American Indian and Alaska Native People Encounter Barriers to Quitting Successfully

Most people who smoke want to quit, and more than half try to do so each year. An estimated 56% of American Indian and Alaska Native (AI/AN) people report wanting to quit.7 Proven treatments, such as FDA-approved medicines and behavioral counseling, make it more likely that people will quit smoking successfully—but AI/AN people who smoke can run into barriers when trying to find and use these treatments:

  • AI/AN people are less likely than white people to have private health insurance – and more likely to have no health insurance at all.44 About 43% of AI/AN people rely on Medicaid or other public insurance coverage.45 Still, as of 2018, only 15 state Medicaid programs fully covered commercial tobacco* cessation (quitting) services for all enrollees in traditional Medicaid.46
Sacred Traditional Tobacco For Healthy Native Communities

Click to Enlarge

  • To provide advice on how to quit, health care providers first routinely screen their patients for commercial tobacco use.
    • Only 56% of outpatient health care visits with AI/AN adults included tobacco use screening in 2005-2008.47
    • Only 38% of AI/AN adults who smoked and visited a health care provider in the last year received health professional advice to quit in 2015.48

These factors may help to explain why AI/AN people quit smoking at lower rates than other racial/ethnic groups.7,49

Connecting every person who wants to quit with treatment proven to help them quit for good is important for improving people’s health.

Examples of strategies that states and communities can use are:
clipboard icon

Provide barrier-free, widely promoted coverage for all evidence-based cessation treatments by all types of health insurance.
For example, as of 2018, only 15 state Medicaid programs fully covered tobacco cessation (quitting) services for all enrollees in traditional Medicaid.46

stethoscope icon

Integrate clinical screening and treatment for commercial tobacco use in all health care settings and with all types of patients.
Community health centers and low-cost health clinics serve people who are more likely to use commercial tobacco products. Talking to people about commercial tobacco use and quitting as a regular part of health care visits in these settings will help make sure that all groups can get effective treatment to help them quit.50,51

Two people and a heart icon

Support AI/AN public health professional in creating, selecting, and sharing tobacco prevention strategies, including strategies for encouraging and supporting cessation, that work in tribal settings.
When it comes to health issues, one size does not fit all. Different people and communities have varying needs and make decisions in different ways. Providing support, learning opportunities, and culturally tailored technical assistance in collaboration with AI/AN health experts can enhance efforts to reduce the health burden of commercial tobacco in communities.52

No smoking conversation icon

Share health messages that population groups identify with and that are created by specific cultural groups.
Mass media campaigns are proven to increase smoking cessation, prevent tobacco use initiation, and reduce the prevalence of tobacco use.7,14 Anti-commercial tobacco messaging and mass media campaigns can have an impact when they speak to people using familiar terms and images. One organization creating messages like this for Indigenous people is the American Indian Commercial Tobacco Program.

*“Commercial tobacco” means harmful products that are made and sold by tobacco companies. It does not include “traditional tobacco” used by Indigenous groups for religious or ceremonial purposes.
  1. Government Printing Office. Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity, 1997 [accessed 2022 Mar 19].
  2. U.S. Census Bureau. American Fact Finder, 2020.  American Community Survey Demographic and Housing Estimates [accessed 2022 Mar 19].
  3. Odani S, Armour BS, Graffunder CM, Garrett BE, Agaku IT. Prevalence and Disparities in Tobacco Product Use Among American Indians/Alaska Natives — United States, 2010–2015 . Morbidity and Mortality Weekly Report, 2017;66(50):1374-8 [accessed 2022 Mar 19].
  4. Substance Abuse and Mental Health Services Administration. Results from the 2018 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2019 [accessed 2022 Mar 19].
  5. Espey DK, Jim MA, Cobb N, et al. Leading Causes of Death and All-Cause Mortality in American Indians and Alaska Natives. American Journal of Public Health, 2014;104(Suppl 3):S303–S311 [accessed 2022 Mar 19].
  6. Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults — United States, 2020. MMWR Morb Mortal Wkly Rep. 2022; 71:397–405 [accessed 2022 Mar 19].
  7. U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020. Pg. 57 [accessed 2022 Mar 19].
  8. O'Donald ER, Miller CP, O'Leary R, Ong J, Pacheco B, et al. Active smoking, secondhand smoke exposure and serum cotinine levels among Cheyenne River Sioux communities in context of a Tribal Public Health Policy. Tobacco control, 2020;29(5): 570-576 [accessed 2022 Mar 19].
  9. Public Health Law Center. Smoke-free Tribal Housing Policies [PDF-446 KB]. June 2020 [accessed 2022 March 19].
  10. Black, HL & Supreme Court of The United States. (1958) U.S. Reports: Williams v. Lee, 358 U.S. 217. Retrieved from the Library of Congress [accessed 2022 Mar 19].
  11. Mowery PD, Dube SR, Thorne SL, et al. Disparities in Smoking-Related Mortality Among American Indians/Alaska Natives. American Journal of Preventive Medicine, 2015 [accessed 2022 March 19].
  12. Heron, M. Deaths: Leading Causes for 2017. National Vital Statistics Reports, 2019;68(6) [accessed 2022 Mar 19].
  13. Kochanek KD, Murphy SL, Xu JQ, et al. Deaths: Final Data for 2017. National Vital Statistics Reports, 2019;68(9) [accessed 2022 Mar 19].
  14. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2022 Mar 19].
  15. Hartmann WE & Gone JP. Psychological-mindedness and American Indian historical trauma: Interviews with service providers from a Great Plains reservation. American Journal of Community Psychology, 2016;57(1-2): 229 –242 [accessed 2022 Mar 19].
  16. Barnes PM, Adams PF, Powell-Griner E. Health characteristics of the American Indian or Alaska Native adult population: United States, 2004 –2008 National health statistics reports; no 20. Hyattsville, MD: National Center for Health Statistics, 2010 [accessed 2022 Mar 19].
  17. Forster JL., Rhodes KL, Poupart J, Baker LO, Davey C. Patterns of tobacco use in a sample of American Indians in Minneapolis-St. Paul. Nicotine & Tobacco Research, 2007;9(Suppl_1): S29-S37 [accessed 2022 Mar 19].
  18. Warne D & Bane Frizzell L. American Indian health policy: historical trends and contemporary issues. American Journal of Public Health, 2014;104(S3): S263-S267 [accessed 2022 Mar 19].
  19. Lempert LK, & Glantz SA. Tobacco industry promotional strategies targeting American Indians/Alaska Natives and exploiting tribal sovereignty. Nicotine and Tobacco Research, 2019;21(7): 940-948 [accessed 2022 Mar 19].
  20. D’Silva J, O’Gara E, & Villaluz NT. Tobacco industry misappropriation of American Indian culture and traditional tobacco. Tobacco control, 2018;27(e1): e57-e64 [accessed 2022 Mar 19].
  21. O’Leary R. Examining the Youth E-Cigarette Epidemic [PDF-4.1 MB]. Testimony Before the Subcommittee on Economic and Consumer Policy. House Committee on Oversight and Reform, U.S. House of Representatives, July 24, 2019 [accessed 2022 Mar 19].
  22. Slopen N, Dutra LM, Williams DR, et al. Psychosocial stressors and cigarette smoking among African American adults in midlifeNicotine Tob Res. 2012;14(10):1161-1169 [accessed 2022 Mar 19].
  23. Hodge F, Nandy K. Factors associated with American Indian cigarette smoking in rural settings. Int J Environ Res Public Health. 2011;8(4):944-954 [accessed 2022 Mar 19].
  24. Johnson-Jennings MD, Belcourt A, Town M, Walls ML, Walters KL. Racial discrimination's influence on smoking rates among American Indian Alaska Native two-spirit individuals: does pain play a role? J Health Care Poor Underserved. 2014;25(4):1667-1678 [accessed 2022 Mar 19].
  25. Soto C, Baezconde-Garbanati L, Schwartz SJ, Unger JB. Stressful life events, ethnic identity, historical trauma, and participation in cultural activities: Associations with smoking behaviors among American Indian adolescents in California. Addict Behav. 2015;50:64-69 [accessed 2022 Mar 19].
  26. U.S. Census Bureau. American Community Survey, 2019. Single-Year Estimates [accessed 2022 Mar 19].
  27. U.S. Census Bureau. American Community Survey, 2019. 2015-2019 5-Year Estimates [accessed 2022 Mar 19].
  28. Goodkind JR, Ross-Toledo K, John S, Hall JL, Ross L et al. Promoting healing and restoring trust: policy recommendations for improving behavioral health care for American Indian/Alaska Native adolescents. American journal of community psychology, 2010;46(3-4): 386–394 [accessed 2022 Mar 19].
  29. Serfaini K, Donovan DM, Wendt DC, Matsumiya B, & McCarty CA. A Comparison of Early Adolescent Behavioral Health Risks Among Urban American Indians/Alaska Natives and their Peers. American Indian and Alaska native mental health research, 2017;24(2), 1–17 [accessed 2022 Mar 19].
  30. Juster RP, McEwen BS, & Lupien SJ. Allostatic load biomarkers of chronic stress and impact on health and cognition. Neuroscience & Biobehavioral Reviews, 2010;35(1): 2-16 [accessed 2022 Mar 19].
  31. Guyll M, Matthews KA, Bromberger JT. Discrimination and unfair treatment: relationship to cardiovascular reactivity among African American and European American women. Health Psychology, 2001;20(5): 315 [accessed 2022 Mar 19].
  32. Brockie TN, Heinzelmann M, Gill J. A Framework to Examine the Role of Epigenetics in Health Disparities among Native Americans. Nurs Res Pract. 2013;2013:410395 [accessed 2022 Mar 19].
  33. Tehee M, Buchwald D, Booth-LaForce C, Omidpanah A, Manson SM, Goins RT. Traumatic Stress, Social Support, and Health Among Older American Indians: The Native Elder Care Study. J Gerontol B Psychol Sci Soc Sci. 2019;74(5):908-91 [accessed 2022 Mar 19].
  34. Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson SM; AI-SUPERPFP Team. Stress burden and diabetes in two American Indian reservation communities. Diabetes Care. 2008;31(3):427-429 [accessed 2022 Mar 19].
  35. US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Washington, DC: US Department of Health and Human Services, 2006 [accessed 2022 Mar 19].
  36. Public Health Law Center. Tribal Tax Policies for Commercial Tobacco [PDF-1.51 MB]. 2019 [accessed 2022 Mar 19].
  37. Nez Henderson P, Leischow S. Air Is Life: The Navajo Nation’s Historic Commercial Tobacco Ban. 7 Febreuary 2022. Navajo Nation Enacts Commercial Tobacco Ban - National Cancer Institute [Accessed 14 Feb 2022].
  38. Tanner J, Henderson JA, Buchwald D, Howard BV, Nez Henderson P, & Tyndale RF. Relationships between smoking behaviors and cotinine levels among two American Indian populations with distinct smoking patterns. Nic Tob Res 2018;20(4): 466-73 [accessed 2022 Mar 19].
  39. Berg CJ, Makosky Daley C, Nazir N, Cully A, Pacheco CM et al. Smoke-Free Policies in the Workplace and in the Home among American Indians. J Health Dispar Res Pract 2012;5(2): 7 [accessed 2022 Mar 19].
  40. Sloan A. Tribal Sovereignty and Tobacco Control in State-Tribe Cigarette Compacts. [PDF-492 KB] BYU Law Review 2017;5: 1261-96 [accessed 2022 Mar 19].
  41. Nez Henderson P, Roeseler A, Moor G, et al. Advancing smoke-free policy adoption on the Navajo Nation. Tobacco Control 2016;25: i26-i31 [accessed 2022 Mar 19].
  42. Blanchard JW, Petherick JT, & Basara H. Stakeholder engagement: a model for tobacco policy planning in Oklahoma Tribal communities. Am J Preventive Med 2015;48(1): S44-S46 [accessed 2022 Mar 19].
  43. Klepeis NE, Dhaliwal N, Hayward G, Acevedo-Bolton V, Ott WR, Read N et al. Measuring indoor air quality and engaging California Indian stakeholders at the Win-River Resort and Casino: collaborative smoke-free policy development. Int J Environmental Res Public Health 2016;13(1): 143 [accessed 2022 Mar 19].
  44. National Center for Health Statistics. Percentage of having private health insurance coverage at time of interview for adults aged 18-64, United States, 2019—2020. [PDF-405 KB] National Health Interview Survey. [accessed 2022 Mar 19].
  45. Berchick ER, Hood E, & Barnett JC. Health Insurance Coverage in the United States: 2017, US Census Bureau, 2018 [accessed 2022 Mar 19].
  46. DiGiulio A, Jump Z, Babb S, et al. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2008–2018. MMWR Morb Mortal Wkly Rep 2020;69:155–160. [accessed 2022 Mar 19].
  47. Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC; Centers for Disease Control and Prevention (CDC). Tobacco use screening and counseling during physician office visits among adults--National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005-2009. MMWR Suppl. 2012 Jun 15;61(2):38-45 [accessed 2022 Mar 19].
  48. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults — United States, 2000–2015. MMWR Morb Mortal Wkly Rep 2017; 65:1457–1464. [accessed 2022 Mar 19].
  49. U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, Hispanics: A Report of the Surgeon General [PDF-2.6 MB]. for Disease Control and Prevention, 1998 [accessed 2022 Mar 19].
  50. A. Lebrun-Harris LA, Fiore MC, Tomoyasu N, and Ngo-Metzger Q. Cigarette Smoking, Desire to Quit, and Tobacco-Related Counseling Among Patients at Adult Health Centers. American Journal of Public Health 2015; 105 (1): 180-188 [accessed 2022 Mar 19].
  51. Flocke SA, Hoffman R, Eberth JM, Park H, Birkby G, Trapl E, et al. The Prevalence of Tobacco Use at Federally Qualified Health Centers in the United States, 2013. Prev Chronic Dis 2017; 14:160510 [accessed 2022 Mar 19].
  52. Williams SL, Kaigler A, Armistad A, Espey DK, & Struminger BB. Creating a Public Health Community of Practice to Support American Indian and Alaska Native Communities in Addressing Chronic Disease. Preventing Chronic Disease, 2019;16: E109 [accessed 2022 Mar 19].