Smartphone applications to help American Indians and Alaska Natives quit smoking

From the Bricker Group, Division of Public Health Sciences

American Indians and Alaska Natives, the descendants of the original people of North and South/Central America who maintain tribal affiliation or community attachment, have very high rates of cigarette smoking (24%). Unfortunately, the tobacco industry has exploited the lack of smoke free laws on tribal land and has used strategies to promote tobacco use in these communities. Although tobacco use can be utilized for their own sacred and medicinal purposes in certain tribes, the tobacco industry has manipulated their cultural history and practice by strategically using American Indian and Alaska Native images on commercial tobacco products and targeting tribal lands. Sadly, the tobacco industry’s opportunistic approaches continue to this date.

Currently, there is a low rate of quitting smoking among this community (38%), especially as compared to non-Hispanic Whites (60%).  The high smoking rates are perpetuated by poor access to evidence-based treatments for smoking cessation. Lack of healthcare and cost of travel can further contribute to the low rates of smoking cessation and high rates of cigarette smoking in this population. Despite the tremendous need for efficacious and accessible interventions for smoking cessation among American Indians and Alaska Natives, very few researchers have studied smoking cessation in this community. Only four randomized controlled trials (RCTs) have been conducted for smoking cessation among American Indians and/or Alaska Natives, and only one of them showed efficacy.  There is a great need for efficacious treatment options.

The need for efficacious and accessible interventions for smoking cessation for American Indians and Alaska Natives encouraged Dr. Jonathan Bricker’s HABIT (Health and Behavioral Innovations in Technology Lab) Group, from the Division of Public Health Sciences, to utilize a novel, theory-based behavioral approach to help people quit smoking. This approach, called Acceptance and Commitment Therapy (ACT), encourages individuals to be open to and not act on their triggers to smoke while focusing on their life values as the motivator to quit smoking. These ACT-theory based processes may resonate with American Indian and Alaskan Native cultural principals. For example, teaching of life values aligns with the cultural principle of relationship-oriented interdependence (family, clanship) as one motivating factor for smoking cessation.

The HABIT Group designed and implemented the iCanQuit randomized clinical trial (RCT) that led to this paper. The iCanQuit trial was a large RCT that tested the efficacy of an ACT-based smartphone application (iCanQuit) against a US clinical practice guidelines (USCPG)-based smartphone application (QuitGuide) among a racially/ethnically diverse sample of 2415 smokers from all 50 US states. This trial showed that, compared with a USCPG-based smartphone application, and ACT-based smartphone application was efficacious and engaging for quitting cigarette smoking and thus can be an impactful treatment option for vulnerable populations.

Due to the success of the ACT-based smartphone application (iCanQuit) for smoking cessation relative to the NCI’s QuitGuide application among a general sample of smokers in the US population, Bricker’s HABIT Group conducted a secondary analysis of the iCanQuit RCT to determine the efficacy of iCanQuit vs. QuitGuide for smoking cessation among American Indians and Alaskan Natives enrolled in the parent trial . The paper was recently published in Nicotine & Tobacco Research . Participants were recruited via Facebook ads, survey sampling company, search engine results, and referrals. A generous donation from the Snoqualmie Tribe in Washington State funded the recruitment of American Indians and Alaskan Natives.



Graphical Representation Figure 1. Geographic Location of American Indian and Alaska Native Trial Participants
Figure 1. Geographic Location of American Indian and Alaska Native Trial Participants. Each point represents one of the 165 American Indian and Alaska Native participants randomized into the iCanQuit trial. Most (70%) of participants resided in an urban area, 30% in a rural area, with 25% of participants residing on tribal land. Visual geographic clusters for high concentrations of participants with residence on tribal land can be seen in Alaska, Oklahoma, Utah, and Washington. Image from Dr. Bricker Click for high-resolution image

The paper found that American Indian and Alaskan Native trial participants in the iCanQuit arm were at least two times more likely to quit smoking than those in the QuitGuide arm in all time periods (3, 6, and 12-month follow-ups). iCanQuit participants also had greater acceptance of physical sensations, emotions, and thoughts that cue smoking. iCanQuit participants opened their application at least 4 times more often compared to QuitGuide participants; and iCanQuit was more satisfying overall. This is the first rigorously designed and successful RCT to report the effects of a digital intervention for smoking cessation among American Indians and Alaska Natives. Dr. Bricker concluded, “Our next major initiative is to adapt, test, and disseminate our digital therapeutic in order to make a significant public health impact on cigarette smoking among American Indian and Alaska Natives communities. To ensure increased enrollment and participation of American Indians and Alaska Natives nationwide, partnerships with tribes and tribal organizations will be invaluable for the future cultural adaptation of iCanQuit." 

This research was supported by the National Cancer Institute.

Fred Hutch/UW Cancer Consortium member Jonathan Bricker contributed to this work.

Santiago-Torres M, Mull KE, Sullivan BM, Kwon DM, Nez Henderson P, Nelson LA, Patten CA, Bricker JB. Efficacy and Utilization of Smartphone Applications for Smoking Cessation Among American Indians and Alaska Natives: Results From the iCanQuit Trial. Nicotine & Tobacco Research. 2021 Oct 13.