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.
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.
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).
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).
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
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
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.
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:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
American Indians and Alaska Natives; cigarette use; metropolitan; rural; tribal lands