www.companyofscientists.com/index.php/chd e1 Cancer Health Disparities RESEARCH 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 www.companyofscientists.com/index.php/chd e2 Cancer Health Disparities RESEARCH 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 www.companyofscientists.com/index.php/chd e3 Cancer Health Disparities RESEARCH 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. www.companyofscientists.com/index.php/chd e4 Cancer Health Disparities RESEARCH 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 www.companyofscientists.com/index.php/chd e5 Cancer Health Disparities RESEARCH 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. www.companyofscientists.com/index.php/chd e6 Cancer Health Disparities RESEARCH 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. www.companyofscientists.com/index.php/chd e7 Cancer Health Disparities RESEARCH “...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 www.companyofscientists.com/index.php/chd e8 Cancer Health Disparities RESEARCH 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 www.companyofscientists.com/index.php/chd e9 Cancer Health Disparities RESEARCH 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). 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