Despite the urgent need to develop effective quit-smoking treatments for American Indian (AI) smokers, only a handful of studies focusing on tribal smokers have been published out of more than 2,300 total cessation studies. 

“I am passionate about this issue because this is an understudied, underserved population with very high rates of smoking who also experiences significantly increased rates of cancer, diabetes and heart disease compared to other groups,” Stevens said, noting that the other project-team members share his passion. They include:

• Mark Caskey, B.S., R.N., C.H.E.S., Wellness Director, Menominee Tribal Clinic.
• Jerry Waukau, B.A., Health Administrator, Menominee Tribe.
• Kevin Culhane, M.D., Medical Director, Menominee Tribal Clinic.
• Rick Strickland, M.A., Program Director, Spirit of EAGLES, UWCCC.
• Leah Arndt, Ph.D., Clinical Assistant Professor, Department of  Educational Psychology, UW-Milwaukee

A Priority for the Menominee Nation
The project blossomed out of the Menominee Nation’s interest in improving smoking-cessation rates among adults in their community. “In 1998, the Menominee Health Plan made addictive behavior and reducing chronic disease two of the top three priorities,” said Lisa Waukau, Menominee Tribal Chairperson. “In 2000, we made our tribal buildings and worksites smokefree. Menominee youth abuse of commercial tobacco has been cut in half. We need to keep trying to help our people stop smoking. Half the people who can't quit die from a smoking-related illness. Heart disease and cancer are our number-one and number-two causes of death. In Menominee County between 1985 and 2000, lung cancer increased by 195 percent.  Recreational abuse of tobacco is killing our people! We can't continue to allow this to happen.  It's preventable and effective treatment exists.”

Back in 2005, Mark Caskey and Jerry Waukau began conversations with Stevens and other UW representatives regarding a potential collaboration. The Menominee-UW team knew that 44 percent of Menominee adults smoke commercial cigarettes, compared to 21 percent of the white population. Not to be deterred when a first study proposal was not funded, the team persevered, re-thought its approach and garnered UW Cancer Center developmental funding. In the end, team members say that extra time and work fostered increased trust and understanding and set the foundation for a collaborative, community-driven research project.

Leah Arndt, UW-Milwaukee Dept. of Educational Psychology, brings to the team particular expertise in qualitative-research methods and her knowledge and experience as an American Indian researcher.  She will also consult on development of the trial’s enhanced, culturally appropriate treatment condition.  The enhanced treatment is designed to be respectful of the sacred, traditional use of non-commercial tobacco (e.g., used in prayers, blessings and offerings) while helping AI smokers quit the use of commercial tobacco (i.e., cigarettes) that is harmful and addictive. The study will randomize 150 AI smokers to two treatment conditions: (1) a standard treatment condition closely modeled on the current cessation treatment used at the Menominee Tribal Clinic (FDA-approved varenicline for 12 weeks + 4 counseling sessions), and (2) an enhanced treatment condition consisting of the standard treatment plus culturally-appropriate treatment. Examples of culturally appropriate treatment elements include:

• The history of sacred/traditional use of tobacco (honoring and respecting native traditions) in contrast to commercial tobacco use (harming health).
• How commercial tobacco use and addiction are inconsistent with AI beliefs about health, spirituality and nature.
• Cessation information presented more visually with familiar Menominee images.
• Stories about tribal members who have quit commercial use.
• Counseling delivered in an accessible, personalized manner by an AI counselor.

Stevens said this research is unique. “What sets this apart is how we’re combining quantitative evaluation of the clinical trial with qualitative interviews,” coordinated by Dr. Arndt. Team members hope the study will reveal successful ways to treat commercial tobacco use within the Menominee Tribe. However, what the results won’t provide is a one-size-fits-all solution for all tribes. Some aspects may be generalizable, but different tribes have distinct traditions and beliefs. Stevens hopes to apply for future funding to expand the project to other tribes in order to explore that diversity.