Nina McEachem picked up smoking as a teen living in Ketchikan, Alaska. She had entered foster care at age 11 after her mother died of leukemia and her father, a school janitor, was overwhelmed caring for five children. In her community—McEachem has both Alaska Native and Aleutian heritage—most people that she knew smoked. Her father was a heavy smoker and experienced a heart attack when McEachem was 19; before that, she said she and her eighth-grade friends smoked behind the school.
“I turned to smoking because it was my friend, my companion,” says McEachem, who is 69.
She knew smoking was bad for her and could see its negative impact on the health of people she cared about, but life was hard, and smoking helped her cope with stress.
“Years ago, I told myself that if I got cancer, I would quit smoking,” she says. But three years ago when she was diagnosed with lung cancer, McEachem learned how hard it was to kick tobacco out of her life.
“I tore apart every cigarette I had in two cartons,” she says. But the stress of moving homes and caring for her adult son who has autism proved too much, and McEachem resumed her habit after two months. For her, addiction to nicotine has proved difficult to overcome.
McEachem hasn’t given up, though. During appointments at Fred Hutchinson Cancer Center, her oncologist, Dr. Eddie Marzbani, always reminds her that if she quit once, she can quit again.
“I have tried talking myself out of it, but every time I turn around, I want to light up,” says McEachem.
Quitting tobacco is hard for anyone. But for many Indigenous people, tobacco is often part of everyday life, making it nearly impossible to escape.
Tobacco has cultural and historical resonance to Native communities, which likely led commercial tobacco companies to target them through advertising and other efforts. The tobacco industry financially supports pow wows, for example. That targeting led to high rates of smoking which have, in turn, caused higher rates of cancer among Indigenous populations.
“Smoking is a way of coping for people that have experienced trauma,” says Ursula Tsosie, manager of Fred Hutch’s həliʔil program, which offers cultural consultation to medical providers, helping them address the topic of quitting smoking in a manner that acknowledges and respects cultural nuances.
“Tobacco was intended to be used in a ceremonial way, but that’s been exploited by the commercial tobacco industry,” says Tsosie.
At Keep It Sacred, the National Native Network for Commercial Tobacco Control and Prevention, Kris Rhodes is working to reframe the role of tobacco in tribal life. “We need to talk about quitting commercial tobacco and protecting traditional tobacco for tribes that use tobacco ceremonially,” says Rhodes, a public health consultant for Keep It Sacred.
There’s even an agricultural distinction between smoking and ceremonial tobacco. Tobacco that is sold and produced for cigarettes and commercial tobacco products is called Nicotiana tabacum, a plant that grows tall with big leaves. Ceremonial plants are Nicotiana rustica and grow only knee-high, with daintier leaves.
Not all Indigenous communities use ceremonial tobacco, but many do. “My daily prayers involve tobacco,” says Rhodes. “For many tribes, a baby naming or a wedding wouldn’t happen with tobacco. It’s embedded in everything we do. As a Native woman, tobacco is the most important thing to my health, and it could be the most dangerous thing to my health.”
The use of traditional tobacco often conjures up the stereotypical image of an American Indian smoking a pipe, but very few Alaska Natives or American Indians smoke pipes, says Rhodes. “Instead, tobacco is placed on the ground, in the water, in a fire as an offering to carry our prayers to our creator,” she says.
It’s also given to somebody when asking for their advice or wisdom. “If I need to know something from an elder, I can’t just go and ask,” says Rhodes. “I need to have tobacco as an exchange.”
Smoking’s popularity within Native communities can be traced to years leading up to the American Indian Religious Freedom Act of 1978, which restored the rights of American Indians to practice their traditional religions through ceremonial and traditional rites. Before its passage, Native people could be arrested for ceremonial worship.
“That led to a lot of tribes using commercial tobacco to hide in plain sight,” says Rhodes. "Commercial tobacco is highly addictive, which resulted in these really high smoking rates. As a community, we have to talk about quitting smoking, but we also need to acknowledge that this high smoking rate is a result of foundational issues like the trauma of genocide, the loss of language and land, plus poverty and stereotypes and caricatures.”
For people interested in quitting, Fred Hutch offers a full spectrum of support, including a variety of providers and programs that approach the process of quitting in a culturally sensitive way. The həliʔil program partners with community organizations to promote lung cancer screening for the Indigenous population. A new study led by Dr. Matty Triplette, medical director of Fred Hutch’s Lung Cancer Early Detection and Prevention Clinic, is focused on identifying barriers to lung cancer screening in Indigenous populations through the use of focus groups and community outreach. Living Tobacco-Free Services provide nicotine replacement therapy, including lozenges and patches, and counseling for patients who are contemplating quitting. And Fred Hutch patient navigators help patients connect to community resources and access the care and support they need.
Fred Hutch’s most recent Community Health Needs Assessment found that mortality rates for lung cancer are highest among the American Indian/Alaska Native and non-Hispanic Black population. “Statistically speaking, the Native population represents a greater proportion of people who traditionally use tobacco,” says Brandon Omernik, a Fred Hutch tobacco cessation specialist.
The tension between tobacco culture and improving health is on full display at casinos owned and run by Native American tribes, where tobacco is sold. But these casinos also play an important role in funding tobacco-cessation efforts.
“Some folks feel shame that they’ve tried to quit four or five times, but that speaks more to their resilience and how they are willing to get back up and keep trying,” says Nick Woo, Fred Hutch community health worker and patient navigator for Indigenous populations.
That’s Nina McEachem’s philosophy. She hasn’t given up on trying to quit and plans to inquire about nicotine replacement therapy. In the meantime, she’s trying to distract herself using a stiff straw that her sister gave her, holding it between her fingers and moving it around like it’s a cigarette. “I’m going to keep trying when the time is right,” says McEachem. “Smoking doesn’t sustain health. It belittles a person."