Focus on priority populations
Circles of Tobacco Wisdom: Learning About Traditional and Commercial Tobacco with Native Elders

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Background

Circles of Tobacco Wisdom (CTW) was an elder-led, community-based project that aimed to enhance tobacco control in the American Indian community. Its goal was to provide elders with the knowledge, opportunities, and support to enable them to assume leadership of a tobacco control movement that was grounded in the ceremonial traditions of tobacco use.

Purpose

The purpose of this study was to test the effects of the pilot intervention on participants.

Design

The design of this pilot study intervention was a single group, pre–post comparison, with a pre–post survey, monthly check-ins, and a post-1-year focus group.

Participants

Twelve elders were included in the pre- and post-analyses. All twelve elders were women who self-identified as American Indian (mean age = 64).

Intervention

The CTW elders participated in monthly talking circles, quarterly learning sessions, and a post-1-year focus group, and took part in other learning, support, and community action opportunities. Data were collected from December 2008 through November 2009 and analyzed throughout the process.

Main outcome measures

American Indian Elders' tobacco-related knowledge, perceptions, beliefs, and behaviors were measured while participating in the CTW project.

Results

Knowledge, perceptions, beliefs, and behavior changes were seen with cigarette smoking, secondhand smoke, and ceremonial tobacco use and risk perception. After 6 months, the number of people the elders had talked with about tobacco increased, elders were more likely to have a discussion on tobacco at a community event, and their comfort level talking about commercial and traditional tobacco also increased. A number of themes also were identified in the focus group: feeling more comfortable talking about tobacco issues, learning a lot about traditional and commercial tobacco, and realizing the dangers of smoking.

Conclusions

Elders increased their knowledge about commercial and traditional tobacco and changed related attitudes as a result of CTW. Further, American Indian Elders perceived that CTW was effective.

Introduction

According to American Indian culture, traditional tobacco is a gift from Mother Earth. Its use was commonplace for centuries among many American Indian tribes of North America, long before Europeans introduced recreational tobacco use. Nicotiana rustica was commonly cultivated in the woodlands of Wisconsin and Minnesota.1 Differing not only physically but morphologically, Nicotiana tabacum is the basis of the worldwide tobacco industry primarily because it produces more tobacco per plant.1

Traditional or ceremonial tobacco use occurs in a variety of forms; tobacco can be offered to the Creator or as a gift when honoring someone.2 It may be placed on the ground or burned in a pipe, dish, shell, or fire, with the smoke believed to carry prayers to the Creator.2 Tobacco also has many uses in traditional Indian medicine and healing.3 For example, the tobacco may be burned and the smoke used to cleanse and heal.4 Sprinkling tobacco on the bed of a sick individual is believed to protect the individual and serve as a healing agent.4

American Indians also use commercial tobacco for ceremonial or traditional purposes.4 Nineteenth- and twentieth-century federal policies and institutional practices promoted the extermination or assimilation of Indian people, prohibiting American Indians to practice traditional ceremonies openly or speak Native languages. Not until the Indian Religious Freedom Act of 19785 was the right to freedom of religion guaranteed to American Indian people. American Indian tobacco was difficult to gather under these repressive conditions, so it is believed that commercial tobacco was substituted for traditional tobacco as a result.2

A shift from the ceremonial use of tobacco to recreational use has had a devastating effect on the health of many American Indians. In the U.S., American Indians have the highest prevalence of current commercial tobacco use (35.8%) among people aged ≥12 years.6 The 2004–2005 Minnesota Treatment Needs Assessment Survey estimated the prevalence among American Indians in Minnesota as 54%.7 The American Indian Community Tobacco Project, using a convenience sample from Minneapolis and in-person interviews, reported in 2007 that 62% were current smokers.2

American Indians in Minnesota and the Northern Plains region have higher rates of cancer compared to other racial/ethnic groups; most of the excess is due to dramatically higher lung cancer prevalence.8, 9 Minnesota is home to a large population of American Indians. Almost 102,000 American Indians (identified as American Indian alone or in combination with another race) reside in the state.10 American Indians served by the Indian Health Board of Minneapolis have disproportionately higher rates of health problems associated with tobacco misuse as well. Four of the five leading causes of death among American Indians in this area are related to tobacco misuse: cancer, heart disease, diabetes, and stroke.11

Given the multifaceted role of tobacco in American Indian communities, culturally appropriate and community-focused interventions are needed for this population to reduce recreational use while at the same time respecting cultural norms. In designing a culturally appropriate intervention, there is a need to promote the traditional uses of tobacco while discouraging the use of commercial tobacco.

Circles of Tobacco Wisdom (CTW) is an elder-led, community-based project designed to engage American Indian Elders in mutual learning, support, and community action regarding traditional and commercial tobacco. Its focus on elders was deliberate. Elders are highly respected and valued members of American Indian society and important cultural guides for their immediate families, clan members and tribe.12 Through storytelling, ceremonies (e.g., sweat lodges, prayer and pipe ceremonies) and cultural events (e.g., talking circles, powwows, feasts, drumming and singing, crafts, cooking), elders are a resource for adults and youth alike about traditional ways of life: how to treat humans, animals, and the earth; how to be self-sustaining as a people; how actions affect future generations; and how to maintain health and well-being.13, 14

The CTW sought to provide elders with the knowledge, opportunities, and support necessary for them to assume tobacco control movement leadership that was grounded in the ceremonial traditions of tobacco use. The CTW Elders participated in monthly talking circles and quarterly learning sessions. They then shared what they learned through informal conversations with family and community members as well as more formally through organized community efforts such as health fairs, workshops, school activities with American Indian youth, and conferences.

The CTW team hypothesized that American Indian Elders' tobacco-related knowledge, perceptions, beliefs, and behaviors would change while participating in this project. Specifically, this study evaluated changes on measures of tobacco-related knowledge, attitudes, or behaviors concerning cigarette smoking, secondhand smoke, commerical tobacco use, ceremonial or sacred use, risk perception, and community-identified problems and solutions.

Section snippets

Methods

The CTW project team was a collaborative research partnership of individuals from the University of Minnesota School of Public Health, Inter-tribal Elder Services (a community social services organization), and the American Indian Policy Center. American Indian Elders were involved in every aspect of the project.

The partnership addressed both the traditional and recreational aspects of tobacco use in the American Indian community by using a participatory action research framework and

Demographics

Twelve elders were included in the pre/post-test analysis. All 12 elders self-identified as American Indian women and were enrolled in a tribe. The mean age at 1-year follow-up was 64 years, and ranged from 57 to 79 years. Regarding the highest level of school completed or the highest degree received, one participant had some high school; three had passed the General Educational Development test; five had some college but no degree; one had an Associate of Arts degree; and two had a Bachelor of

Discussion

The elder participants in the CTW pilot project used a variety of activities to make a positive effect on tobacco issues specific to American Indian communities and ultimately to benefit the overall health of American Indians.

Some of the changes seen in the survey responses were unanticipated. The increase in the number of cigarettes smoked by elders who smoked from 7.8 to 9.4 per day may have been because two elders quit smoking and the elders who didn't quit were heavier smokers. An increase

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