIs.

METHODS

We collected questionnaire data on smoking behaviors and analyzed blood and saliva samples from two Tribal populations with dramatically different cultures and smoking prevalence, one in the Northern Plains (n = 323) and the other in the Southwest (n = 176). A total of 384 SNPs were genotyped using an Illumina custom GoldenGate platform. Samples were also assessed for cotinine and 3-hydroxycotinine as markers of nicotine intake and nicotine metabolite ratio.

RESULTS

Among 499 participants, we identified, in the Northern Plains sample only, a variant of the gamma-aminobutyric acid receptor subunit alpha-2 (GABRA2) (rs2119767) on chromosome 4p that was associated with many of the intake biomarkers of smoking we examined, suggesting a role for this gene in modifying smoking behavior in this population. We also identified three SNPs, in the Southwest sample only, as significant correlates of only cigarettes per day: rs4274224, rs4245147 (both dopamine receptor D2 gene), and rs1386493 (tryptophan hydroxylase 2 gene).

CONCLUSIONS

The contribution of many genes known to underlie smoking behaviors in NHWs may differ in AIs.

IMPACT

Once validated, these variants could be useful in developing more effective cessation strategies.

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.

Relationships Between Smoking Behaviors and Cotinine Levels Among Two American Indian Populations With Distinct Smoking Patterns

Introduction

Smoking prevalence, cigarettes per day (CPD), and lung cancer incidence differ between Northern Plains (NP) and Southwest (SW) American Indian populations. We used cotinine as a biomarker of tobacco smoke exposure to biochemically characterize NP and SW smokers and nonsmokers and to investigate factors associated with variation in tobacco exposure.

Methods

American Indians (N = 636) were recruited from two different tribal populations (NP and SW) as part of a study conducted as part of the Collaborative to Improve Native Cancer Outcomes P50 project. For each participant, a questionnaire assessed smoking status, CPD, second-hand smoke exposure, and traditional ceremonial tobacco use; plasma and/or salivary cotinine was measured.

Results

Cotinine levels were (mean ± 95% confidence interval [CI]) 81.6 ± 14.1 and 21.3 ± 7.3 ng/ml among NP smokers and non-mokers, respectively, and 44.8 ± 14.4 and 9.8 ± 5.8 ng/ml among SW smokers and nonsmokers, respectively. Cotinine levels correlated with CPD in both populations (p < .0001). Cotinine ≥15 ng/ml was measured in 73.4% of NP smokers and 47.8% of SW smokers and in 19.0% of NP nonsmokers and 10.9% of SW nonsmokers. Ceremonial traditional tobacco use was associated with higher cotinine among NP smokers only (p = 0.004). Second-hand smoke exposure was associated with higher cotinine among NP non-smokers (P < 0.02). More secondhand smoke exposure was associated with smoking more CPD in both populations (p = 0.03-0.29). Linear regression modeling mirrored these findings.

Conclusions

High prevalence of smoking in the Northern Plains and high cotinine levels among nonsmokers in both regions highlights the tribal populations' risk for tobacco-related disease.

Implications

There is a high prevalence of smoking in Northern Plains American Indians. Among Northern Plains and Southwest nonsmokers, relatively high cotinine levels, representative of high tobacco exposure, suggest considerable exposure to second-hand smoke. It is critical to highlight the extent of second-hand smoke exposure among the Northern Plains and Southwest American Indians and to enhance efforts to initiate smoke-free policies in tribal communities, which are not subject to state-level polices.

Effect of the Smoke-Free Illinois Act on casino admissions and revenue

OBJECTIVE

As part of the Smoke-Free Illinois Act, smoking on the gambling floors of all commercial casinos in Illinois became prohibited. This study examined the effects of the Smoke-Free Illinois Act on casino admissions per-capita and real per-capita adjusted gross receipts using 18 years of data (10 years before and 8 years after the Illinois law went into effect).

METHODS

We employed a difference-in-difference regression technique using monthly data for the states of Illinois, Indiana, Iowa and Missouri and control for numerous determinants expected to affect casino admissions and revenue.

RESULTS

The Smoke-free Illinois Act was found not to be a statistically significant determinant of per-capita casino admissions and of real per-capita gross adjusted receipts in all the models we estimated.

CONCLUSIONS

The estimates from this study clearly indicated that the Illinois law that banned smoking in casinos has had no significant negative economic consequences for casinos in terms of per-capita admissions or revenues.

Breathing clean air is Są'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 Są’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.

Master Settlement Agreement Compliance Tobacco Directories: A Tool to Track Tribally Manufactured Cigarettes

INTRODUCTION

Little is known about the scope of the tribally manufactured cigarette market. This study illuminates the topic by examining the Master Settlement Agreement Compliance Tobacco Directories, regularly updated documents that list the cigarette manufacturers and brand families that can be legally sold within participating states.

METHODS

In July 2014, the latest Tobacco Directories were identified for 43 states and the District of Columbia. Colorado archival tobacco directories were extracted, by month since 2003. Tribal manufacturers and brands were identified in the directories and mapped by state.

RESULTS

A total of 11 tribal manufacturers and 39 tribal cigarette brand families were identified in publicly available tobacco directories. Total unique brands were tallied by state, ranging from 1 to 24 unique brands. Historical data from Colorado showed that tribal manufacturers, as a percentage of all manufacturers, increased from 3.2% in 2003 to 20.6% by mid-2014.

DISCUSSION

Analysis of Tobacco Directories offers an innovative approach to better understand the tribally manufactured cigarette market. More research is needed to understand reporting and compliance to the Tobacco Directories by manufacturers and retailers, and their usefulness as a research tool to the tobacco control community.

IMPLICATIONS

This study aims to make three contributions to the literature: (1) identify tribal tobacco manufacturers and brands in the Master Settlement Agreement Compliance documents; (2) highlight the presence and scope of the tribally manufactured cigarette brands across the United States; and (3) observe any upward or downward trends in tobacco brands and manufacturers since the directories' implementation.

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.

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.

Short-term effects of a smoking prevention website in American Indian youth

BACKGROUND

The rate of smoking commercial tobacco products among American Indian youth is double the rate for white youth. Interventions are needed to reduce this disparity.

OBJECTIVE

To test the feasibility of a Web-based intervention to influence attitudes toward and intentions about smoking cigarettes among American Indian youth who attended a Native summer camp in the Northern Plains.

METHODS

The study website, the SmokingZine, was originally developed and tested in Canadian youth, then adapted to be appropriate for American Indian youth. We conducted a randomized controlled trial to test the influence of exposure to the adapted SmokingZine website on smoking attitudes and behaviors among American Indian youth 12-18 years of age. Participants assigned to the intervention group were given access to the website for 1 hour per day during their camp experience and asked to sign in to the site and use it. Control group participants were not given access to the site.

RESULTS

A total of 52% of intervention youth signed in to the website at least once. Among nonsmokers, intentions to try a cigarette in the intervention group declined from 16% to 0%, and increased from 8% to 25% in the control group (P < .05). Compared with the control group, youth in the intervention group were more likely to help others quit (21 percentage point change in intervention versus no change in control; P < .05) and had less positive attitudes about the drug effects of smoking (-0.19 change in intervention versus 0.67 in control; P < .05).

CONCLUSION

These data indicate that SmokingZine needs more long-term, rigorous investigation as a way to keep American Indian youth from becoming regular smokers. Because the intervention group could use computers only 1 hour per day, increasing access might result in more visits and a greater effect of the website on smoking behaviors.

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.

Access, relevance, and control in the research process: lessons from Indian country

OBJECTIVE

To illustrate successful strategies in working with American Indian (AI) and Alaska Native (AN) communities in aging and health research by emphasizing access, local relevance, and decision-making processes.

METHODS

Case examples of health studies involving older AIs (greater than or equal to 50 years) among Eastern Band Cherokee Indians, a federally recognized reservation; the Cherokee Nation, a rural, nonreservation, tribal jurisdictional service area; and Lakota tribal members living in Rapid City, South Dakota.

RESULTS

Local review and decision making reflect the unique legal and historical factors underpinning AI sovereignty. Although specific approval procedures vary, there are common expectations across these communities that can be anticipated in conceptualizing, designing, and implementing health research among native elders.

CONCLUSIONS

Most investigators are unprepared to address the demands of health research in AI communities. Community-based participatory research in this setting conflicts with investigators' desire for academic freedom and scientific independence. Successful collaboration promises to enhance research efficiencies and move findings more quickly to clinical practice.

Smoking cessation and its determinants among older American Indians: the Strong Heart Study

OBJECTIVE

To examine the relationship between sociodemographic, clinical, and smoking history factors, and smoking cessation among older American Indians.

DESIGN

Nested cohort study of cigarette smokers in the Strong Heart Study, a longitudinal study of cardiovascular disease among American Indians.

SETTING

Thirteen American Indian tribes from Arizona, Oklahoma, and North and South Dakota.

PARTICIPANTS

American Indian men and women (N = 998), aged 45-74 years, who identified themselves as smokers at the initial Strong Heart Study examination.

MEASUREMENTS AND MAIN RESULTS

Twenty-one percent of smokers quit during the 4-year follow-up period. Multivariate logistic regression was used to assess the relationship between baseline sociodemographic, clinical, and smoking history factors, and smoking cessation. Factors associated with smoking cessation included being 65-74 years old (odds ratio [OR] 2.1; 95% confidence interval [CI], 1.3 to 3.3), being examined at the Arizona regional center (OR 2.2; 95% CI 1.3, 3.7), being non-daily smokers (OR 5.4; 95% CI 1.3, 18.5), smoking fewer than 6 cigarettes daily (OR 2.8; 95% CI 1.3, 4.7), being a smoker for fewer years(OR 2.0; 95% CI 1.0, 3.9), beginning to smoke at an older age (17 years or older, OR 1.6; 95% CI 1.1, 2.4), and having a history of diabetes (OR 1.7; 95% CI 1.2, 2.3). Factors not associated with smoking cessation included gender, level of education, childhood exposure to tobacco smoking, and a history of cardiovascular diseases, cancer, or respiratory diseases.

CONCLUSION

Several determinants of smoking cessation among older American Indians identified in this study may have important implications for designing appropriate interventions for this special population.

An alternative method of closed silicone intubation of the lacrimal system

An alternative method of closed lacrimal intubation is described, the basis of which is to place the end of a piece of silicone tubing over the end of a small-diameter metal introducer, stretch the silicone tubing back along the introducer, and then pass the introducer together with the tubing through the lacrimal system into the nasal cavity. The tubing is visualized in the inferior meatus, from where it is retrieved, and then the introducer is withdrawn. The other end of the tubing is passed in a similar fashion. The technique is easily mastered, inexpensive, and less traumatic than other described techniques.

A modified trephining technique for the insertion of Jones tube

The functional success of a Jones Pyrex tube depends on the accurate positioning of the tube. The modified trephining technique for the insertion of a Jones tube ensures accurate positioning by using a guide wire to maintain the selected position and direction of the tube while a 1.5-mm-diameter trephine cuts a cylindrical track around the guide wire, down which a straight Pyrex tube is threaded. The snug fit between the tube and the trephined track has minimized postoperative extrusion (5%) and migration (7%). This technique has been used to insert 93 tubes in 84 patients aged 7 to 83 years.

Actinomycotic canaliculitis

Actinomycotic infection should always be considered in any patient with persistent purulent conjunctivitis of chronic canaliculitis. The clinical features, investigation including macrodacryocystography, and treatment in four patients with actinomycotic canaliculitis are presented. The difficulty of microbiological diagnosis is stressed and the occurrence of associated lacrimal obstruction is reported.

The COMMIDO. Combined Operation Magnifiers and Miniature Indirect Ophthalmoscope

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The histopathology of small vessels following microvascular repair

The histopathological findings following microvascular repair of 105 arteries and 89 veins in Englishstrain rabbits are reported. The importance of (a) the accurate apposition of the vessel walls and (b) the avoidance of excesive medial necrosis is stressed. The process of subintimal hyperplasia is described and the importance of its role in the repair of small vessels is discussed. Previously, the new formation of elastin tissue has been considered pathognomonic of vascular disease. The appreciably slower rate of repair in veins is also reported. From these observations suggestions have been made with regard to improved technique of surgical repair.

Fascia lata rack for retinal detachment surgery

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