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National Cancer Institute

Networks Among Tribal Organizations for Clean Air Policies

Project Title: Networks Among Tribal Organizations for Clean Air Policies

Organization: Mayo Clinic

Grant Number: 1U01CA154300

Principal Investigator: Scott Leischow

Note: The descriptions in this section were provided by the principal investigator and are not maintained or updated by NCI.

Co-Investigator:  Patricia Nez Henderson, Black Hills Center for American Indian Health

Study Summary
Dr. Leischow and his research team partnered with “Team Navajo,” a broad-based Navajo-led coalition dedicated to eliminating secondhand smoke in workplaces and public places on the Navajo Nation. When they developed this study, the primary focus was to examine how Team Navajo was working to impact smoke-free policies in Navajo Nation. After receiving feedback from the Navajo Nation Human Research Review Board and to better understand multiple sides of this complex issue, they expanded their focus to assess the perspectives of elected officials, Navajo traditional healers and others on commercial tobacco smoke-free policies. Thus, the overarching goal of this study was to evaluate both the Team Navajo network and the opinions and attitudes of other Navajo Nation stakeholders — including those who were not supportive of Team Navajo’s efforts and those who were neutral or undecided with regard to these efforts — and to provide evidence-based dissemination materials to inform the Navajo people in their discussions about the adoption and implementation of policies that eliminate exposure to commercial (nonceremonial) tobacco smoke.

Research Aims and Methods
1.    To map the structure and function of the Navajo Nation smoke-free network (i.e., Team Navajo), both cross-sectionally and over time.
2.    To document opinions of Team Navajo members and other social and political leaders and Navajo citizens who support, oppose, or are uncommitted in their opinions about Navajo Nation smoke-free policies, to understand the range of perspectives influencing passage of smoke-free policies in Navajo Nation.
3.    To track changes in smoke-free policies within Chapter communities, the five Agencies, and the Navajo Nation as a whole, to assess the relationship between social influences and policy change.
4.    To disseminate findings to Team Navajo, others in Navajo Nation and other tribes to inform discussions related to commercial tobacco smoke-free policies at local and national tribal levels.

Target Population: Navajo Nation smoke-free network

Key Findings

  • The analysis of the smoke-free network showed that few people served as key hubs in this grassroots coalition working toward smoke-free policies in Navajo Nation. This can be advantageous for ensuring that consistent information is disseminated through the network. It can also be risky, because the network may be vulnerable to collapse if the key hubs leave the network. Several sub-groups were identified, showing to some extent, the networks the coalition has tapped in order to accomplish all that it has achieved to date. Regional subgroups were also evident in the network. However, the data also showed that these subgroups became less distinct over the course of the three years and that they appeared to be starting to merge together.
  • We compared the opinions and beliefs of Navajo elected officials about smoke-free policies with those of Team Navajo members. A great majority of respondents in both groups support smoke-free policies, and a segment of both groups of respondents are concerned about the economic impact of smoke-free policies, particularly as it relates to gaming facilities and other businesses that allow smoking indoors. Our results suggest the proportion of elected officials with such concerns is decreasing over time.
  • Research demonstrated that it is possible to obtain tribal permissions to use the STARS instrument and to collect additional data on pricing, product mix and advertising in Indian Country. Examples of what we found are regional differences in product mix and taxation rates, that few tribally manufactured products are being sold, and that sales of ENDS products and supplies are ubiquitous in some regions.
  • Out of 390 tribal casinos surveyed by phone, 50.5% reported no smoking restrictions, 46.5% reported some non-smoking areas and 2.8% reported that they prohibited all smoking.
  • A survey of 103 attendees at the National Indian Gaming Association conference showed that 46.6% would support their gaming facilities going completely smoke-free if revenues would not go down and nearly as many (42.7%) would support a switch to smoke-free gaming if research showed that smoke in gaming facilities definitely harms employees and customers.
  • An economic analysis using difference-in-difference regression of monthly data on casino admissions per capita and real per capita adjusted gross receipts for state regulated casinos in Illinois, Indiana, Iowa and Missouri, from January 1998 through September 2015, showed that the Smoke-free Illinois Act of 2008 had no impact on casino business in Illinois.

Key Implications

  • Research is needed to identify the next steps for interventions in American Indian communities where casinos that allow smoking are seen as economic engines for tribes with high poverty rates.
  • Point-of-sale research in Indian Country could be used to help tribal leaders with issues related to sovereignty (surveillance, responding to FDA inquiries), revenues (taxation), and potential avenues for tribal regulation or deregulation of tobacco retailing
  • Economic and health analyses are needed to better understand the balance of health and economic factors that could impact tribal casino decision-making regarding smoke-free policies.

Original Abstract
Many jurisdictions prohibit smoking in work places and public spaces because of the clear threat to human health, and such prohibitions have been found to result in reduced tobacco use initiation and increased cessation. However, because of the sovereign status of federally-recognized American Indian tribes, state smoke-free laws are generally not implemented on tribal lands, and enclosed environments on these tribal lands continue to allow smoking. On the Navajo Nation, there have been concerted efforts led by a Navajo-led coalition called Team Navajo', to eliminate secondhand smoke in workplaces and public places. Team Navajo has worked for two years within the Navajo legislative system for passage of a bill that would prohibit secondhand smoke in Navajo Nation. Though to no avail so far, these efforts are being watched closely as a test case with implications for tribal and other communities across the U.S. and globally. We believe that changing policy regarding secondhand smoke on the Navajo Nation and other tribal communities can only come about through the development and effective implementation of coalitions and partners in a strong, broad and strategic network. This community participatory research will begin with a formative year of instrument development and team building between the researchers and Team Navajo members. Three waves of quantitative social network data in years 2-4 will be augmented with ethnographic data, to examine relationships and communication patterns that have the potential to be optimized for increasing policy change. In addition, contextual factors (e.g. local and state-specific policies, gaming industry efforts, etc.) will be analyzed, including data from all 110 Chapter Houses (the Navajo equivalent of counties), in order to track and explain barriers to policy change, and to evaluate progress. The data will be analyzed with guidance from three different advisory groups, including members of Team Navajo, and findings will be shared with members of Team Navajo and other tribal nations throughout the term of the grant, to maximize the impact of the research.