Spotlight: Community Creates Unique American Indian Quit Smoking Program

The Americans with the highest smoking rates among all ethnic groups have been the least researched—and perhaps the least helped by smoking cessation efforts. It’s a sobering situation—one that has challenged a team of tenacious experts to create a unique long-term public health strategy to help American Indians quit smoking, funded by the American Lung Association.

Community-Based Participatory Research At Work!
Some of the American Lung Association’s most successful, innovative projects are built on community-based participatory research. We draw together members of the community we’re trying to reach, understand what they need, where and how we can best work with them to meet those needs, and produce programs “created with you, for you”.

Not-On-Tobacco (N-O-T) is based on work among high school students, teachers and counselors who work with teens, and quit smoking experts. The result? N-O-T is the most successful and widely-used teen smoking cessation program in the country, boasting more than 150,000 graduates. N-O-T helps kids understand why they smoke and assists them to develop the skills, confidence and support they need to quit. Kids learn the techniques they need to tackle tough problems like nicotine withdrawal, getting through urges and cravings and responding to peer pressure. N-O-T also deals with issues that are important to teens, such as how to manage their weight after quitting, how to deal with stress in healthy ways and how to communicate effectively.

Now we are taking that success to a deeper level, working with American Indian teens and community leaders to develop a version of N-O-T specifically for American Indian youth. Teens and program leaders are currently pilot testing the program before it becomes finalized and available nationwide.

Christine Makosky Daley, PhD., MA, SM and Won Choi, PhD, MPH of the University of Kansas worked through the layers of barriers to create an effective smoking cessation program for American Indians, whose culture includes sacred rituals using traditional tobacco. Their program, All Nations Breath and Life (, arose from a request from patients at an Indian Health Services clinic who asked for a novel smoking cessation program that was culturally sensitive to American Indians. 

American Indians, living throughout the U.S. in more than 500 tribes with unique customs, use traditional tobacco to welcome and honor guests, for blessings, as gifts, and as part of sacred ceremonies and powwows, for example. The distinction between misuse of commercial tobacco and ceremonial use of traditional tobacco is just one of the cultural elements researchers must understand. "We realized right away that we couldn't modify existing smoking cessation programs for the general population or other cultures," explained Dr. Daley. "They all say 'don't use tobacco at all', and we were working among a culture of tobacco. There is very little we know from a research perspective about that culture of tobacco, so we really needed to start at the beginning, understanding traditional use of tobacco as well as the fact that it is an economic mainstay on some reservations. We had to dive in and start something new."

  Diving into that culture meant conducting community-based participatory research, including the community in all phases of research and program development, so that the program ultimately reflects the American Indians' culture and is a product of the community who will use it. After 5 years' research and pilot testing, All Nations Breath and Life presents a comprehensive smoking cessation program of group sessions, one-on-one phone counseling and pharmacotherapy of the individual's choice—all free of charge. "We have a very intense beginning because most relapse happens in the first two or three weeks after someone quits, given the addictive nature of nicotine," Dr. Choi explained. "We focus on keeping people motivated. It's all about smokers helping each other with the facilitator."

Lance CulleyThe researchers are tracking the efficacy of the program and are learning about the personal impact on American Indians who have quit smoking. "One elderly gentleman had smoked for 40 years and would go to powwows but couldn't dance because he would get out of breath too quickly," said Dr. Daley. "After completing the program he could get out with his grandson and dance a two-day powwow without getting winded.  Being able to get out there with his grandson was a huge event for him!"        

The program currently is being used in Kansas and Missouri and soon will expand to Oklahoma and North Dakota, thanks to the outreach of the American Indian Health Research & Education Alliance (, which Dr. Daley directs.  Ultimately, the researchers hope to move All Nations Breath and Life throughout the country.  Anyone interested in the program can send an e-mail to or call the KUMC Program in American Indian Community Health at 913-588-0866.

Dr. Choi and Dr. Daley view their community-based participatory research in smoking cessation as baseline work that could serve as a model for many other health issues that disproportionately affect American Indians. "This population has the greatest health disparities in the country," said Dr. Choi. "There has been minimal assistance for American Indians, but we are finding answers through the work we are doing."