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A Southwestern Tribal Perspective on 

Traditional and Commercial Tobacco 
Priscilla R Sanderson1*, Erelda Gene2, Rebecca Scranton3, Angela A A Willeto4; Lori Joshweseoma5; Lisa J 

Hardy6 

Health Sciences Department of the College of Health and Human Services at Northern Arizona University1; 

Northeastern State University Oklahoma, College of Optometry2; Arizona Department of Health Services3; 

Sociology and Social Work Department in the College of Social and Behavioral Sciences at Northern 

Arizona University4; Hopi Tribe, Hopi Health Department5; Anthropology Department in the College of 

Social and Behavioral Sciences at Northern Arizona University6 

*Corresponding author e-mail: Priscilla.Sanderson@nau.edu 
 

ABSTRACT 
American Indian or Alaska Natives have the highest rates of current cigarette (36.5%) and smokeless 

tobacco use (5.3%), and tobacco product (40.1%) and the second highest rate of current cigar use 

(6.1%) compared to all other racial-ethnic groups in the U.S. rates of American Indian or Alaska Native 

tobacco use vary by gender. Few studies examine perceptions of tobacco use among tribal members 

residing on and off the reservation. This study fills a gap in the literature by reporting the perceptions of 

34 enrolled members of a southwestern tribe who reside on and off a tribal land using a Community-

Based Participatory Research (CBPR) design through a collaboration between a university and a tribal 

health program. Researchers conducted seven focus groups; four on the southwest reservation and 

three within an urban community. The discussions were audio-recorded, transcribed, and analyzed 

using a multi-investigator consensus model. The use of tobacco (commercial or traditional) in southwest 

tribes is essential to cultural practices. Results depicted different views on cultural meaning and health 

impacts of commercial and traditional tobacco. Findings suggest the importance of local research to 

understand dimensions of tobacco use before moving forward with tobacco cessation programming. 

KEYWORDS: American Indians, commercial tobacco, traditional tobacco, Community-Based 

Participatory Research, focus groups 

 

Citation: Sanderson P et al (2018) A Southwestern Tribal Perspective on Traditional and Commercial 

Tobacco. Cancer Health Disparities 2:e1-e10. doi:10.9777/chd.2018.10004 



 
 
 
 
 

 

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INTRODUCTION 

American Indian or Alaska Natives (AI/AN) have 

the highest rates of cigarette (36.5%) and 

smokeless tobacco use (5.3%) compared to all 

other racial-ethnic group (Substance Abuse and 

Mental Services Administration, 2014), current 

tobacco product (40.1%) and the second highest 

rate of current cigar use (6.1%). High rates of 

tobacco use factor in various health problems 

evident among American Indians or Alaska 

Natives, such as heart disease and cancer (Heron, 

2016). Yet, American Indian and Alaska Natives’ 

tobacco use rates vary across regions. Northern 

plains and Alaska areas demonstrate the highest 

rates of smoking [40.2% and 40.0%, respectively], 

while the southwest reveals the lowest rates [21.1%] 

(Steele, Cardinez, Robertson, Tom-Orme, & Shaw, 

2008). 

Studies show different use patterns among men 

and women. Historical analyses indicate 

differentiation in use rates by gender began in the 

1930s (Kunitz, 2016). Northern plains tribes 

demonstrate high rates of smoking among both 

men (49%) and women (51%) (Nez-Henderson et 

al., 2005). Whereas, in a southwest tribe, men 

(19%) have higher rates of smoking than women 

(10%); furthermore southwest women have the 

highest prevalence of never smoking (75%) (Nez-

Henderson et al., 2005). However, rates of tobacco 

use also differ by age. A longitudinal study on 

Indigenous adolescents found that girls aged 10 to 

13 years (20%) smoked more frequently than boys 

aged 10 to 13 years (14%) (Yu & Whitbeck, 2016).  

Literature Review 

American Indians have used traditional tobacco 

epochs prior to the introduction of commercial 

tobacco (Struthers & Hodge, 2004; Redwood et 

al., 2010; Nadeau, Blake, Poupart, Rhodes, & 

Forster, 2012; Henderson & Henderson, 2015). Use 

of traditional tobacco varies by ceremony and 

tribe. Many people of different tribal affiliations 

share a common belief that traditional sacred 

tobacco is non-addictive (Struthers & Hodge 2004; 

Henderson & Henderson, 2015; Arndt et al., 2013). 

Unlike commercial tobacco practice, traditional 

smoke is not inhaled, but held in one’s mouth then 

released skyward towards the atmosphere where 

the smoke from the tobacco carries thoughts and 

prayers to deities (Struthers & Hodge, 2004; 

Nadeau et al., 2012). Traditional smoke is used to 

cleanse, heal those who are ill, protect those who 

feel they need to be shielded from harm, or to 

teach lessons (Struthers & Hodge, 2004; Nadeau 

et al., 2012; Arndt et al., 2013). While commercial 

tobacco is typically used recreationally and 

traditional tobacco is expended for spiritual 

purposes, that distinction is becoming blurred as 

some tribes struggle to access traditional tobacco 

and use commercial tobacco due to availability 

(Struthers & Hodge, 2004; Nez-Henderson et al., 

2005; Unger, Soto, & Baezconde-Garbanati, 2006; 

Forster et al., 2007; Margalit et al., 2013).  

Some tribes evidence both men and women’s use 

of tobacco while in other tribes, tobacco use is 

restricted to men in ceremonial environments. 

Beliefs and use practices on tobacco on and off 

tribal lands also vary. However, studies comparing 

on/off reservation or rural/urban are few in 

number, even more so when examining tribes’ 

perceptions of ceremonial and commercial 

tobacco use (Unger, Soto, & Baezconde-Garbanati 

2006). American Indian people (combining 

southwestern and northern plains regions) that 

reside 75% or more of their lives on reservations 

had lower rates of current smoking (men=46%, 

women=48%) than those who reside less than 



 
 
 
 
 

 

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75% of their lives on the reservation (men=56%, 

women=61%) (Nez-Henderson et al., 2005). Urban 

American Indian men in California demonstrated 

higher rates of smoking (57%) than their rural male 

counterparts (43%) (Hodge, Fredericks, & Kipnis, 

1996). 

Enhancing the nuances of tobacco use among 

different people based on place, age, and gender 

is important to effectively target programs for 

locally and culturally appropriate smoking 

cessation. These findings add to the literature 

indicating distinct perceptions and uses of 

commercial and traditional tobacco. The uses for 

the different types of tobacco are important to 

explore for the sake of better understanding the 

health impacts of tobacco within American Indian 

communities.  

This study addresses the following: What are 

perceptions toward commercial and traditional 

tobacco use among members of a southwestern 

tribe, particularly in light of this region's’ 

comparatively low rates of cigarette use? Do tribal 

members make distinctions of tobacco use as 

recreational or ceremonial; will theme differences 

emerge among men and women; or will residing 

on the reservation or in an urban locale lead to 

different themes on tobacco use among members 

of the same southwestern tribe?  

Materials and Methods 

The team obtained permission from the tribe and 

the University Institutional Review Board before 

beginning research. Project goals naturally 

developed through Community Based 

Participatory Research (CBPR) (Israel, Schulz, 

Parker, & Becker, 1998; Buchwald, Beals, & 

Manson, 2000; Wallerstein & Duran, 2006; 

Wallerstein & Duran, 2010; Verney et al., 2016), in 

that the original idea for the research came from 

community members knowledgeable about tribal 

health. The research team included members of a 

tribal health organization, university professor, and 

undergraduate students of public health and 

applied indigenous studies. The research team 

developed focus group questions, recruited 

participants, and held four focus groups on a 

reservation (n=20) and three in a bordertown, a 

city adjacent to the reservation (n=12). Inclusion 

criteria included being 18 years or older and an 

enrolled member of the Tribe. Participants had to 

reside on either the reservation or urban location 

for six continuous months. At the focus group 

sessions, participants signed an Informed Consent, 

received a $25.00 stipend and resource materials. 

Participants completed a survey beforehand to 

collect demographic information, current smoking 

status, and smoking cessation status.  

Data Analysis 

Qualitative analysis of participant responses 

included a multi-investigator consensus method as 

described in two studies (Teufel-Shone, Siyuja, 

Watajomigie, & Irwin, 2006; Sanderson, Teufel-

Shone, Baldwin, Sandoval, & Robinson, 2010). 

Audio-recorded discussions were transcribed 

verbatim and analyzed by researchers through 

coding and memoing (Miles & Huberman, 1984; 

Groenewald, 2004) using Atlas.ti. Descriptive 

statistics were used to analyze the demographic 

information.  

RESULTS 

Participant Demographics 

Table1 shows the participant demographics. Five 

(14.7%) of the participants reported currently 

smoking tobacco. 



 
 
 
 
 

 

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Table 1. Demographics by Focus Group Location. 

Characteristic Reservation 

n=22 (65%) 

Urban 

n=12 (35%) 

Total 

n=34 (100%) 

Gender 

  Women 

  Men 

 

12 (55%) 

10 (45%) 

 

5 (42%) 

7 (58%) 

 

17 (50%) 

17 (50%) 

Education  

  Less than high school 

  High school grad/GED 

  Some college or higher 

  College 4 years or more 

 

1 (5%) 

 8 (36%) 

12 (55%) 

1 (5%) 

 

0 (0%) 

2 (17%) 

6 (50%) 

4 (33%) 

 

1 (3%) 

10 (29%) 

18 (53%) 

5 (15%) 

Current Smokers? 

  Yes 

   No 

 

2 (9%) 

20 (91%) 

 

3 (25%) 

9 (75%) 

 

5 (15%) 

29 (85%) 

Age  

  Mean (Range, SD) 

 

38 (21-69, 14)* 

 

28 (20-44, 9) 

 

35 (20-69, 14) 

*One participant refused to provide their age.

Traditional Tobacco 

Traditional tobacco is sacred, and preparation 

requires traveling long distances and using an 

involved process. In response to the question 

about what participants thought about smoking 

traditional tobacco, tribal members (irrespective of 

gender or residential location) believe traditional 

tobacco is sacred and serves important spiritual 

functions in their culture and society. One 

participant reflected:  “…Traditional tobacco is the 

most important thing in all [removed tribal name 

for privacy] ceremonies where, smoking is a part of 

everything, and the smoking of the [ceremonial 

place], it’s it own ceremony, how they smoke, how 

they acknowledge each other in that circle and how 

it’s passed, how it’s held, so it’s vital I think, to keep 

that as tobacco.” (Reservation woman). 

Furthermore tobacco plays an active role in 

carrying prayers. One participant stated, “…I feel 

the use of traditional tobacco in the ceremony has 

more significance in the ceremony…because usually 

when traditional tobacco is being used, that’s when 

you know that the prayers are actively happening 

at that time,” (reservation woman). Other 

participants also reflected on these beliefs 

throughout the focus groups in the discussions of 

the meaning and value of traditional tobacco use. 

Women who lived off of tribal lands said that 

traditional tobacco use was culturally important: “I 

think it’s necessary for us...like, a lot of them smoke 

just the regular cigarettes and everything, but I 

think it would be just most men, they just do it... 

around the ceremonies sometimes and other than 

that, they don’t smoke at all, so some people just 

do it specifically for the ceremonies and our 

tradition.” Participant women also discussed the 

difference between recreational and ceremonial 

use of tobacco: “But I think that people who use 

the traditional tobacco during the traditional 

ceremonies have a purpose, and aren’t just using it 

to have something to smoke.” This difference 

between ceremonial and traditional uses of 

tobacco remained clear in all focus groups with 



 
 
 
 
 

 

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general statements regarding the differences in 

use patterns and meaning/value of the tobacco.  

Participating men living on reservation also 

reflected on the importance of traditional tobacco 

use in how traditional tobacco use is intertwined 

within the cultural landscape. “…I think using 

traditional tobacco- it’s very sacred, a building block 

that’s part of our [tribal name] society as they find 

this where-where we need to.” This participant 

discusses tobacco as a “building block” 

underscoring the foundational importance of this 

part of life and ritual among people within this 

tribal context. Another participant raised the 

importance of understanding the traditional 

substance and use of tobacco and set this apart 

from non-traditional use: “…the understanding of 

traditional tobacco, you really have to be, true to 

understand what it’s used for and how it’s used. So, 

my understanding is really highly respected toward 

traditional tobacco.” Men living off-reservation 

showed consensus on the traditional use of 

tobacco: “what we call it, is, the purpose behind it 

carries our prayers and so it’s used in multiple 

ceremonies.” And beyond the use of the tobacco, 

one participant also discussed the purpose of 

tobacco as an active entity: “The use of the 

traditional tobacco is a way of communicating your 

prayers to what  [tribal name] we [tribal name] 

believe is the rain clouds.” Men, though, expressed 

difficulties obtaining traditional tobacco in their 

local areas when they were in a rush to get to a 

ceremony while commercial tobacco was more 

accessible in local stores. Women stated strong 

opposition to commercial tobacco use, though all 

participants discussed traditional tobacco as a 

vehicle for prayer interwoven within the 

foundation of tribal identity.   

 

Commercial tobacco 

With regard to the use of commercial tobacco, 

participants had other ways of understanding and 

discussing the substance and its purpose. Men and 

women stated that there were negative risks 

associated with commercial tobacco that could 

lead to death. Some participants focused on the 

impact of commercial tobacco on the respiratory 

system,  “...obviously you can develop problems 

with your lungs, problems breathing people who do 

a lot of smoking obviously have asthma and all 

these other breathing difficulties that don’t make for 

much of a quality of life” (urban woman). Another 

participant echoed these thoughts, by noting the 

difference between smokers and nonsmokers, 

“Their health is a little bit different than someone 

who doesn’t smoke at all. And you can see the 

difference, I mean they’re coughing, hacking, and 

like can barely breath. They just sound awful.” 

(urban woman). And beyond that: “…it affected my 

lungs, my mind, and even my muscles... I took 

weight classes and I wasn’t lifting as much as I used 

to and I just had a motivational shut to my body 

where it wasn’t working as much as it was, used to 

cut down my motivation.” Another man stated 

that: “…all of these health issues that come up, of 

course it starts slowly and it eventually starts eating 

away at the body, eventually leads to death.” 

Another risk of commercial tobacco use that 

participants discussed was oral health: “oral 

health…that starts to become a factor and you look 

at the addiction that’s not natural that starts to 

consume and control your life, to a point that you 

wake up first thing in the morning and that’s what 

you’re reaching for.” Each of these quotes 

demonstrates negative associations with 

commercial tobacco that are both immediate and 

long-term.  



 
 
 
 
 

 

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Generational Role 

Data collection included participants spanning five 

generations from age 20 to 69. Findings about 

generational perceptions and use of tobacco 

included older people reflecting on youth practices 

and young people discussing their own ideas on 

tobacco. In general, participants felt that education 

on tobacco use was present in schools, however it 

is the main responsibility of elderly and older male 

relatives. Some stated that education is insufficient 

in light of the need to reduce risks to young 

people. One of the women living on reservation 

pointed out how local schools are addressing the 

manner:   

“Since that time I think some of the other local 

schools have picked up that type of education, but 

now it’s usually only during certain times of the 

year like during drug week or what-whatever 

national smoking week or whatever it is. But at 

least they’re starting to get it into the curriculum at 

school. I think that’s one of the first steps of 

teaching, I mean, ‘cause I think every one of us has 

said that we weren’t really aware.” Another woman 

supported previous statement in that education is 

the key:  “I think ...in order to try to stop them from 

doing that, we need to do a lot of education and 

the dangers of smoking, what it can lead to, 

especially addiction to tobacco and how it affects 

your life if you continue to smoke.” 

Other participants discussed education within 

families that could be transmitted across 

generations. One man stated: “I think the majority 

of education that we can do as adults, as parents, 

as uncles, as nephews, as grandparents is at home 

and also with the males is in the  [ceremonial 

place]. And: “There’s not that much education 

about tobacco use, and what the consequences are 

about it, the teaching just don’t stop in school, it 

continues into the community, into the family.” 

Participants discussed reasons why young people 

use commercial tobacco including ‘modeling the 

behavior of adults’. In the urban focus group, one 

participant stated: “Kids are exposed to 

[commercial tobacco] at a young age, watching 

their elders smoke or family members smoke, it’s 

definitely present, but if it’s being reflected in the 

culture or the environment then, it shows up in the 

kids” (urban man). Other participants in the urban 

focus groups discussed this further by stating that 

“…the kids and teenagers just do what the adults 

are doing, what they see, so if the adults didn’t do 

it, or the elders, or like…well the elders in the 

[ceremony place], they do it for a purpose, but not 

all kids and teenagers see it that way.” With regard 

to traditional tobacco use, participants had 

different perspectives on the behavior of young 

people.  

Participants said that youth did not know how to 

respect traditional tobacco. One woman stated, “I 

see them just doing it, just for that purpose…and 

the older men allowing that … if they’re taught 

right, they know how to respect that and to do it 

and use it only during the ceremonial purposes” 

(urban woman). Adults, and in particular uncles, 

were viewed as having a responsibility to teach 

youth about how to use tobacco with the right 

purpose, “Maybe [young people] would [listen] to 

their their uncles if their uncles would step up and 

get mad at them and tell them when’s the right 

time and when not to, but sometimes the uncles 

are the only guys that, cheer or laugh at then. 

When they cough they laugh like it’s okay” (urban 

male). Young men living in urban areas state that 

other young people used tobacco for the nicotine 

high and to fit in with their peers. One man stated. 



 
 
 
 
 

 

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“...the men know how to use [tobacco], what the 

purpose of it. But then it’s the younger children, 

kids, teens, who just smoke it just to feel the 

nicotine high and impress other people or try to fit 

in so they’re not left out.”  

Men and women had differing responses 

regarding the use of commercial tobacco in 

ceremony. Women stated a strong preference for 

men to use only traditional tobacco in ceremony. 

In the urban group, one woman stated: “I would 

think tobacco is more important that the men 

should stick to the traditional tobacco instead of 

commercial.” Another woman added that 

traditional tobacco use over commercial use would 

reduce direct health risks and help to educate 

young people about the meaning of traditional 

tobacco: “I think if they did use the traditional 

tobacco [all] the time, it would be less people just 

smoking the commercial tobacco and that the 

younger generation would understand more of how 

to use and not just go down there [traditional 

ceremonial place] just to smoke cigarettes.” Some 

men differed on this perception, however, stating: 

“You pray then your prayers go to the spirits no 

matter what kind of tobacco you use.”  

Participants also noted resistance by the youth to 

listen to their elders, “...now-a-days teenagers, kids, 

they don’t listen to the elders, to the older folks, 

they sometimes even get mad at them or argue 

with them back. They get high-headed, they think 

they know everything, the elders are just trying to 

look out for the health. The kids really [do not] 

have respect as much as they used to…” (urban 

man). The reflection of older and young people on 

their observations of youth tobacco use is 

illustrative of the ways in which elders perceive of 

differences, value, respect, and ritual associated 

with traditional versus commercial tobacco.  

DISCUSSION 

Findings demonstrate important differences in 

perceptions regarding the use of commercial and 

traditional tobacco. Emergent themes included 

gender and generational roles in understanding 

the use of commercial and traditional tobacco. The 

common thread among participants was the 

knowledge that traditional tobacco is a vital part of 

culture and commercial tobacco is unhealthy and 

harmful to the body. Women stated more clearly 

that commercial tobacco should never be used in 

ceremony because of health risks and potential 

impact on younger generations. Men stated 

immense health risks associated with commercial 

tobacco but were less strongly opposed to 

commercial tobacco in ceremony.  

Upon entering a ceremonial place, men are 

welcomed and invited to sit and smoke. 

Participants stated that smoke is used to send 

prayers in ceremonies, which aligns with other 

studies reporting the customary practice where 

smoke from the tobacco carries thoughts and 

prayers to deities (Struthers & Hodge, 2004; 

Nadeau et al., 2012). Most participants, regardless 

of gender, saw no negative side effects from using 

traditional tobacco, which is consistent with other 

studies (Struthers & Hodge, 2004; Unger et al., 

2006; Arndt et al., 2013; Henderson & Henderson, 

2015). Other studies cite challenges in securing 

traditional tobacco have lead members of other 

tribes to use commercial tobacco in proxy of 

traditional tobacco due to its ready availability 

(Struthers & Hodge, 2004; Nez-Henderson et al., 

2005; Unger et al., 2006; Forster et al., 2007; 

Margalit et al., 2013). 

Participants confirmed the importance of tobacco 

in traditional ceremonial milieu. The men shared 

personal experiences with smoking traditional and 



 
 
 
 
 

 

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sometimes commercial tobacco during 

ceremonies. While women do not have direct 

experience with traditional tobacco, they have 

observed the negative impact on men’s health 

with the transition from traditional to commercial 

tobacco use in ceremonies. These underlying 

cultural differences in tobacco use by gender 

could partially explain why several studies have 

observed higher rates of tobacco use among 

southwest American Indian men, when compared 

to southwest American Indian women (Nez-

Henderson et al., 2005; Redwood et al., 2010).  

Women were strongly opposed to commercial 

tobacco due to concern for their children’s health. 

The men did not come to a consensus on youth 

smoking in general. Most of the men stated that 

kids have access to commercial tobacco, but they 

did not voice direct opinions either for or against 

youth smoking. In addition, it was mentioned that 

there is leniency among some of the tribal 

members toward commercial tobacco and youth 

smoking. They seem to value beliefs about 

ceremonial purpose of tobacco as more important 

than what substance is being smoked. This theme 

was particularly prominent among urban men who 

had a lower mean age relative to the reservation 

men. Other studies have found higher rates of 

commercial tobacco use among young American 

Indian southwest men (Nez-Henderson et al., 

2005; Redwood et al., 2010; Kunitz, 2016), which 

may explain complacency toward commercial 

tobacco. Men and women were hopeful that the 

younger generation would learn culturally-specific 

purposes behind the use of traditional tobacco.   

Recommendations 

This study provides an example of a promising 

CBPR practice between a tribal health program 

initiated collaboration with university partners. 

Understanding the nuances of traditional tobacco 

in a cultural context is imperative for effective 

smoking cessation program planning with tribal 

communities. The authors were able to work with 

the tribe to identify policy change strategies that 

were implemented to reduce the youth’s exposure 

to commercial tobacco used in ceremonies.  

Once community-engaged research and practice 

lays the foundation for tobacco cessation 

programs, the authors suggest obtaining financial 

support to the tribal tobacco prevention programs 

where possible. Additional resources could 

support community-engaged efforts to advertise 

the dangers of commercial tobacco through the 

use of billboards and other visual means. Other 

suggested policies include prohibiting youth from 

smoking commercial cigarettes at traditional 

ceremonies, pow-wow, or tribal gatherings. Most 

importantly, tobacco cessation programs must be 

implemented in an engaged way with a clear 

understanding of local uses and perceptions of 

tobacco for ceremonial and individual uses. 

Without that understanding, programs may not be 

successful in communicating with and to the 

people who may be positively impacted by a 

reduction in the use of commercial tobacco on 

tribal lands.  

ACKNOWLEDGEMENTS 

The authors disclosed receipt of the following 

financial support for the research, authorship, 

and/or publication of this article: Research 

reported in this publication was supported by the 

National Institute of Health (NIH), National Cancer 

Institute (Grant Number: 5U54CA143925, The 

Partnership for Native American Cancer 

Prevention) and National Institute On Minority 

Health and Health Disparities of the National 

Institutes of Health under Award Number 



 
 
 
 
 

 

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P20MD006872 to Co-PI: Priscilla R. Sanderson, 

Ph.D., CRC and Nicolette I. Teufel-Shone. The 

content is solely the responsibility of the authors 

and does not necessarily represent the official 

views of the National Institutes of Health.”  

The authors would like to thank both the funders 

and participants who made this research 

project.  This work would not have been possible 

without the support of Kwaayesnom Onsae, Jalen 

Redhair, B.S., Eldon Kalemsa, Joyce Hamilton, and 

Kassondra Yaiva who contributed to the research. 

The authors recognize the partnership support of 

the University of Arizona team: Sylvia Brown, Ph.D, 

MPH, Robin Harris, Ph.D., and Neil Weinstein, 

Ph.D.   

Conflict of interest statement 
The co-authors have declared that no competing 

or conflict of interests exist. The funders had no 

role in study design, writing of the manuscript and 

decision to publish. 

Author’s Contributions 
Priscilla R. Sanderson was the Co-Leader of the 

pilot research project, supervised and mentored 

the undergraduate research students while the 

research was conducted, focus group facilitator, 

led the multi-investigator analysis meetings, and 

draft paper editing and review. 

Erelda Gene and Rebecca Scranton assisted with 

focus group discussions, assisted with the multi-

investigator analysis meetings, transcribed and 

coded with Atlas, t.i., conducted the literature 

review, wrote the draft paper, and draft paper 

editing and review.  

Angela A A Willeto conducted the literature 

review, wrote the literature review section, and 

draft paper editing and review. 

Lori Joshweseoma presented and received tribal 

council approval, assisted with focus group 

discussions and facilitator, and assisted with the 

multi-investigator analysis meetings Lisa J Hardy 

draft paper editing and review. 

REFERENCES 
Arndt, L. N., Caskey, M., Fossum, J., Schmitt, N., Davis, A. R., 

Smith, S. S., Kenote, B. Strickland, R., & Waukau, J. (2013). 

Menominee perspectives on commercial and sacred 

tobacco use. American Indian and Alaska Native Mental 

Health Research Journal, 20(3), 1-22. ISSN: 1533-7731. 

Buchwald, D., Beals, J., & Manson, S. (2000). Use of traditional 

health practices among Native 

Americans in a primary care setting. Medical Care, 38(12),1191-

1199. 

Chief C., Sabo S., Clark, H., Nez Henderson, P., Yazzie, A., 

Nahee, J., & Leischow, S.J. 

(2016). 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). Tobacco Control, 25(Suppl 1), i19-

i25. https://doi.org/10.1136/tobaccocontrol-2016-053081. 

Forster, J. L., Rhodes, K. L., Poupart, J., Baker, L. O., & Davey, 

C. (2007). Patterns of tobacco use in a sample of 

American Indians in Minneapolis-St. Paul. Nicotine and 

Tobacco Research, 9(Suppl 1), S29-S37. 

https://doi.org/10.1080/14622200601083434 

Groenewald, T. (2004). A phenomenological research design 

illustrated. International Journal of Qualitative Methods, 

3(1), 42-55. 

Henderson, J, & Nez Henderson, P. (2015). Differences 

between commercial tobacco and Dził Nát’oh Traditional 

Mountain Smoke [video segment]. 

https://www.youtube.com/watch?v=YErtq3OQJCc 

Heron, M. (2016). Deaths: Leading causes for 2014. Hyattsville, 

MD: U.S. Department of Health and Human Service, 

Centers for Disease Control and Prevention, National 

Center for Health Statistics, National Vital Statistics 

Reports. DHHS Publication No. 2016–1120. 

Israel, B.A., Schulz, A.J., Parker, E.A., & Becker, A.B. (1998). 

Review of community-based research: Assessing 

partnership approaches to improve public health. Annual 

review of public health, 19(1), 173-202. 

Kunitz, S. J. (2016). Historical influences on contemporary 

tobacco use by northern plains and southwestern 

American Indians. American Journal of Public Health, 

106(2), 246–255. 

https://doi.org/10.2105/AJPH.2015.302909 

Margalit, R., Watanabe-Galloway, S., Kennedy, F., Lacy, N., 

Red Shirt, K., Vinson, L., & Kills Small, J. (2013). Lakota 

Elders’ views on traditional versus commercial/addictive 

tobacco use; Oral history depicting a fundamental 

https://doi.org/10.1136/tobaccocontrol-2016-053081
https://doi.org/10.1080/14622200601083434
https://www.youtube.com/watch?v=YErtq3OQJCc
https://doi.org/10.2105/AJPH.2015.302909


 
 
 
 
 

 

www.companyofscientists.com/index.php/chd                    e10                                               Cancer Health 

Disparities 

RESEARCH 

distinction. Journal of Community Health, 38, 538-545. 

https://doi.org/10.1007/s10900-012-9648-7 

Miles, M. B., & Huberman, A. M. (1984). Qualitative data 

analysis, a sourcebook of new methods. Newbury Park, 

CA: Sage. 

Nadeau, M., Blake, N., Poupart, J., Rhodes, K., & Forster, J. L. 

(2012). Circles of Tobacco Wisdom: Learning about 

traditional and commercial tobacco with Native elders. 

American Journal of Preventive Medicine, 43(5 Suppl. 3), 

S222-S228. https://doi.org/10.1016/j.amepre.2012.08.003  

Nez-Henderson, P., Jacobsen, C., & Beals, J. (2005). Correlates 

of cigarette smoking among selected southwest and 

northern plains tribal groups: the AI-SUPERPFP study. 

American Journal of Public Health, 95(5), 867-872. 

https://doi.org/10.2105/AJPH.2004.050096 

Redwood, D., Lanier, A. P., Renner, C., Smith, J., Tom-Orme, 

L., & Slattery, M. L. (2010). Differences in cigarette and 

smokeless tobacco use among American Indian and 

Alaska Native people living in Alaska and the Southwest 

United States. Nicotine and Tobacco Research, 12(7), 791-

796. https://doi.org/10.1093/ntr/ntq087 

Sanderson, P. R.,Teufel-Shone, N. I., Baldwin, J. A., Sandoval, 

N., & Robinson, F. (2010). Breast cancer education for 

Navajo women: a pilot study evaluating a culturally 

relevant video. Journal of Cancer Education, 25(2), 217-

223. https://dx.doi.org/10.1007/s13187-009-0036-7 

Steele, C. B., Cardinez, C. J., Robertson, L. C., Tom-Orme, L., & 

Shaw, K. M. (2008). Surveillance for health behaviors of 

American Indians and Alaska Natives – Findings from the 

Behavioral Risk Factor Surveillance System, 2000-2006. 

Cancer Supplement, 113(5), 1131-1141. 

https://doi.org/10.1002/cncr.23727 

Struthers, R. & Hodge, F. S. (2004). Sacred tobacco use in 

Ojibwe communities. Journal of Holistic Nursing, 22(3), 

209-225. 

https://dx.doi.org/10.1177%2F0898010104266735 

Substance Abuse and Mental Health Services Administration. 

(2014). Results from the 2013 National Survey on Drug 

Use and Health: Summary of national findings. Rockville, 

MD: SAMSHA. 

https://www.samhsa.gov/data/sites/default/files/NSDUHr

esultsPDFWHTML2013/Web/NSDUHresults2013.pdf 

Teufel-Shone, N. I., Siyuja, T., Watajomigie, H. J., & Irwin, S. 

(2006). Community-based participatory research: 

conducting a formative assessment of factors that 

influence youth wellness in the Hualapai community. 

American Journal of Public Health, 96(9), 1623-1628. 

https://dx.doi.org/10.2105/AJPH.2004.054254 

Unger, J. B., Soto, C., & Baezconde-Garbanati, L. (2006). 

Perceptions of ceremonial and nonceremonial uses of 

tobacco by American-Indian adolescents in California. 

Journal of Adolescent Health, 38(4), 443.e9-443.e16. 

https://doi.org/10.1016/j.jadohealth.2005.02.002 

Verney, SP, Avila M., Espinoza P.R., Cholka C.b., Benson J.G., 

Baloo A., & Pozernick C.D.  

(2016). Culturally sensitive assessments as a strength-based 

approach to wellness in Native  communities: A 

community-based participatory research project. 

American Indian  Alaska Native Mental Health 

Research, 23(3), 271-92. 

Wallerstein, N.B., Duran, B. (2006). Using community-based 

participatory research to address 

health disparities. Health Promotion Practice, 7(3), 312-323. 

Wallerstein, N., Duran, B. (2010). Community-based 

participatory research contributions to 

intervention research: The intersection of science and practice 

to improve health equity. 

American Journal of Public Health, 100(S1), S40-S46 

Yu, M. & Whitbeck, L. B. (2016). A prospective, longitudinal 

study of cigarettes smoking status among North 

American Indigenous adolescents. Addictive Behaviors, 

58, 35-41. https://doi.org/10.1016/j.addbeh.2016.02.007 

 

 

http://doi.org/10.1007/s10900-012-9648-7
http://doi.org/10.1016/j.amepre.2012.08.003
http://doi.org/10.2105/AJPH.2004.050096
http://doi.org/10.1093/ntr/ntq087
http://dx.doi.org/10.1007/s13187-009-0036-7
http://doi.org/10.1002/cncr.23727
http://dx.doi.org/10.1177%2F0898010104266735
http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf
http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf
http://dx.doi.org/10.2105/AJPH.2004.054254
http://doi.org/10.1016/j.jadohealth.2005.02.002
http://doi.org/10.1016/j.addbeh.2016.02.007

