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Cigarette Use Among American Indians and Alaska Natives in Metropolitan Areas, Rural Areas, and Tribal Lands

Cunningham, James K. PhD; Ritchey, Jamie PhD, MPH; Solomon, Teshia A. PhD; Cordova, Felina M. DrPH, MPH

Journal of Public Health Management and Practice: September/October 2019 - Volume 25 - Issue - p S11–S19
doi: 10.1097/PHH.0000000000001026
Research Reports
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Context: Cigarette use among the US general population is significantly lower in metropolitan areas than in rural areas.

Objective: To assess whether cigarette use among American Indians and Alaska Natives (AI/AN) is lower in metropolitan areas than in rural areas and tribal lands (which are predominantly rural).

Design: Data came from the National Survey on Drug Use and Health (2012-2016). Regressions with adjustments for demographics were performed to assess whether cigarette use differed in association with type of place.

Settings: The AI/AN in tribal lands (n = 1569), nontribal large metropolitan (1+ million people) areas (n = 582), nontribal small metropolitan (<1 million) areas (n = 1035), and nontribal rural areas (n = 1043).

Main Outcome Measures: Cigarette abstinence, current smoking, daily use, number of cigarettes used, and days of use—all in the past month. Nicotine dependence was also examined.

Results: Metropolitan (large or small) areas versus rural areas: no statistically significant differences in cigarette use were found. Metropolitan (large or small) areas versus tribal lands: days of cigarette use and daily use were significantly lower in tribal lands. Tribal lands were also lower than small metropolitan areas regarding number of cigarettes used and nicotine dependence. Rural areas versus tribal lands: cigarette measures were consistently lower in tribal lands. For example, the prevalence of current smokers, daily users and nicotine dependence, respectively, was 37.9%, 25.9%, and 16.3% in rural areas and 27.4%, 13.6%, and 8.9% in tribal lands.

Conclusions: Differences in cigarette use between AI/AN in nontribal rural and metropolitan areas were not indicated. Instead, the place differences found were lower cigarette use in tribal lands than in nontribal rural areas and, to some extent, metropolitan areas. These findings can help inform policy makers working to develop context-sensitive anticommercial tobacco efforts for AI/AN.

Department of Family and Community Medicine (Drs Cunningham, Solomon, and Cordova), Native American Research and Training Center (Drs Cunningham, Solomon, and Cordova), and Western Region Public Health Training Center (Dr Cunningham), The University of Arizona, Tucson, Arizona; and Tribal Epidemiology Center, Inter Tribal Council of Arizona, Phoenix, Arizona (Dr Ritchey).

Correspondence: James K. Cunningham, PhD, Department of Family and Community Medicine, The University of Arizona, 655 N Alvernon Way #228, Tucson, 85716 (jkcunnin@email.arizona.edu).

The authors thank Margaret Thielemeir for helpful comments and the National Survey on Drug Use and Health for providing public use data sets. The authors are solely responsible for the analysis and conclusions presented here.

The authors declare no conflicts of interest.

Information on how cigarette use is associated with type of place, an environmental variable, is needed to help support development of context-sensitive anticommercial tobacco efforts.1–4 Research has found that cigarette use among the US general population is lower in metropolitan areas than rural areas.5–8 Limited work, however, has been conducted to assess whether this pattern holds for American Indians and Alaska Natives (AI/AN), leaving anticommercial tobacco efforts for AI/AN with little guidance on the issue. It is well established that AI/AN have a unique history regarding tobacco, one that entails reverence and conventions regarding consumption.9–11 When histories with a substance differ, so too can its current use,9–11 including possibly use by type of place.

To date, at least 2 studies have considered cigarette use among selected groups of AI/AN in metropolitan (urban) and rural areas; findings were mixed. A study of American Indians at 18 health clinics in northern California (N = 1369) reported a higher prevalence of smokers among the urban (44%) than rural clients (38%).12 A study using data for urban and rural Native Americans from a school-based survey in California (N = 1060) did not find a significant difference in the prevalence of past month smoking—28% and 29%, respectively.13 A dearth of other published research on the subject exists.14

This study examines cigarette use among the AI/AN general population in nontribal metropolitan areas (both large and small), nontribal rural areas, and tribal lands. In work published on cigarette use by place for the US general population, tribal lands have commonly been subsumed under other types of places,5–8 mainly rural areas as tribal lands are predominantly rural. Tribal lands were nevertheless classified as a separate category here because they are qualitatively distinct. For example, tribal lands have sovereign AI/AN governments, they are major centers for AI/AN culture, and the extent to which AI/AN in tribal lands intermix with, or at least are proximate to, other racial/ethnic groups can be relatively less. Also, some empirical analyses suggest that, regarding cigarette use prevalence, tribal lands may be quantitatively distinct. A survey of AI/AN in 2 Montana locations reported that 50% and 34% of on-reservation women and men versus 62% and 63% of off-reservation women and men were smokers.15 A survey of a Northern Plains tribe and a Southwest tribe suggested that current smoking was less among respondents who spent more than 75% of their lives on a reservation.16 The federal government, using unadjusted estimates for AI/AN adults, reported that past month daily cigarette use was lower in tribal than in nontribal lands, though no difference was found regarding abstinence from cigarettes.17

Data for the present study come from the National Survey on Drug Use and Health (NSDUH), pooled for the period of 2012-2016. For each type of place examined, 6 cigarette measures were considered, ranging from abstinence to number of cigarettes used in the past month.

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Methods

The NSDUH uses multistage area sampling to construct representative samples of civilian, noninstitutionalized individuals aged 12+ years living in the United States. Most questions in NSDUH are administered with Audio Computer-Assisted Self-Interviewing to provide respondents with a highly private/confidential mode for answering questions.18–20

The NSDUH asks respondents whether they are Hispanic and which racial group best describes them: white, black/African American, American Indian/Alaska Native, and Asian. This study examined data for those who self-identified as American Indian/Alaska Native only (non-Hispanic).18,21 Gender, age, income, marital status, and education were also examined, as they can be associated with cigarette use.22,23

Six cigarette measures were examined: cigarette abstinence in the past month; current smoker (past month use plus lifetime consumption of 100+ cigarettes); number of days cigarettes were used in the past month; number of cigarettes used in the past month; daily cigarette use in the past month; and nicotine dependence (Nicotine Dependence Syndrome Scale score of ≥2.75).24

In this study, tribal lands are federally recognized American Indian reservations and off-reservation trust lands, state-recognized American Indian reservations, Oklahoma tribal statistical areas, tribal designated statistical areas, and state-designated tribal statistical areas.19 All AI/AN respondents in a tribal land were coded as such, regardless of its metropolitan or rural status. Other places examined in this study, all exclusive of tribal lands, were metropolitan places with 1+ million people—labeled large metropolitan areas, metropolitan places with less than 1 million people—labeled small metropolitan areas, and the remaining nonmetropolitan places—labeled rural areas.

The Institutional Review Board at The University of Arizona classified the study as exempt.

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Sample size and statistical analysis

The unweighted counts of respondents per type of place were as follows: large metropolitan areas (n = 582), small metropolitan areas (n = 1035), rural areas (n = 1043), and tribal lands (n = 1569). All analyses used weighted data and complex sampling procedures in Stata 14.2.25 Logistic regressions with adjustments for the aforementioned demographic indicators were used to assess associations between place and the study's dichotomous cigarette measures. Associations between place and the cigarette use count variables (number of cigarettes and days of use) were examined using zero-inflated negative binomial regressions, also adjusted for the demographic indicators.

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Results

Descriptive estimates: demographics

The weighted percentages of AI/AN (12+ years of age) across the types of places examined were as follows: large metropolitan areas (20%), small metropolitan areas (21%), rural areas (19%), and tribal lands (40%).

Females constituted a slight majority in large metropolitan areas (Table 1). Large and small metropolitan areas had higher percentages of persons who were aged 65+ years; they also had higher percentages of persons who were college graduates and persons with annual family incomes of $75 000+.

TABLE 1

TABLE 1

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Descriptive estimates: cigarette measures

Rural areas had the lowest percentage of persons abstaining from cigarettes (58.3%); tribal lands had the highest (69.1%) (Table 2). Rural areas had the highest percentages of persons who were current smokers (37.9%), daily cigarette users (25.9%), and nicotine dependent (16.3%). Tribal lands had the lowest percentages for these same 3 variables—27.4%, 13.6%, and 8.9%, respectively. Rural areas had the highest percentages of persons using at least 500 cigarettes in the past month (11.6%) and persons using cigarettes 21 or more days in the past month (28.1%); tribal lands had the lowest percentages for these 2 variables—3.5% and 16.0%, respectively (Figure).

FIGURE

FIGURE

TABLE 2

TABLE 2

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Regression analyses: cigarette abstinence, current smoking, daily use, and nicotine dependence

No statistically significant differences were found between AI/AN in rural and metropolitan areas regarding cigarette abstinence, current smoking, daily use, or nicotine dependence (see rows in Table 3 that have “Rural area” as the referent for “Type of place”). However, in comparison with rural areas, those residing in tribal lands had significantly greater odds of being cigarette abstinent and significantly lower odds of current smoking, daily use, and nicotine dependence.

TABLE 3

TABLE 3

Also compared with tribal lands, the odds of daily use were significantly higher in small and large metropolitan areas (see rows in Table 3 that have “Tribal land” as the referent for “Type of place”). The odds of being nicotine dependent were higher in small metropolitan areas than in tribal lands as well. No significant differences in cigarette abstinence, current smoking, daily use, or nicotine dependence were found between small metropolitan areas and large metropolitan areas (not shown here).

Persons with a college education had higher odds of being cigarette abstinent and lower odds of current smoking, daily use, and nicotine dependence (Table 3). Persons with lesser family income, particularly annual incomes below $20 000, had lower odds of being cigarette abstinent and higher odds of current smoking, daily use, and nicotine dependence.

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Regression analyses: number of cigarettes used and days of use

When testing for differences in number of cigarettes used and in days of use, it is important to consider that these are count variables with large numbers of zeros (reports of no cigarette use in the past month). The zeros occurred because some respondents never engage in cigarette use and because some respondents by chance did not engage in cigarette use in the past month. Zero-inflated negative binomial regression can help take into consideration these 2 types of zeros.26

Using zero-inflated negative binomial regression, a “negative binomial part” was produced to assess the association between number of cigarettes used in the past month and type of place among persons open to smoking (would-be and past month smokers), and a “zero-inflated part” was produced that focused on persons not open to smoking. Similarly, zero-inflated negative binomial regression was used to examine days of cigarette use.

The negative binomial parts of the equations did not indicate significant differences between rural and metropolitan (small or large) areas regarding number of cigarettes used or days of cigarette use (Table 4). However, compared with tribal lands, AI/AN in rural and small metropolitan areas consumed significantly more cigarettes. Also compared with tribal lands, AI/AN in rural, small metropolitan, and large metropolitan areas had significantly more smoking days. The zero-inflated parts of the equations indicated that AI/AN in tribal lands compared with rural areas were significantly less likely to engage in cigarette use in the past month (also see Table 3).

TABLE 4

TABLE 4

No significant differences in number of cigarettes used or days of cigarette use were found between small metropolitan areas and large metropolitan areas (not shown here).

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Discussion

Although research for the US general population reports greater cigarette use in rural than in metropolitan areas,5–8 this study did not find significant differences in cigarette use between AI/AN in nontribal rural and metropolitan areas. It did, however, find that AI/AN in rural areas exceeded those in tribal lands on every cigarette use measure examined here. More specifically, the prevalence of current smokers, daily users, and nicotine dependence, respectively, was 37.9%, 25.9%, and 16.3% in rural areas and 27.4%, 13.6%, and 8.9% in tribal lands. Cigarette abstinence in rural areas and tribal lands was 58.3% and 69.1%, respectively. And the numbers of cigarettes used and smoking days were significantly higher in rural areas than in tribal lands.

Cigarette use among AI/AN in metropolitan areas also was greater than that in tribal lands, though less consistently so. No significant metropolitan area-tribal land differences were found regarding abstinence or current smoking. However, small and large metropolitan areas exceeded tribal lands regarding number of smoking days and daily use. Small metropolitan areas also exceeded tribal lands regarding number of cigarettes used and nicotine dependence.

Given these findings, AI/AN in rural and metropolitan areas compared with tribal lands might be expected to have greater tobacco-related morbidity and mortality, as daily use is associated with both.27–29 Other things equal, risk of exposure to secondhand smoke from AI/AN cigarette users might be higher in rural and metropolitan areas as well. And AI/AN tobacco treatment programs in rural areas and small metropolitan areas might expect to encounter a greater prevalence of nicotine dependence among their clientele.30–32

As is commonly indicated in cigarette consumption studies, education and income were associated with cigarette use.22,23 American Indians and Alaska Natives with college educations were less likely to smoke. Those with lower annual family incomes, especially below $20 000, were also more likely to smoke. Education and income, however, do not appear to explain why tribal lands had less cigarette use. Consider that rural areas and tribal lands were fairly similar regarding education (eg, 5.7% and 6.3% reported a college education, respectively) and income (eg, 12.2% and 11.4% reported incomes of $75 000+), yet these 2 types of places differed on each of the cigarette measures examined. Also, the regression analyses indicated significant differences in cigarette use between tribal lands and other areas, even though education and income were included as control variables.

This notwithstanding, there could be multiple reasons why cigarette use was lower in tribal lands. Historically, tobacco use among AI/AN has been reserved for social occasions and spiritual, ceremonial, and medicinal functions.9–11 Such traditional practice, a possible preventive factor,11,33 might be more pronounced in tribal lands, perhaps helping to explain lesser cigarette use there. Places other than tribal lands might be associated with reduced familial support and social contact among AI/AN and increased stress related to money, jobs, competition, and crowding, in turn perhaps elevating risk for health problems such as tobacco consumption.12,16,34–36 Also, access to care for AI/AN outside of tribal lands is often less than that for AI/AN on tribal lands,37 suggesting that AI/AN in rural and metropolitan areas are less likely to encounter health practitioners who would encourage cigarette use cessation and abstinence from recreational cigarette use. It might also be that AI/AN in tribal lands have greater access to tobacco prevention and treatment programs that are culturally appropriate and thus possibly more effective.38–40

Public health administrators may wish to consider fostering research to test which factors in fact explain lower cigarette use in tribal lands, and whether those factors can be incorporated into anticommercial tobacco programs for AI/AN in nontribal rural and metropolitan areas.

In keeping with the Indian Health Care Improvement Act that calls for Tribal Epidemiology Centers to analyze health data for AI/AN tribes and AI/AN in urban areas,41 this study considered cigarette use data for AI/AN in tribal lands, metropolitan areas, and rural areas. Its findings provide further evidence indicating that an environmental variable, type of place, is associated with one of the major sources of premature mortality among AI/AN—cigarette use.42,43

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Limitations

Accuracy of self-reported cigarette use is dependent on respondent candidness and memory; under- and overreporting consequently may have taken place.18,44 That said, self-reported cigarette use appears to be accurate in most studies.45

This study did not examine region in addition to type of place (regional indicators were not provided by NSDUH). Cigarette use among the US general population tends to be higher in the Midwest than in the west.46 Consistent with this, Cobb et al47 reported that cigarette use among AI/AN was higher in the northern plains (which overlap with the Midwest) than in the southwest and Pacific Coast. A US general population study by Roberts et al8 using regression models indicated that rural areas compared with urban areas had significantly more daily cigarette use and more use of at least 1 cigarette in the past month, even when region (north, west, south, and east) was included as a control variable. Research for AI/AN that similarly examines both region and type of place is needed.

Although this study treated tribal lands as a unique type of place, they can be classified according to large metropolitan, small metropolitan, and rural area criteria. If such classification had been used here, 5.4%, 20.1%, and 74.5% of the AI/AN in tribal lands would have been considered large metropolitan, small metropolitan, and rural areas residents, respectively.

The NSDUH and thus this study did not distinguish between ceremonial and recreational use of cigarettes. The study's estimates of cigarette use by type of place are averages. The prevalence of cigarette use within specific metropolitan areas, rural areas, and tribal lands can be expected to often differ from (be higher/lower than) these averages. While NSDUH's definitions of metropolitan and nonmetropolitan (rural) areas were used here, other definitions of metropolitan and rural areas exist.48

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Implications for Policy & Practice
  • In general, metropolitan areas compared with rural areas are a protective factor regarding cigarette use among the US general population, yet a similar pattern was not found for American Indians and Alaska Natives in nontribal rural and metropolitan areas.
  • Tribal lands, compared with nontribal rural and metropolitan areas, appeared to be a protective factor regarding cigarette use among American Indians and Alaska Natives.
  • Public health administrators should consider fostering research that explicates the determinants of lesser cigarette use in tribal lands, and whether they can be incorporated into anticommercial tobacco efforts for AI/AN in nontribal rural and metropolitan areas.
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Conclusions

Differences in cigarette use between AI/AN in nontribal rural and metropolitan areas were not indicated. Instead, the place differences found were lower cigarette use in tribal lands than in nontribal rural areas and, to some extent, metropolitan areas. These findings can help inform policy makers working to develop context-sensitive anticommercial tobacco efforts for AI/AN.

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Keywords:

American Indians and Alaska Natives; cigarette use; metropolitan; rural; tribal lands

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