Cigarette Smoking Among American Indian Youth in Minneapolis–St. Paul Jean L. Forster, PhD, Isaiah Brokenleg, MPH, Kristine L. Rhodes, MPH, Genelle R. Lamont, MPH, John Poupart, MPA Background: Reported prevalence of cigarette smoking among American Indian youth is higher than other racial/ethnic minorities, and limited data indicate that this disparity is especially pronounced in the Upper Midwest of the U.S. The purposes of this study are to measure traditional and recreational tobacco use among American Indian youth in an urban Upper Midwest area, and to identify social and environmental factors associated with recreational tobacco use (cigarette smoking). Methods:

A cross-sectional convenience sample of 336 American Indian youth aged 11–18 years was given a self-administered survey. Data were analyzed using bivariate chi-square tests and multivariate logistical stepwise regression.

Results:

Almost 37% reported some recreational smoking in the previous 30 days, with about three times as many in the group aged 16 –18 years reporting smoking as in the group aged 11–13 years (p�0.0001). Social exposure to cigarette smoking was very strong; more than three fourths reported living with an adult who smokes, and 44% have a brother/a sister who smokes. Yet more than 65% report a household rule against their smoking, and 43% report a household rule against anyone smoking inside. Youth who smoke report buying cigarettes often and smoking on school property. Household rules against smoking and hearing of someone getting caught smoking at school have an independent negative association with likelihood of being a smoker.

Conclusions: These results indicate that American Indian youth in this area report high use of recreational tobacco, and the statewide focus on youth smoking prevention has not eliminated the disparity in smoking levels between American Indian youth and Minnesota youth overall. These findings suggest several pathways to reduce cigarette smoking among urban American Indian youth. (Am J Prev Med 2008;35(6S):S449 –S456) © 2008 American Journal of Preventive Medicine

Introduction

A

merican Indians in the Upper Midwest are reported to smoke cigarettes earlier, at higher levels, and with more severe health conse­ quences compared to other racial/ethnic groups in the U.S.1– 4 Smoking prevalence among American Indians varies by geographic and cultural factors, but is highest in the Northern Plains area including Minnesota. American Indians in the Upper Midwest have higher prevalence of cancer and cardiovascular disease com­ pared to other racial/ethnic groups, and higher than

From the Division of Epidemiology and Community Health, Univer­ sity of Minnesota (Forster, Rhodes, Lamont), Minneapolis, Minne­ sota; Great Lakes Inter-Tribal Epidemiology Center (Brokenleg), Lac du Flambeau, Wisconsin; and the American Indian Policy Center (Poupart), St. Paul, Minnesota Address correspondence and reprint requests to: Jean L. Forster, PhD, Division of Epidemiology and Community Health, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis MN 55454. E-mail: [email protected].

American Indians in other parts of the U.S. Most of the excess cancer is due to the dramatically higher lung cancer prevalence.1,3,5 Reports suggest that cigarette smoking prevalence among American Indian youth is higher compared to other racial/ethnic groups as well. The National Survey on Drug Use and Health reports that 21.2% of Ameri­ can Indian youth (aged 12–17 years) in a national sample of households smoked cigarettes in the previous month in 2006, the highest level of any racial/ethnic group.6 Beauvais et al.7 compared Indian and nonIndian data from the 2004 Monitoring the Future Study. They found that the prevalence of daily smoking was 13% for 8th-grade, 15% for 10th-grade, and 16% for 12th-grade American Indian students, while it was 4%, 8%, and 16%, respectively, for the non-Indian sample. While they indicate a disturbing disparity in smoking prevalence, these national data mask the geographic and cultural variation in cigarette smoking known to exist among American Indians, and reveal an even greater disparity.

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0749-3797/08/$–see front matter S449 doi:10.1016/j.amepre.2008.09.005

The 2007 Minnesota Student Survey, administered to most Minnesota students in grades 6, 9, and 12, revealed past-month smoking prevalence among American Indian students to be 4.8%, 23.0%, and 35.1%, respectively, higher than any of the other racial/ethnic groups (un­ published data).8 The Great Lakes Inter-Tribal Epidemi­ ology Center (GLITEC) has sponsored youth tobacco surveys of American Indian middle school students in Wisconsin in 20009 and in Michigan in 2004,10 states whose American Indians share some cultural characteris­ tics with Minnesota. They reported that 39% of Wisconsin and 31% of Michigan American Indian middle school students had smoked a cigarette in the past 30 days.9,10 These levels are much higher than those reported for the general population of comparable age students (Michi­ gan, 7.2%, 2003 Youth Tobacco Survey; Wisconsin, 12.2%, 2000 Youth Tobacco Survey).11 These comparisons sug­ gest that great disparities still exist in smoking prevalence between white and American Indian youth in the upper Midwest. Evidence suggests that social and environmental strat­ egies may be the most effective methods to reduce smok­ ing among adolescents.12 Policies prohibiting smoking in public places and household bans on smoking indoors change the normative environment around smoking and reduce adolescent as well as adult smoking.13–15 Strict youth access laws that are enforced reduce the likelihood that youth will initiate smoking or progress to regular smoking.16,17 Increasing cigarette prices through tax in­ creases appears to affect youth smoking intensity.18 Al­ though these are largely broad-based measures expected to affect entire communities, nothing has been reported about their specific effects on American Indian youth. The Twin Cities (Minneapolis–St. Paul MN) area is home to a large population of urban, off-reservation American Indians, estimated at about 33,000 by the U.S. Census, or about 41% of all American Indians in Minnesota.19 The majority of urban American Indians in this area are Anishi­ naabe (Ojibwe/Chippewa); Dakota/Lakota (Sioux); or HoChunk (Winnebago), reflecting the indigenous peoples of Minnesota, Wisconsin, and the Dakotas, but many are affili­ ated with other tribes. American Indian tribes in the Upper Midwest have used tobacco (asema, consasa) for spiritual and medicinal purposes for centuries. Traditional Indian tobacco is different from commercial tobacco, and may contain other herbs as well as tobacco plants native to the area. However, commercial tobacco is frequently used for traditional purposes now, because of either difficulty obtaining Indian tobacco or historical attempts to suppress traditional Indian spiritual practices.12 Traditional tobacco use most often does not involve smoking the tobacco, but it is an open question whether traditional tobacco use is positively or negatively associated with cigarette smoking. The American Indian Community Tobacco Project (AICTP) is a community-based participatory research project located in the Minneapolis–St. Paul urban area.

Goals of this project include collecting and disseminat­ ing information about recreational tobacco use (ciga­ rette smoking) and traditional tobacco use among American Indian adults and youth, in culturally mean­ ingful and valid ways and in collaboration with mem­ bers of the American Indian community. This informa­ tion can then be used by the community as the basis for efforts to reduce cigarette smoking among local Amer­ ican Indians. Here AICTP reports on the descriptive characteris­ tics associated with cigarette smoking in a sample of American Indian youth in the Twin Cities. The focus is particularly on social and environmental factors possi­ bly associated with cigarette smoking, specifically smok­ ing among family and friends, smoking rules in the household, secondhand smoke exposure, and associa­ tion of smoking with their awareness of and compliance with tobacco policies.

Methods Design and Sample A cross-sectional survey was administered to a convenience sample of American Indian youth aged 11–18 years in Min­ neapolis and St. Paul, in spring 2006. Participants were identified and contacted in two ways. The Director of Indian Education for the St. Paul Public Schools identified schools with a high proportion of American Indian students, mailed letters to parents/guardians of Indian students providing information about the survey including a phone number to call if they did not want their child to participate, and coordinated the administration of the survey during the school day. The Minneapolis Public Schools would not permit the survey to be administered in association with the schools, despite the support of their Director of Indian Education. Therefore, AICTP collaborated with a charter school, Heart of the Earth Center for American Indian Education, and four American Indian after-school youth programs in Minneapo­ lis: Division of Indian Work youth programs; Minneapolis American Indian Center Youth Leadership Program; Little Earth United Tribes after-school programs; and MIGIZI (which means the bald eagle in the Ojibwe language) Commu­ nications Academic Enrichment Program. Parents/guardians of students enrolled in these programs were also sent letters providing information about the survey and a phone number to call if they did not want their child to participate. Youth read an assent statement at the time of the survey, and were given the opportunity to decline participa­ tion. No parents or children in either Minneapolis or St. Paul declined to participate. Eligibility criteria included self-identified American Indians aged 11–18 years. The survey was adminis­ tered by project staff in either school or after-school settings. The survey was anonymous and required about 15 minutes to complete. Cooperating organizations and schools were given $5 per participant, and participants were given $15 gift cards following completion of the survey. Confidential lists of participants were maintained to avoid duplicate surveys. A total of 386 participants completed the survey, including 50 who did not identify as American Indian on the survey and

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were subsequently removed from the sample. The reported enrollment of American Indian students in Minneapolis and St. Paul public and charter schools in grades 6 –12 was 1545 in 2005–2006.20 Thus the sample represents approximately 22% of the local American Indian youth of this age. About 30% of the participants were from St. Paul schools, and 70% were from Minneapolis programs, which reflects the distribution of reported enrollment in the two school districts. The St. Paul Public Schools Research Committee and the University of Minnesota IRB reviewed and approved the study.

Measures The survey includes items from the CDC’s National Youth Tobacco Survey,21 from a survey developed by the Great Lakes Inter-Tribal Epidemiology Center for American Indian students, and ten items from the Minnesota Adolescent Community Cohort Study,22 as well as measures developed specifically for the survey. Questions used in this analysis are shown in Table 1. The entire survey was pre-tested with American Indian adolescents for comprehension prior to administration. For this article, AICTP includes variables measuring traditional tobacco use, recreational cigarette smoking, social exposure to smoking among family and friends, secondhand smoke exposure, and perceptions and compliance with tobacco policies.

Analysis All analyses were conducted in 2007. Bivariate analyses of recreational smoking, traditional tobacco use, social expo­ sure, secondhand smoke exposure, and policy-related vari­ ables were first conducted with age, gender, and smoking status using chi-square test statistics. Type-III tests for multi­ variate association between the probability of any past-month smoking and independent variables were conducted using multinomial stepwise regression. Age and gender, followed by traditional tobacco practices, social exposure, secondhand smoke exposure, and finally a policy-related variables group were added as groups in stepwise fashion. At each step, variables newly added were retained if p�0.05. Once the final model was obtained, point estimates and CIs were calculated. All analyses were conducted using SAS v. 9.1.

Results Description of Sample As shown in Table 2, the sample was evenly split by gender, and consisted of 32% aged 11–13 years, 39% aged 14–15 years, and 30% aged 16–18 years. The majority of partici­ pants reported belonging to the Ojibwe Tribe (58%) or

Table 1. Survey items Category

Question

Response categories

I never use tobacco this way; native tobacco plant/mixture; cigarettes; pouch/packaged tobacco Never smoked whole cigarette; [age How old were you when you smoked a whole Recreational categories] cigarette for the first time? tobacco use During the past 30 days, on how many days did you 0 days; 1–2 days; 6–9 days; 10–19 days; 20–29 days; all 30 days smoke cigarettes? I don’t have a brother/sister; yes at least 1 Social exposure Do any of your brothers/sisters smoke cigarettes? (brother/sister) smokes; none smoke 0–4 How many of your 4 closest friends smoke cigarettes? Yes; no Do any of the adults who live with you smoke cigarettes? All smokers are; some smokers are; no one Which of the following is true inside your home? is allowed to smoke in my home Yes; no Would you say your household has rules against you smoking cigarettes? During the past 7 days, on how many days were you 0 days; 1–3 days; �4 days Secondhand in the same room with someone who was smoke smoking cigarettes? exposure Bought them at a store; (all others During the past 30 days, how did you usually get Policy collapsed) your cigarettes? awareness, compliance Yes; no Have you ever heard of anyone getting in trouble at your school for smoking cigarettes on school property? During the past 30 days, on how many days did you Number dichotomized to yes; no smoke on school property? How has the price of cigarettes changed in the past Cigarettes have gotten more expensive; less expensive; about the same 12 months? Yes; no Have you ever heard of anyone getting caught smoking by the police? Traditional tobacco use

What type of tobacco do you usually use for ceremonial prayer or traditional reasons?

Source GLITEC NYTS NYTS

NYTS NYTS MACC; NYTS NYTS NYTS MACC NYTS

MACC

GLITEC, Great Lakes Inter Tribal Epidemiology Center14; MACC, Minnesota Adolescent Community Cohort Study22; NYTS, National Youth Tobacco Survey18

December 2008

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Table 2. Tobacco-related behaviors and exposures by age and gender among urban American Indian youth Age group (yr)

Recreational cigarette smoking (%)**** Never (n�107) Not in past month (n�98) 1–19 days past month (n�66) 20� days past month (n�54) Traditional tobacco practices (%) Uses native tobacco for ceremony (n�79) Uses commercial tobacco for ceremony (n�128) Does not use tobacco this way (n�121) Social exposure (% yes) 3 or 4 closest friends smoke (n�133)**** Sister who smokes (yes�147) Brother who smokes (yes�149)**** Adult in hhld smoke (yes�261) Hhld rules against you smoking (yes�212) Hhld smoking ban for everyone (yes�140)** Secondhand smoke exposure (%)****� None (n�77) 1–3 days past week (n�106) �4 days past week (n�153) Policy related (% yes) Usually buys cigarettes from store (yes�23)a*** Smoked on school property past month (yes�50)a Cigarettes more expensive (yes�210)**� � Heard of getting caught smoking at school? (yes�243)* Heard of getting caught smoking by police? (yes�191)*

Gender

11–13 n�106

14–15 n�130

16–18 n�100

Male n�168

Female n�168

Total n�336

50.5 33.0 16.5 0

26.2 29.4 28.6 15.9

22.9 28.1 13.5 35.4

36.9 30.0 18.1 15.0

29.5 30.1 22.1 18.4

32.9 30.2 20.3 16.6

23.8 35.6 40.6

28.5 35.4 36.2

18.6 47.4 34.0

21.9 36.9 41.3

26.5 41.6 31.9

24.1 39.0 36.9

19.8 38.8 27.5 77.9 73.8 55.8

42.8 46.9 52.7 78.5 64.8 37.6

56.0 46.9 53.0 78.0 57.9 35.4

34.7 40.9 40.7 77.4 65.8 44.0

44.6 47.6 48.8 79.2 65.0 41.9

39.5 44.4 45.0 78.1 65.6 42.7

41.5 31.1 27.4

15.4 31.5 53.1

13.0 32.0 55.0

28.9 27.7 43.4

17.3 34.5 48.2

22.9 31.6 45.5

0 29.4 50.5 63.8

15.6 38.2 68.8 79.5

44.4 51.1 69.7 76.5

18.6 41.5 56.7 73.8

25.9 43.1 70.5 73.8

23.5 42.0 63.3 73.6

46.7

62.5

62.6

58.2

57.0

57.5

a

Past-month smokers only � *Age p�0.05; **age p�0.01; ***age p�0.001; ****age p�0.0001; gender p�0.05; Hhld, household

Dakota/Lakota Tribe (39%). Almost 37% reported some recreational smoking in the previous 30 days, with about three times as many in the older age group reporting smoking as in the youngest age group (p�0.0001). About 63% of all respondents reported using tobacco for tradi­ tional purposes, with more using commercial tobacco than native tobacco for these ceremonies. Traditional tobacco use did not differ by age or gender.

��

gender p�0.01

Girls are more likely to be exposed, with almost half report­ ing being in a room where someone was smoking most days in the previous week (p�0.05). Younger youth were least likely to report exposure, but more than half of those aged �14 years experience secondhand smoke most days.

Policy-Related Activity and Awareness

About 40% of the entire sample reported that three or four of their closest friends smoke cigarettes, with a higher proportion in the oldest age group. About 44% have a brother/a sister who smokes, but a considerably higher proportion (78%) live with an adult who smokes cigarettes. Almost two thirds reported that their household has rules against their smoking, and 43% reported that no one is allowed to smoke inside their homes. This proportion is significantly higher for the younger age group (p�0.01).

Almost one quarter of those who smoked in the past month buy cigarettes from a store, including over 44% of those aged 16 –18 years. Almost half of smokers reported smoking on school property during the previous month. Sixty-four percent of the sample thought that cigarettes had recently become more expensive, including 70% of the girls, and almost 70% of those aged �14 years. Almost three quarters of the youth in this sample had heard of other youth getting caught smoking at school, and about 57% had heard of other youth getting caught smoking by the police, with fewer from the youngest age group aware of either enforcement action.

Secondhand Smoke Exposure

Bivariate Associations with Smoking Frequency

More than 75% of the youth in this sample reported exposure to secondhand smoke during the previous week.

The relationship of the traditional use of tobacco to recreational smoking is complex but significant, as

Social Exposure to Cigarette Use

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Table 3. Tobacco-related behaviors and exposures by smoking frequency among urban American Indian youth Smoking frequency

Traditional tobacco use (%)* Uses Indian tobacco for ceremony Uses commercial tobacco for ceremony Does not use tobacco this way Social exposure (% yes) 3 or 4 closest friends smoke**** Sister who smokes*** Brother who smokes** Adult in hhld smokes** Hhld rules against you smoking **** Hhld smoking ban for everyone**** Secondhand smoke exposure (%)**** None 1–3 days past week �4 days past week Policy related (% yes) Usually buys cigarettes from storea*** Smoked on school property past montha* Cigarettes more expensive*** Heard of getting caught smoking at school* Heard of getting caught smoking by police*

Never n�105

Not in past 30 days n�98

1–19 of past 30 days n�66

>20 of past 30 days n�54

28.2 27.2 44.7

22.1 41.1 36.8

26.2 49.2 24.6

19.23 51.9 28.6

18.8 30.2 30.5 69.5 80.8 54.9

34.7 47.9 47.9 75.6 75.0 48.5

72.6 46.2 55.4 83.3 56.9 37.5

96.0 67.1 55.6 92.6 32.1 18.9

40.0 33.3 26.7

20.4 38.8 40.8

15.2 34.9 50.0

3.7 13.0 83.3

NA NA 50.5 65.8 49.5

NA NA 62.2 82.7 55.7

12.7 33.9 71.9 70.8 58.5

42.9 51.9 83.0 75.5 75.5

a

Past-month smokers only *p�0.05; **p�0.01; ***p�0.001; ****p�0.0001 Hhld, household

shown in Table 3. Those who do not smoke cigarettes are least likely to participate in traditional use. How­ ever, those who do smoke cigarettes are more likely to use commercial tobacco for traditional purposes than to use Indian tobacco. Each of the social exposure variables was associated with cigarette smoking frequency, with nonsmokers least likely to have close friends who smoke, to have a sister/a brother who smokes, or to live in a household with a smoker. Nonsmokers were most likely to report house­ hold rules against their smoking, and living in a house­ hold where no one is allowed to smoke indoors. The relationship between social exposure and frequency of smoking was linear in most cases, with those smoking �20 of the past 30 days reporting the most social exposure and lowest likelihood of living in a household with rules about smoking. Secondhand smoke exposure was also strongly associated with smoking frequency, with the most fre­ quent smokers reporting the most exposure. There are marked differences even between those who had never smoked a whole cigarette and those who had not smoked in the previous 30 days, categories of youth frequently grouped together as not current smokers. Never-smokers were twice as likely to report no secondhand smoke exposure. The policy-related variables were each associated with smoking status. More than 40% of those who smoked �20 of the past 30 days reported buying cigarettes from a store in the previous month compared to just 13% of the less-frequent smokers (p�0.001). December 2008

More than half of the heavy smokers reported smoking on school property in the previous month compared to one third of the less-frequent smokers (p�0.05). The likelihood of believing that cigarettes were more expen­ sive in the past year increased with frequency of smok­ ing (p�0.001). Those who never smoked were the least likely while those who had smoked but not in the past month were the most likely to hear of someone getting caught smoking at school (p�0.05). Hearing of some­ one getting caught smoking by the police increased with frequency of smoking (p�0.05).

Multivariate Model The stepwise multinomial logistic regression model of the likelihood of being a past-month smoker revealed a number of independent associations (Table 4). Age group pre­ dicted likelihood of smoking in the past 30 days, with adolescents aged 14 –15 years and aged 16 –18 years more likely than the youngest age group to be smoking. Num­ ber of friends who smoke was highly predictive of pastmonth smoking, with those with three or four friends who smoke more than nine times more likely to smoke com­ pared to those with fewer friends smoking. Both house­ hold rules against youth smoking and household smoking bans were protective against youth smoking, with those who reported these rules 34% and 45%, respectively, as likely to smoke as those without the rules. Hearing of someone caught smoking in school was also indepen­ dently associated with nonsmoking. Am J Prev Med 2008;35(6S)

S453

Table 4. Multivariate model of past-month smoking among urban American Indian youth

Traditional tobacco use (%) Uses Indian tobacco for ceremony Uses commercial tobacco for ceremony Does not use tobacco this way Age (years) 16–18 14–15 11–13 3 or 4 closest friends smoke: yes vs no Hhld rules against you smoking: yes vs no Hhld smoking ban for everyone: yes vs no Heard of getting caught smoking at school

OR

95% confidence limits

0.95

0.42, 2.13

2.0

0.96, 4.05

p value 0.09

ref 0.005 2.44 3.65 ref 9.47

1.05, 5.66 1.67, 8.01

0.34

0.19, 0.64

0.0008

0.45

0.24, 0.86

0.02

0.41

0.20, 0.84

0.02

4.96, 18.07

�0.0001

Hhld, household

Discussion These results show prevalence of past-month smoking of 16.5% for participants aged 11–13 years, 44.5% for those aged 14 –15 years, and 48.9% for those aged 16 –18 years. These levels are staggeringly high com­ pared to the prevalence reported for the state as a whole by the Minnesota Student Survey in 2007: 1.5% for Grade 6, 10.4% for Grade 9, and 23.0% for Grade 12.20 While 35% of participants aged 16 –18 years in this study smoked �20 of the previous 30 days, fewer than 12% of Minnesota high school seniors overall smoked that heavily in 2007.23 These data suggest that, despite targeted efforts to reduce recreational tobacco use among youth in Minnesota, a huge disparity in smoking prevalence remains between American Indian youth and youth in Minnesota overall. American Indians from the Upper Midwest have a complex relationship with tobacco. The majority of adults are addicted to commercial tobacco, but tobacco also is considered a sacred plant and can be used traditionally for spiritual, ceremonial, or medicinal purposes inconsis­ tent with addictive use.24 Each tribe has specific tradi­ tional practices for growing, cultivating, and sharing In­ dian tobacco.25 However, commercial tobacco also has come to be used by American Indians for traditional purposes, because Indian tobacco is difficult to obtain, or because of historical efforts to suppress traditional prac­ tices. Anecdotal evidence suggests that ceremonies where cigarettes are used for traditional purposes can provide an opportunity for young people to take cigarettes to exper­ iment with them. This may explain our findings that youth who have never smoked are less likely than smokers

to use any tobacco for traditional purposes, but those who do smoke are more likely to use commercial tobacco than Indian tobacco for traditional purposes. Possibly, non­ smokers have not been exposed to use of commercial tobacco for traditional purposes. American Indian youth in this sample are exposed to a great deal of smoking within their social environment, as expected by the 62% level of smoking reported by adults from this community.12 Social exposure is associated with smoking status in this population, as has been reported with other populations.26 –30 About 46% of the youth in this sample report exposure to secondhand smoke most days, also not surprising given the high percentage of adults who smoke. Secondhand smoke exposure is asso­ ciated with increased frequency of smoking. The neversmokers were most likely to report no secondhand smoke exposure, while almost all of the most-days smokers were routinely exposed to secondhand smoke. Household rules against smoking had a strong and independent negative association with the likelihood of youth smoking. Youth who reported household rules against their smoking were only one third as likely to be past-month smokers compared to those without a rule. A household ban on smoking indoors for everyone was also negatively associated with youth smoking, similar to some previous reports on other populations of youth.31,32 The significance of these associations in a multivariate analysis including family smoking and peer smoking point to the leverage adults in the household, who may include extended family or unrelated adults, have with these American Indian youth, and the strong role of family in American Indian culture. Minnesota has a number of tobacco-related laws expected to affect youth. The state has had a strong youth access law since 1998, penalizing businesses and clerks for selling cigarettes to those under age 18 and requires compliance checks. Yet over 22% of pastmonth smokers reported usually buying cigarettes from a store, including 43% of those who smoked most or all days in the previous month. These levels are consider­ ably higher than the 11% of past-month smokers among the general population of high school students in Minnesota who report usually buying their own cigarettes.33 Minnesota state law also prohibits pur­ chase, possession, or use of tobacco products by youth. Just over 40% of these respondents who were pastmonth smokers reported smoking on school property in the previous month. However, almost three fourths of all students had heard of someone getting caught smoking at school, and those who had tried smoking but not in the past month were the most likely to be aware of someone getting caught. Those who knew about enforcement of a no-smoking rule in school were only 40% as likely to be a past-month smoker in the multivariate analysis. Minnesota also raised the tobacco tax by $0.75 to $1.23 per pack in August 2005, about 8 –9 months

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before the survey was administered. The majority of all participants believed that cigarettes had gotten more expensive in the previous year. Smokers, even those who had not smoked in the previous 30 days, were more likely to believe that cigarettes had gotten more expen­ sive compared to never-smokers. This high perception of the increasing price of cigarettes may reflect in part the practice of past-month smokers of buying their cigarettes from a store, and possibly the discussion of increasing price among parents and peers who buy cigarettes. This study has several limitations constraining the interpretation of the results. First, the sample is crosssectional and so causality from the associations cannot be inferred. Second, the sample is not random, and thus may not be representative of the population of urban American Indian youth in the Twin Cities. However, because the youth in this sample were either in school or in after-school programs, the results are likely to be conservative estimates of smoking-related behavior. Third, the youth in this sample are primarily Anishinaabe or Dakota, and thus not representative of American Indian youth from other tribes and locations. Finally, all the youth in this study live in the Twin Cities; therefore results cannot be extrapolated to all Indian youth in Minnesota or the Upper Midwest. Nevertheless, these results suggest several pathways to reduce cigarette smoking among urban American Indian youth. First, any attempts to target youth must be accompanied by attempts to reduce smoking among adults in the community. American Indian youth are highly influenced by their social environment, and in this community, including many adults who smoke. A coordinated effort to encourage parents/guardians to establish rules about youth smoking, to ban smoking for everyone in their homes, and to support smoke-free environments in other community locations is impor­ tant. Second, encouraging schools to continue to en­ force no-smoking rules on school grounds may reduce the proportion of experimental smokers who go on to become regular smokers. Third, focused enforcement of youth access laws in the neighborhoods where Amer­ ican Indian youth live may reduce the number of youth who are able to purchase cigarettes and accelerate their smoking. Finally, making traditional Indian tobacco available for traditional use may reduce the number of youth who will be exposed to commercial tobacco in that way. Cigarette smoking is responsible for a large propor­ tion of premature mortality among American Indians in this area; yet the prevalence of use remains high despite the tobacco-control efforts that have dramati­ cally reduced the prevalence of tobacco use among youth and adults in the larger population. Clearly, different approaches are required to address this public health crisis in the American Indian community. An important component must be surveillance that in­ December 2008

cludes adequate samples and appropriate methods to document the problem and evaluate progress. Also, culturally appropriate interventions and research-based validation of those interventions are sorely needed. This work was supported in part by grant RC 2004 – 0032 from ClearWay MinnesotaSM; its contents are solely the responsi­ bility of the authors and do not necessarily represent the official views of ClearWay MinnesotaSM. We acknowledge the contributions of the other members of the American Indian Community Tobacco Policy Steering Council: Linda Azure, Hope Flanagan, Julie Green, Loretta Rivera, Donald WhippleFox, Lannesse Baker, Lana King, and Cynthia Davey; and we thank the study participants for sharing their information. No financial disclosures were reported by the authors of this paper.

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