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Tobacco Treatment Specialists In Healthcare: Spotlight on Care for American Indians/Alaska Natives

This occasional series highlights some of the practice areas where tobacco treatment specialists (TTS) work. In this post, we share tips on how to tailor your smoking cessation message for American Indians and ways to decrease health disparities created by commercial tobacco use.

American Indians and Alaska Natives (AI/AN) have one of the highest rates of smoking in the nation with more than 1 in 5 AI/AN adults (22.6%) using cigarettes. For context, the smoking prevalence among all U.S. adults is 12.5%. As a result of these high rates of commercial tobacco use, AI/AN adults are more likely to develop and die from tobacco-related illnesses, such as heart disease and lung cancer.

I had a chance to sit down with Lu McCraw, Native Americans Commercial Tobacco Use Prevention & Treatment Coordinator for the North Carolina Department of Health and Human Services, to talk about the nuances of addressing tobacco use in the AI/AN community. As a member of the Otoe-Missouria Tribe of Indians of Red Rock, OK, she brings her personal experience as a tribal member to her work. She also has over two decades of experience working in public health and tobacco prevention in tribal communities. Lu McCraw is one of several experts who speak during Duke-UNC TTS Comprehensive Tobacco Treatment Specialist Training on ways to eliminate disparities created by tobacco use and promote health equity.

A big challenge in addressing commercial tobacco use among the AI/AN community is trying to get data on who is smoking and how much. Lu explains that CDC data lumps all the tribes together. This leads to data that is not very accurate, as each tribe is different and may have different patterns of tobacco use.

When talking to American Indian and Alaskan Native individuals, it is important to respect the sacred, religious, and traditional use of the tobacco plant and focus on the harmful effects of commercial tobacco products. --Lu McCraw

“Last year through a health equity grant we were able to start our own American Indian survey of the tribes in North Carolina,” which has been an ongoing project for Lu’s department. There are seven state tribes and one federally recognized tribe in NC.

Another big barrier for AI/AN communities is access to treatment. “Many live in poor, rural areas. They don’t have good access to the Internet,” she says. “COVID has also had a big impact,” in that people are afraid to come in person to receive treatment.

Another challenge to providing effective treatment is the mistrust that exists within many tribal communities for government interventions based on historical abuses. “Natives aren’t keen on government programs. There is also a lot of resistance to using nicotine replacement therapies and other cessation medications. Medications often give them a panicky feeling,” says Lu.

Interventions that do work for AI/AN communities include providing cessation services by someone who is familiar with their shared experience and passing smoke-free policies for tribal buildings and pow-wows. Lu’s team relies heavily on brochures to share information about the harms of commercial tobacco use and treatment options. They personalize the brochures with each tribe’s own pictures, language, and history. “Members of the tribe like seeing people they know on the brochures,” she says.

Most tribal communities rely on quitlines for smoking cessation treatment. North Carolina and many states have quitlines with dedicated coaches, who are Native Americans.

Lu’s main takeaway for the TTS community: “Sometimes you don’t know if people are tribal people. They come in all shapes, sizes, and colors. Be respectful of the traditions and culture of tribal people. Be aware that some folks are using traditional tobacco in their ceremonies, which is very different from the use of commercial tobacco.”

Drawing the distinction between commercial tobacco products used for recreation, such as cigarettes and cigars, and traditional tobacco, which is used by many tribes for ceremonial and medicinal purposes, is important when speaking to members of the AI/AN community.

“The tobacco plant was the first plant given by the creator,” explains Lu. “For many tribes it is considered blasphemous to smoke commercial tobacco products.” For many years, tribes were not allowed to grow and use their own tobacco for ceremonies, Lu says. “So they just substituted commercial tobacco for their ceremonies but in the meantime got addicted to nicotine.”

Lu will be representing the Duke-UNC TTS Training Program as an exhibitor at the upcoming National Tribal Public Health Conference from April 11-13, 2023 in Durant, Oklahoma.

Visit to find out more about our upcoming training events.

About The Author

Rachael Joyner is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.

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