It was used ceremonially for centuries, but these days tobacco — now manufactured into highly addictive, commercial cigarettes — has become a scourge for many Indigenous people.
“Since the early 1980s, American Indians and Alaska Natives have maintained the highest rates of commercial cigarette smoking of any racial or ethnic group in the U.S., due to tobacco industry practices and government policies,” said Fred Hutchinson Cancer Center behavioral psychologist Jonathan Bricker, PhD, whose research focuses on smoking cessation. “Commercial cigarette smoking now accounts for half of all deaths of these people nationwide.”
Fred Hutch and Bricker hope to change these startling statistics with a newly funded randomized clinical trial just for American Indians and Alaska Natives (AIANs). The five-year, $3.6 million grant from the National Cancer Institute will test the efficacy of the Fred Hutch-tested smartphone app ICanQuit versus that of QuitGuide, a digital smoking prevention app offered by the NCI.
"The need for this study is long overdue,” said Bricker. “American Indian and Alaska Native peoples have extraordinarily high cigarette smoking rates and there are few programs proven effective for helping them quit. They lack access to smoking cessation treatments.”
This new trial, Bricker said, is aimed at “breaking down these challenges” with a nationwide study that will test out a version of the iCanQuit app specifically tailored for American Indians and Alaska Natives.
A longtime public health researcher, Bricker will work with what he calls “two tremendous partners.”
One is Lonnie Nelson, PhD, a descendent of the Eastern Band of Cherokee Indians and Chair of the Department of Nursing and Systems Science within Washington State University's College of Nursing. Bricker will also work with Black Hills Center for American Indian Health Co-Director Patricia Henderson, MD, MPH, a member of the Navajo Tribe who has a long history or working with Tribes and Tribal communities in tobacco and nicotine research.
According to data, 27% of all American Indian and Alaska Natives smoke commercial cigarettes. But compared to other racial/ethnic groups, they have over six times higher rates of smoking-related cancers, including lung cancer.
These individuals also tend to have disproportionately higher rates of respiratory and heart disease, Bricker said. Unfortunately, data also shows that Indigenous people are also only half as likely to quit smoking compared to other ethnic groups.
“These are dramatic inequities, and I think they’re mainly due to two things,” Bricker explained. “The first is the lack of access to smoking cessation interventions, due to inequities in the health care systems, lack of health insurance, systemic racism, historic trauma and just the fact many of these people live in rural areas.”
A lack of efficacious smoking cessation interventions for American Indians and Alaska Natives also contributes to the high smoking (and low quitting) rate, he said.
“Even though more than 27% of all American Indian and Alaska Native adults in the U.S. currently smoke, a mere .3% of randomized controlled trials have focused on this group,” he said.
Smartphone apps can deliver low-cost smoking cessation interventions to a wide variety of people. And they don’t require in-person training or delivery.
“Given that around 70% to 80% of American Indians and Native Alaskans own smartphones, apps have potentially high reach in these populations,” he said.
Like most of Bricker’s behavior-changing apps, iCanQuit is based on Acceptance and Commitment Therapy, or ACT, which encourages users to acknowledge and accept cravings in order to move past them.
A 2020 study involving more than 2,400 adult smokers throughout the U.S. compared Bricker’s iCanQuit with QuitGuide and found the Fred Hutch-tested app was almost 1.5 times more effective than QuitGuide in helping smokers stop smoking after 12 months.
“We think the approaches of ACT to accept cravings and follow your core values would resonate with American Indian and Alaska Natives,” he said.
A preliminary study comparing the efficacy of the two apps among American Indians and Native Alaskans from 31 states did indeed find that iCanQuit was “more efficacious, engaging, and satisfactory among American Indians and Alaska Natives nationwide.”
Now, the team will recruit around 800 study participants, starting in about a year, to run a larger trial with multiple aims.
One will be to biochemically verify abstinence from smoking in order to show which app works better. Another will determine whether one of the two apps is better at mediating cues to smoke and triggering personal motivations to quit, such as family, community and honoring the earth.
Finally, Bricker and his collaborators plan to analyze the data to further determine if the apps’ efficacy depends on gender, income level or whether the person is a heavy or light smoker. They also plan to conduct qualitative interviews with a small subset of participants to better understand their experience.
“The results of our last aim will inform our approach to disseminating iCanQuit throughout American Indian and Alaska Native tribal communities and organizations,” he said. “Eventually, we believe our smoking cessation program has potential for broad dissemination and high impact.”
As with many public health researchers, it’s all about finding new ways to upend longstanding health inequities.
"This research project is important for addressing serious cancer disparities among American Indians/Alaska Natives,” Bricker said. “Among all U.S. racial/ethnic populations, Indigenous people have the highest rates of combustible cigarette smoking and few resources to help them quit.
“We truly believe we can improve health equity by providing a highly accessible and efficacious intervention,” he said, adding the work also dovetails with the White House's Cancer Moonshot focus on addressing disparities in access to effective smoking cessation programs.
Diane Mapes is a staff writer at Fred Hutchinson Cancer Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she blogs at doublewhammied.com and tweets @double_whammied. Email her at email@example.com. Just diagnosed and need information and resources? Visit our Patient Care page.
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