Introduction

Approximately 9 million American adults use two or more tobacco products regularly, referred to as dual or poly tobacco users. In Alaska, where tobacco is not native, approximately 20% of the population smokes cigarettes, and among smokers, 10% use two or more tobacco products. Previous research suggests that dual tobacco product use may be especially high among Alaska Native people. The current study examined cultural and demographic characteristics associated with dual tobacco use.

Methods

Alaska Native adults reporting daily smoking and identified with high blood pressure or cholesterol were recruited in the Norton Sound region of Alaska between 2015-2019 as part of a treatment trial targeting cardiovascular disease risk factors. Participants reported their tribal group, level of identification with their Alaska Native heritage, speaking of their tribal language, basic demographic characteristics, and past 30-day use of tobacco products in addition to smoking cigarettes.

Results

Participants (n=299) were 48.5% female and identified as Yup'ik (31.1%), Inupiat (60.5%), and other or multiple tribal group(s) (8.4%). Most participants (85.3%) strongly identified with their Alaska Native heritage. Past 30-day dual tobacco use was reported by 10.0%, specifically 9.0% chew/snuff, 1.3% e-cigarettes, and 0.7% Iq'mik. Multivariate regression models indicated that dual tobacco use was more likely among men (OR=3.35; 95% CI: 1.30-8.64), younger participants (OR range: 10.97-12.35; 95% CI: 2.33-57.86), those identifying as Yup'ik (OR=2.86; 95% CI: 1.13-7.19), and those who identified very little or not at all with their Alaska Native heritage (OR=2.98; 95% CI: 1.14-7.77).

Conclusions

Young men identifying as Yup'ik were more likely to use dual forms of tobacco. Stronger identification with one's Alaska Native heritage was associated with lower risk of dual tobacco use. The findings highlight cultural and demographic factors for further consideration and attention in tobacco cessation treatment interventions.

Research on nicotine metabolism has primarily focused on white adults. This study examined associations between nicotine metabolism, tobacco use, and demographic characteristics among Alaska Native adults who smoke cigarettes. Participants (N = 244) were Alaska Native adults who smoked and who provided a plasma sample at baseline (70.1%) or follow-up (29.9%) of a randomized controlled trial of a cardiovascular risk behavior intervention. At baseline, participants self-reported age, sex, Alaska Native heritage, cigarettes per day, time to first cigarette upon wakening, menthol use, perceived difficulty staying quit, tobacco withdrawal symptoms, and past-month tobacco product use, binge drinking, and cannabis use. At 3-, 6-, 12-, and 18-month follow-ups, participants self-reported 7-day point prevalence abstinence from smoking. Height and weight were measured to calculate body mass index (BMI). Participants' nicotine metabolite ratio (NMR), calculated as the ratio of plasma cotinine and trans-3' hydroxycotinine, was log-transformed. The sample (52.0% male, age M = 47.0 years [SD = 13.8], 60.3% of Inupiaq heritage) averaged 12.5 cigarettes per day (SD = 10.5); 64.0% smoked within 30 min of wakening. NMR was not significantly associated with age, sex, Alaska Native heritage, BMI, cigarettes per day, time to first cigarette upon wakening, menthol use, perceived difficulty staying quit, past-month dual tobacco product use, withdrawal symptoms, past-month binge drinking, past-month cannabis use, or abstinence from smoking (all p-values > .050). Characteristics that relate to NMR in Alaska Native adults may differ from those typically identified among white adults. Specifically, results may suggest that Alaska Native adults with slower nicotine metabolism do not titrate their nicotine intake when smoking. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Though not native to Alaska, tobacco use is common among Alaska Native people in the Norton Sound region, an area consisting of 16 communities with population size 107 to 3,695. We summarise best practices in recruiting Alaska Native adults who smoke for a randomised controlled tobacco treatment trial. Participants were Alaska Native, 19 years and older, smoking daily, with hypertension and/or high cholesterol, residing in the Norton Sound region of Alaska. Study staff travelled to the remote communities to recruit, typically staying 5 days. Screening and enrolment success was examined by day, season, and staffing level. From June 2015 - December 2018, the study team made 122 trips, screening 1089 individuals and enrolling 314 participants. In the field, days 2-3 (51%) were best for screening, while days 3-4 (53%) had the greatest enrolment. Community size correlated with enrolment (r = 0.83, p <.001). Recruitment was optimised in spring and with multiple staff in the field. Despite challenges (e.g., harsh weather, poor internet connectivity), with active outreach (e.g. tabling in busy areas, attending community events, utilising mixed media, collaborating with clinic staff), the project reached its recruitment goal. Study findings can inform community-based tobacco treatment research trials in remote areas.

Abbreviations

CVD: Cardiovascular disease; VTC: Video teleconferencing; ANMC: Alaska Native Medical Centre; HEALTHH: Healing and Empowering Alaskan Lives Towards Healthy Hearts; NSHC: Norton Sound Health Corporation; RERB: Research Ethics Review Board.

The perspectives of Alaska Native (AN) peoples are rarely represented in quality of life (QOL) research. AN representation and voice is imperative to mitigating health disparities and in health promotion for AN peoples. To address these gaps, a sample of 15 AN people (six male, nine female) was recruited to participate in stakeholder QOL research. Five focus groups participated in activities that led participants to identify 28 themes; qualitative data analyses led researchers to identify seven additional themes. All 35 themes were integrated and reduced to the following nine culturally-grounded QOL themes: family, subsistence, access to resources, health and happiness, traditional knowledge and values, acts of self, providing, sobriety, and healing. These themes reflect the values of the participants and are exemplars of a culturally relevant, community based participatory research approach. Future research and health service implications - such as future development of a measure of AN QOL to improve wellness in healthcare settings and beyond - are discussed.

This cross-sectional study assessed how traditional eating relates to cultural and community factors. Alaska Native adults from the Norton Sound region were recruited and surveyed between 2015-2018 for a randomized clinical trial of multiple risk behavior change interventions for cardiovascular disease prevention. Participants (n = 291) were 49% female with a mean age of 47 years (SD = 14). A 34-item food frequency questionnaire assessed consumption of foods traditional and nontraditional to the regional Alaska Native diet. A novel measure, termed the "traditional foods index", was computed as weekly servings of culturally traditional food consumption divided by total foods reported. Overall, the sample's traditional foods index averaged 21%±16%, with higher values reported by participants assessed in summer (23%±17%) than winter (19%±15%, p<0.05); by women (22%±16%) than men (19%±16%, p < .05); and by residents of smaller communities (22%±17%) than the comparatively larger community of Nome (17%±14%, p<0.05). The traditional foods index was correlated with age (r = .26, p < .01), as well as the cultural variables of community connectedness (r = .19, p < .01), community standing (r = .15, p < .01), and traditional language comprehension (r = .19, p < .01). In a multivariate regression model, age, community connectedness, and community standing remained significantly associated with traditional diet. These findings may inform the design and evaluation of community-based, culturally-relevant dietary initiatives for heart health.

Background

Tobacco use and tobacco-related diseases disproportionately affect Alaska Native (AN) people. Using telemedicine, this study aims to identify culturally-tailored, theoretically-driven, efficacious interventions for tobacco use and other cardiovascular disease (CVD) risk behaviors among AN people in remote areas.

Design

Randomized clinical trial with two intervention arms: 1) tobacco and physical activity; 2) medication adherence and a heart-healthy AN diet.

Participants

Participants are N = 300 AN men and women current smokers with high blood pressure or high cholesterol.

Interventions

All participants receive motivational, stage-tailored, telemedicine-delivered counseling sessions at baseline and 3, 6, and 12 months follow-up; an individualized behavior change plan that is updated at each contact; and a behavior change manual. In Group 1, the focus is on tobacco and physical activity; a pedometer is provided and nicotine replacement therapy is offered. In Group 2, the focus is on medication adherence for treating hypertension and/or hypercholesterolemia; a medication bag and traditional food guide are provided.

Measurements

With assessments at baseline, 3, 6, 12, and 18 months, the primary outcome is smoking status, assessed as 7-day point prevalence abstinence, biochemically verified with urine anabasine. Secondary outcomes include physical activity, blood pressure and cholesterol, medication compliance, diet, multiple risk behavior change indices, and cost-effectiveness.

Comments

The current study has the potential to identify novel, feasible, acceptable, and efficacious interventions for treating the co-occurrence of CVD risk factors in AN people. Findings may inform personalized treatment and the development of effective and cost-effective intervention strategies for use in remote indigenous communities more broadly. Clinical Trial Registration # NCT02137902.

Introduction

Innovations are needed for preventing cardiovascular disease (CVD) and for reaching diverse communities in remote regions. The current study reports on a telemedicine-delivered intervention promoting a traditional heart-healthy diet and medication adherence with Alaska Native men and women residing in the Norton Sound region of Alaska.

Methods

Participants were 299 men and women with high blood pressure or high cholesterol smoking daily who were randomized to receive telemedicine-delivered counseling and printed materials on diet and medication adherence or on smoking and physical activity. Intervention contacts were at baseline and 3-, 6-, and 12-months follow-up, with a final assessment at 18 months. Nutrition outcomes were the ratio of heart-healthy foods and traditional heart-healthy foods relative to all foods reported on a 34-item food frequency questionnaire. Recent and typical adherence for heart medications were self-reported.

Results

Intervention effects were significant for the heart-healthy foods ratio at 6 months only (p = 0.014) and significant for the traditional heart-healthy foods ratio at 6 months only for those aged 47+ (p = 0.031). For recent and typical medication adherence, there were no significant group differences by time.

Discussion

In a remote region of Alaska, telemedicine proved feasible and acceptable for engaging Alaska Native men and women in counseling on CVD risk behaviors. The findings indicate that more touchpoints may be necessary to impart comprehensive lasting change in heart-healthy eating patterns. Medication adherence group differences were not significant; however, medication adherence was high overall.