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Service Delivery Innovation Profile

Culturally Tailored Cessation Program Significantly Reduces Tobacco Use Among Members of American Indian Tribe


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Snapshot

Summary

Based on the American Lung Association's "Freedom from Smoking" curriculum, the Fond du Lac Smoking Cessation Program offers flexible, culturally tailored support to members of the Reservation of the Fond du Lac Band of Lake Superior Chippewa who want to quit smoking. Specially trained counselors meet with members one-on-one or in groups, with session format and location based on the individual's preferences. The curriculum incorporates cultural and historical characteristics from the tribe, and clearly distinguishes between the abuse of commercial tobacco and its appropriate use as a sacred item in ceremonies and offerings of prayer. It also addresses nutrition, exercise, and other health-related topics. The program significantly reduced tobacco use and generated high levels of engagement and satisfaction among participants.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation trends in tobacco use, obtained from self-reported surveys completed by just under half (141 out of 303) of participants; key metrics include 7-day abstinence rates and tobacco use at baseline, program completion, and 90 days after program completion.
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Developing Organizations

Fond du Lac Band of Lake Superior Chippewa
Cloquet, MNend do

Date First Implemented

2004
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Patient Population

Race and Ethnicity > American indian or alaska nativeend pp

Problem Addressed

American Indians are more likely to smoke and have more difficulty quitting than those in other racial and ethnic groups. Yet few tobacco cessation programs have been developed specifically for American Indians.
  • More likely to smoke; more trouble quitting: Just under one-third (32 percent) of American Indian adults smoke, well above the 21-percent smoking rate for all U.S. adults.1 Although American Indian adults who smoke often express a strong interest in quitting, they have less success in doing so and in avoiding relapses than do smokers in other racial and ethnic groups.2
  • Few culturally tailored cessation programs: Few treatment programs recognize the cultural and traditional values and the unique relationship with sacred tobacco that exists for American Indian smokers.3-5

What They Did

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Description of the Innovative Activity

The Fond du Lac Smoking Cessation Program, offered through the Wiidookawishin (Help Me) QUITPLAN Center, provides flexible, culturally tailored support to tribal members who want to quit smoking. Specially trained counselors meet with these members one on one or in groups, with session format and location based on the individual's preferences. The curriculum incorporates cultural and historical characteristics from the tribe, and clearly distinguishes between the abuse of commercial tobacco and its appropriate use as a sacred item in ceremonies and offerings of prayer. It also addresses nutrition, exercise, and other health-related topics. Key program elements are described below:
  • Program referrals and promotion:Housed in the Department of Public Health Nursing, individuals are referred to the program by medical and dental providers, public health workers, and others involved in the health and well-being of tribal members. In addition, tribal members who want to quit smoking can contact the program directly (self-referral). Program staff make presentations to promote the program to all potential referral sources, as well as at women's health fairs, men's health brunches, pow-wows, elders' meetings, and other community events. Descriptions of the program also appear on the tribal Web site and in the Reservation newsletter.
  • Flexible program design based on individual preferences: Program staff contact those referred to the program (either by phone or in person) to determine an appropriate meeting place and time. Depending on individual preferences, counselors conduct group and one-on-one sessions during the day, in the evenings, and on weekends. Participants can attend sessions at the Department of Public Health Nursing offices in Cloquet or Duluth and at the Mashkiki Waakaaigan Pharmacy in Minneapolis. If preferred, counselors also will meet at an individual's home, workplace, or other setting deemed comfortable.
  • Culturally tailored curriculum: Participants attend four 1-hour sessions over a 4-week period of time. The program coordinator from the Department of Public Health Nursing leads most sessions; however, pharmacists, certified in tobacco dependence treatment, are also available to provide cessation support. Each session starts with the sharing of a story from one of the Tribe's seven clans that incorporates cultural and historical characteristics, values, and traditions from the community, including use of tobacco as a sacred item in ceremonies and prayer offerings. This approach provides common ground for building trust and respect. Each session focuses on a specific theme, as outlined below:
    • Building motivation: The first session focuses on building motivation, making the decision to quit, and the costs of smoking. Participants discuss reasons to stop smoking, ways to manage stress, and the role of traditional tobacco. They learn about the damaging effects of carbon monoxide and take a breath test that gives them visible proof of their high levels. Although not required, participants can take the test again at subsequent sessions to monitor changes.
    • Planning to quit: The second session teaches strategies for coping with urges and helps the individual make a plan to quit. It addresses the symptoms of recovery and the rewards for change. Counselors encourage participants to set a quit date and describe the benefits of various tobacco cessation aides, including nicotine patches, prescription drugs, acupuncture, herbal remedies, hypnosis, homeopathy, and brain wave optimization (an advanced form of neurofeedback). 
    • Social support and weight management: The third session covers social support and weight management. When addressing social support, counselors discuss the benefits of stopping smoking and how to deal with high-risk situations. They also have participants develop a contract for accountability with a strong supporter. They further discuss how nicotine can depress one's appetite and the potential for weight gain when quitting. In addition, they address the role that good nutrition has in weight management and provide information about the availability of cooking classes. 
    • Exercise, assertive communication, and relapse prevention: The final session reviews the importance of exercise, use of assertive communication, and strategies to avoid relapse. Counselors inform participants about exercise classes and the opportunity to receive points they can use to obtain home goods by participating in On the Move classes sponsored by the Diabetes Prevention Program, also run by the Department of Public Health Nursing. They provide examples of how to assert one's desire to quit when confronted with pressure to smoke and tips on managing nicotine withdrawal to avoid relapse.
  • Free pharmacotherapy: Those enrolled in the program who complete at least one counseling session become eligible for free nicotine replacement therapy and/or cessation medications. During the initial trial, roughly two-thirds of participants qualified for free pharmacotherapy. Those completing all four sessions also received a $25 gift card. 

Context of the Innovation

The Reservation of the Fond du Lac Band of Lake Superior Chippewa is one of six Reservations inhabited by members of the Minnesota Chippewa Tribe, the second largest ethnic group of Indians in the country. The Reservation is located adjacent to Cloquet, Minnesota, approximately 20 miles west of Duluth. Between 2002 and 2004, the Fond du Lac Department of Public Health Nursing conducted a smoking cessation program designed to help individuals make informed decisions about quitting. However, the program did not reduce use of commercial tobacco, leading department leaders to look for a more effective approach. In 2004, they successfully applied to ClearWay Minnesota for a community research grant to develop an evidenced-based, culturally tailored smoking cessation program for tribal members. A nonprofit organization funded by a portion of the Minnesota Tobacco Settlement, ClearWay Minnesota works to reduce tobacco use and exposure to secondhand smoke through research, action, and collaboration.

Did It Work?

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Results

The program significantly reduced tobacco use and generated high levels of engagement and satisfaction among participants.
  • Significantly less tobacco use: Shortly after completing the program, almost one-third of participants reported not smoking in the last 7 days. After 90 days, that figure reached almost half (47 percent) of participants. Those who still smoked at this time significantly reduced the number of cigarettes consumed each day, from an average of 17 at baseline to 9 at the 90-day followup. The proportion smoking within 30 minutes of waking declined from 73 percent to 42 percent over the same time period.
  • Driven by high engagement and satisfaction, free pharmacotherapy: Participants reported high levels of engagement and satisfaction with the program, with nearly two-thirds (63 percent) attending all four counseling sessions (a much higher proportion than other face-to-face programs offered to tribal members). Approximately 90 percent of participants indicated they recommended the program to friends and family, and half of those on medication cited pharmacotherapy as the most helpful factor in quitting.  

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation trends in tobacco use, obtained from self-reported surveys completed by just under half (141 out of 303) of participants; key metrics include 7-day abstinence rates and tobacco use at baseline, program completion, and 90 days after program completion.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Developing grant proposal: With full support from the Reservation Business Committee, staff partnered with researchers from the University of Minnesota to develop the proposal to ClearWay. As part of this effort, staff obtained permission from the American Lung Association to use its evidence-based smoking cessation curriculum as a starting point and gathered input from tribal elders and other community stakeholders regarding design of the proposed program.
  • Adapting program to tribal culture: Program development staff tailored the curriculum content and designed strategies for delivering the program based on local needs and culture. As part of this process, they obtained additional input from tribal elders, current smokers, and other stakeholders, including medical and dental providers and public health workers. They also worked with tribal pharmacy staff to pass a resolution/policy requiring anyone who received cessation medication to participate in the program.
  • Hiring and training staff: Through the ClearWay grant, the Department of Public Health Nursing hired a full-time person to run the cessation program. This individual, along with two pharmacists, received specialized training at the Mayo Clinic on tobacco dependence and the curriculum.

Resources Used and Skills Needed

  • Staffing: As noted, one full-time person coordinates the program and conducts the majority of counseling sessions. This individual has a Bachelor's Degree in Applied Science with a focus on health education. Two pharmacists who are certified as tobacco dependence treatment counselors also conduct sessions on the Reservation and at a satellite pharmacy in Minneapolis.
  • Costs: Costs associated with the program include salary and benefits for the full-time coordinator/counselor, overhead costs for meeting rooms and materials, travel costs for counselors, and certification training.
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Funding Sources

ClearWay Minnesota
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Tools and Other Resources

For more information about the Fond du Lac Band of Lake Superior Chippewa, go to: www.fdlrez.com

For more information about ClearWay Minnesota, go to: www.clearwaymn.org

Adoption Considerations

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Getting Started with This Innovation

  • Obtain buy-in from key stakeholders: Would-be adopters should meet with elders and the Tribe's governance committee members to discuss the benefits of developing a culturally tailored smoking cessation program. These meetings can also serve to identify other key stakeholder groups and potential funding sources.
  • Obtain buy-in and input from referral sources, smokers: Medical providers and other health-related professionals often serve as a major source of referrals to smoking cessation programs. Would-be adopters should meet with them to get their input on the program and win their support for it. They should also meet with current tobacco users to identify barriers to participation and suggestions for effective program design.
  • Identify initial and ongoing funding source(s): Although existing programs and materials can serve as a starting point, funding will be needed to support adaptation of the program to the unique needs and culture of the community, and to cover ongoing staffing and overhead costs. In most cases, program operating funds can be allocated from the budgets of existing medical and public health programs.
  • Consider use of incentives: Would-be adopters should consider the need to provide incentives for individuals to participate in the program. Certain types of incentives may require approval from a tribal governing committee.

Sustaining This Innovation

  • Consider full-time staff person: The program will work best if one individual takes ownership over it. This person can also handle the majority of counseling for both individual and group sessions. 
  • Monitor and share data on program impact: Sharing data that documents the program's positive impact on smoking can serve to maintain momentum with key stakeholders.
  • Regularly promote program: In addition to maintaining regular contact with referral sources, program leaders should give periodic presentations to key stakeholders throughout the community, and make program information available at health fairs and other community events.

More Information

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Contact the Innovator

Nate Sandman, Community Health Services Coordinator
Community Health Services
Min No Aya Win (MNAW) Human Services Center
927 Trettel Lane
Cloquet, MN 55720
(218) 878-2104
E-mail: natesandman@fdLrez.com

Innovator Disclosures

Mr. Sandman has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Footnotes

1 Cigarette smoking among adults and trends in smoking cessation—United States, 2008. MMWR. 2009;58:1227-32. [PubMed]
2 Gohdes D, Harwell T, Cummings S, et al. Smoking cessation and prevention: an urgent public health priority for American Indians in the Northern Plains. Public Health Rep. 2002;117:281-90. [PubMed]
3 Choi W, Daley C, James A, et al. Beliefs and attitudes regarding smoking cessation among American Indians: a pilot study. Ethn Dis. 2006;16:35-40. [PubMed]
4 Unger J, Soto C, Thomas N. Translation of health programs for American Indians in the United States. Eval Health Prof. 2008;31:124-44. [PubMed]
5 Struthers R, Hodge F. Sacred tobacco use in Ojibwe communities. J Holist Nurs. 2004;22:209-25. [PubMed]
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Original publication: January 18, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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