Larry Aitken (Bezhigoogahbow), Leech Lake Tribal College’s founder and inaugural president, said you must always have asemaa (tobacco) to prepare for anything that you do, as everything in your life requires preparation. Although individual beliefs and opinions offer many polarizing viewpoints about tobacco, its sanctity among Indigenous peoples and the dangers of its commercialized adaptations offer few debates. The path that Leech Lake Tribal College (LLTC) has taken to find a balance between sacred and commercial tobacco has not been an easy one. As campus members try their best to live life in a good way, finding a healthy, respectful balance with tobacco requires a great deal of thought, insight, and preparation.
Leech Lake Tribal College, in Cass Lake, Minnesota, desires to be a place of support and encouragement for students, and seeks to collectively advance the Anishinaabe worldview. Among the Seven Grandfather Teachings, one aspect of the value of manaaji’idiwin (respect) calls to safeguard the rights of others. LLTC initially created an outdoor smoking area to limit non-smokers’ exposure to secondhand smoke. While this was a significant step for the college at the time, LLTC leaders remained concerned that commercial tobacco use anywhere on campus would continue to expose non-smokers and may be a trigger for those attempting to quit. The college therefore sought to make the entire campus commercial tobacco free.
TOBACCO AMONG NATIVE PEOPLES
Prior to colonization, Indigenous peoples had access to the necessary and sacred medicines of their respective areas, including their own versions of tobacco. After colonization, much of this access was restricted and commercial tobacco’s place among American Indian communities became increasingly detrimental. Until the American Indian Religious Freedom Act of 1978 restored traditional religious rights and practices, the U.S. government prohibited American Indians from using tobacco or any mixture of indigenous plants such as kinnikinnick (mullein, bearberry, etc.) or apaakozigan (dried red willow bark) for spiritual use. It was no coincidence that during this prohibition, the commercial tobacco industry began extensive marketing efforts which targeted American Indians, using cultural symbols such as iconic leaders, pipes, and regalia on their products (Truth Tobacco Industry Documents, 2015). The resulting high rates of commercial tobacco use led to a disproportionate burden of tobacco-related diseases among American Indians in Minnesota and the nation at large.
Several studies have shown that American Indians and Alaska Natives (AI/ANs) experience higher smoking rates and related disease and mortality than Caucasians. AI/ANs have higher rates of smoking-related diseases, including ischemic heart disease, other forms of heart disease, and stroke deaths (Mowery et al., 2015). In a study of American Indians in the Northern Plains regions, the prevalence of commercial tobacco use is as high as 49% among men and 51% among women (Henderson et al., 2005). Among Northern Plains tribal college students, 44% smoke cigarettes (Choi et al., 2015). Similarly, Northern Plains American Indians experience greater health disparities, including smoking- related diseases, than the general population (Holm et al., 2010). Recent studies specific to American Indians in Minnesota are even more alarming. Despite reducing the statewide adult smoking rate to 14.4% (Boyle et al., 2015), the smoking rate for American Indians in Minnesota is 59% (Forster et al., 2016).
In recent years, the State of Minnesota has taken significant steps to reduce commercial tobacco use through cessation programming, educational activities, and commercial tobacco control policies. However, the majority of these efforts have focused on the mainstream community, with few being tailored specifically to Indigenous communities. Although Minnesota passed the Freedom to Breathe Act in 2007, which prohibited smoking indoors, tribal entities may utilize their sovereignty to embrace or reject it. Thus, organizations and businesses within reservation borders—such as LLTC—are left to determine their own individual policies related to commercial tobacco use on their premises.
Mainstream approaches to reduce commercial tobacco use ignore the important role of traditional tobacco use that is so important to many American Indians, yet initial studies indicate that respect for cultural traditions should be included in efforts to curtail tobacco use. As asemaa was given to the Anishinaabeg to communicate with the Creator, it is honored and held in the highest regard. Asemaa is not only used in many ways during ceremonies, but may also be gifted to others, put out or burned after prayer, or presented as an offering before gathering medicines. Since traditional tobacco itself requires preparation, its inclusion before, during, or after sacred and ceremonial acts is a testament to its reverent position. Qualitative studies with the Menominee in Wisconsin found that Menominee-centric ways of knowing commercial and sacred use should be part of any tobacco-prevention programming (Arndt et al., 2015). Studies of cessation programs have found participants who use tobacco in a traditional way had longer periods of abstinence from commercial tobacco than previous quit attempts in which there was no acknowledgement of the sacred history of traditional tobacco use (Daley et al., 2011; D’Silva et al., 2011). Evidence also suggests that commercial tobacco-free campuses influence smoking behaviors in other parts of one’s life. Campus policies have been associated with the creation of smoke-free policies within the home and a reduced likelihood of those involved becoming smokers themselves (Berg et al., 2013).
Of the 35 accredited tribal colleges in the United States, currently only five have enacted commercial tobacco-free campus policies of any kind (American Nonsmokers’ Rights Foundation, 2016). LLTC and one other tribal college explicitly encourage traditional use while prohibiting commercial use (Oglala Lakota College); one college restricts commercial tobacco without mentioning traditional use specifically (United Tribes Technical College); one allows ceremonial use at events after an approved request to the college president (Fort Peck Community College); and one is tobacco free with no differentiation between commercial and traditional use (Sinte Gleska University).
BACKGROUND OF LLTC’S COMMERCIAL TOBACCO-FREE CAMPUS POLICY
Leech Lake Tribal College officially implemented its commercial tobacco-free campus policy at the beginning of the 2014–2015 school year, prohibiting commercial tobacco use anywhere on campus while supporting and encouraging sacred uses of tobacco. LLTC worked on its policy formation for several years; college leaders made the decision to educate and cultivate the effort on campus a full year prior to implementation. This decision, along with the innovative provisions within the policy, was instrumental to the initiative’s success.
A unique component of LLTC’s policy is that it not only prohibits all commercial tobacco use campuswide, but strongly encourages and supports the vital role of asemaa as a medicine within Anishinaabe culture. Taking the time to educate the campus on the dangers of commercial tobacco, as well as upholding the sacred and ceremonial uses of asemaa, was a critically important facet to the successful implementation of the policy.
To increase acceptance of the policy and better prepare students, faculty, and staff for the change, LLTC devoted the 2013–2014 school year to education and awareness activities to promote ceremonial practices, provide relevant information, and offer cessation support for current smokers seeking help to quit. Led by the Mino-ayaawigamig Wellness Center, LLTC hosted a variety of events that encouraged those who wanted to quit using commercial tobacco and offered support for them in their efforts. At the same time, LLTC continued to observe traditional tobacco practices on campus, including offering pipe ceremonies at campus events and education about using asemaa in the proper way. Additionally, the Mino-ayaawigamig Wellness Center hosted sessions on campus with local elders who shared their valuable insights on the role that traditional tobacco plays in tribal history.
EVALUATION DESIGN AND METHODS
To inform the implementation process and assess the impact of the policy, LLTC contracted with an external evaluator to undertake an evaluation of its policy work. The evaluation consisted of a pre- and post-survey administered to students, faculty, and staff to assess support for the policy and their knowledge of the harmful effects of commercial tobacco, tobacco industry tactics, and traditional tobacco. It also consisted of qualitative interviews with purposive samples of students, faculty, and staff before and after policy implementation. Evaluation work was further informed by evaluator site visits to campus who met with Mino-ayaawigamig staff and key stakeholders, and who reviewed related documents, reports, and promotional materials. Minoayaawigamig staff and LLTC’s spiritual advisor provided input and reviewed the survey instrument.
The student survey was conducted in person by the evaluator on campus in December 2013 (n=126) prior to policy implementation and again in December 2014 (n=92) after the policy was in place. Mino-ayaawigamig staff promoted survey dates through emails, social media, the LLTC website, and signage posted throughout campus. Faculty and staff were surveyed online through a link sent to all staff and faculty. Students signed a consent form in person before completing the survey; faculty/staff consent was obtained by clicking on the email link available after consent procedures were described. The percentage of students who completed surveys out of the total number of registered students was 61.2% in 2013 and 54.4% in 2014, while 78% of faculty/staff (n=40) completed surveys in 2013, and 77% (n=43) completed surveys in 2014.
In order to learn more about individual student, faculty, and staff opinions on commercial tobacco-related issues and attitudes about the policy, in-person qualitative interviews were conducted on campus in March 2014 (n=12) before policy implementation and by telephone (n=6) in July 2015 after policy implementation. Apurposive sample sought specifically to find a diversity of students, faculty, and staff smokers/non-smokers who were then recruited by the Mino-ayaawigamig director. Interviews were analyzed for emerging themes to provide more in-depth information on the experiences of LLTC students and staff related to the policy.
The evaluation design and tools were reviewed by the Minnesota Department of Health Institutional Review Board (review #13-318) prior to the beginning of the evaluation and re-reviewed one year later.
The percentage of student respondents who reported smoking commercial tobacco decreased from 48.4% (n=61) in 2013 to 41.3% (n=38) in 2014 (see table 1). Among staff/faculty, the percentage of smokers increased slightly from 15.4% (n=6) in 2013 to 18.6% (n=8) in 2014. The percentage of student smokers who have attempted to quit increased from 71.6% in 2013 to 79% in 2014 (see table 1). For faculty/staff smokers, 100% reported quit attempts in both years. Since the number of faculty/staff smokers was low, additional findings for them are not presented in this report.
Support for the new, commercial tobacco-free campus policy was high among students (82.6%) and faculty/ staff (83.7%). Student non-smokers were more supportive (90.2%) than smokers (71.1%). Faculty/staff non-smokers overwhelmingly supported the policy (94.3%). Almost all respondents were aware of the policy: 95.7% of students and 100% of faculty/staff reported they knew about the policy. Respondents also had high awareness of the main elements of the policy, knowing that it prohibits smoking in buildings, outside on campus grounds and in parking lots, and that there is no longer a designated smoking area where commercial tobacco use is allowed. Smokers were more aware than non-smokers of the policy elements.
Large percentages of respondents found several aspects of the policy valuable. They like having a smoke-free campus; feel the policy shows that LLTC’s administration values its students, faculty, and staff; feel it contributes to improved health; and believe that it is important for the campus to be smoke-free. In addition, nearly half (47.4%) of student smokers reported they smoke less because the campus is commercial tobacco-free.
Respondents also reported they were less likely to experience problems related to others’ commercial tobacco use on campus (see table 2). Non-smokers appreciated not having to walk through smokers standing outside building entranceways: “The main thing is I don’t have to breathe any cigarette smoke. Before, I used to have to walk through it to get into the building.”
Well over two-thirds of respondents were quite knowledgeable of the risks of occasional smoking, breathing secondhand smoke, and knew that secondhand smoke causes lung cancer and respiratory problems. Over half of the respondents knew that secondhand smoke causes other types of cancer or heart disease, whereas less than half knew there is a connection between Sudden Infant Death Syndrome and secondhand smoke. There were only small changes in knowledge between 2013 and 2014. Knowledge is slightly higher among non-smokers.
Students and faculty/staff both reported increased use or observance of traditional tobacco from the previous year. Student observance increased from 46.4% in 2013 to 71.1% in 2014; this was the case for smokers (increased from 47.5% to 71.1%) and non-smokers (increased from 45.0% to 69.4%). Faculty/staff observance increased from 56.4% to 70.7%; this was true for both smokers (increased from 66.7% to 87.5%) and non-smokers (increased from 54.8% to 66.7%). Nearly one-third of students (28.3%) and faculty/staff (30.2%) attended one of the informational presentations on traditional tobacco.
Prior to implementation, interview respondents cautioned that it was important that LLTC leaders make it clear that the policy does not restrict traditional use of tobacco. They stressed that education on both the policy content as well as more opportunities to learn about sacred use were important. Those interviewed after implementation of the policy understood and supported this.
There is still some confusion about the level of enforcement of the policy and what the consequences are for violating the policy. Only 44.6% of students and 43.3% of faculty/staff thought the policy is being enforced.
Some respondents still thought there should be an area where smokers can use commercial tobacco on campus, but the percentage that supported a total ban on commercial use on campus increased after policy implementation. In 2014, 76.9% (up from 39%) of students and 82.6% (up from 68.4%) of faculty/staff thought commercial tobacco use should be prohibited everywhere on campus.
One smoker said that in order to smoke, s/he has to go up on the road, which is unsafe and means missing class: “And when you go out and smoke on the road, people are flying by, that does put us at risk, too, you know.” Concern was expressed for elders who smoke on campus, and the difficulty they may have dealing with the new policy. Those who identified this concern said they would not feel comfortable asking an elder not to smoke.
Another concern expressed was the need to support commercial tobacco users who are trying to quit. Suggestions included providing cessation services and having strategies for commercial tobacco users to cope with stress related to not smoking.
Initial implementation of LLTC’s commercial tobacco-free campus policy has been successful and shows progress in knowledge of the dangers and harms related to commercial tobacco use and secondhand smoke. Support for the policy is widespread, even among smokers. Awareness of the policy is nearly universal and the elements of the policy are well understood.
Just as important to LLTC leaders, campus members understand that the policy encourages and supports the traditional uses of tobacco. A testament to this is that the observance of the traditional uses of asemaa increased after the policy was enacted. Encouraging the traditional use of asemaa honors the Anishinaabe values that LLTC is founded upon. This emphasis may contribute to reduced use of commercial tobacco evidenced by LLTC students.
While it is not possible to make a causal connection between the policy and smoking status, the reduced percentage of students who report being smokers and the increased percentage of smokers who have tried to quit suggests that the policy contributes to an environment that encourages non-use of commercial tobacco. This was supported by some respondents who were previously smokers, who stated that the policy has helped to keep them from smoking. This is similar to findings from mainstream research, which have demonstrated that students at campuses with tobacco-free policies report less exposure to secondhand smoke and less intent to smoke on campus (Fallin et al., 2015).
LLTC’s president at the time, Dr. Donald Day, championed efforts to enact the commercial tobacco-free policy. A study of a national sample of college presidents suggests their support is important to successfully passing smoke-free policies on campus (Reindl et al., 2014). This may also be true for tribal colleges, as early involvement and support of the LLTC president was important to successful adoption and implementation as he worked inside the campus community and sought outside expertise to inform implementation.
More information is needed on tobacco-control work that affects American Indian communities. Although there is a lot of evidence showing that smoke-free policies contribute to a reduction in smoking prevalence in mainstream populations, few of those examples are specific to Indigenous peoples. LLTC’s experience with the commercial tobacco-free campus policy suggests that when developed internally and preceded by a period of preparation and education, policy efforts that ban commercial tobacco and encourage traditional use can be effective at supporting reduced tobacco use and exposure to secondhand smoke, while encouraging sacred use of asemaa within Anishinaabe culture and heritage. This is especially important in light of the disproportionately high rates of commercial tobacco use among American Indians and the related health consequences.
While the evaluation included pre- and post-policy implementation data, not all students participated in the surveys, so results should be interpreted with some caution. At the time of the postsurvey, the policy had been fully implemented for four months. The education and awareness activities may have been recent enough to be fresh in people’s minds. The long-term results of the policy, and if they continue to be sustained, are unknown. A follow-up survey might provide additional insights into the ongoing impact.
Leech Lake Tribal College has successfully created and implemented a commercial tobacco-free campus policy. The LLTC experience suggests that when deciding to implement a commercial tobaccofree policy, tribal colleges may benefit from leading those efforts from within, and allowing sufficient time before enactment to educate the campus community on commercial tobacco harms, prepare campus members for the upcoming ban, connect the ban to improved health, and include an emphasis on encouraging traditional tobacco heritage and observances to distinguish between commercial tobacco and sacred medicine/asemaa.
Support for the policy is widespread, even among commercial tobacco users. There is a high awareness of the policy and the majority of respondents like having a smoke-free campus. Alower percentage of students reported being smokers and the vast majority of smokers have tried to quit, suggesting LLTC may be having success creating a supportive environment for students and faculty/staff.
It is likely that the policy has been broadly accepted due to the implementation process LLTC undertook—hosting cessation activities, commercial tobacco education presentations, and offering opportunities on campus for students and faculty/staff to reconnect with and learn more about traditional practices surrounding tobacco. LLTC’s experience may provide a useful model for other tribal colleges that wish to become commercial tobacco-free.
Linda M. Bosma, Ph.D., is an independent evaluation consultant. Matt Hanson is director of the Mino-ayaawigamig Wellness Center at Leech Lake Tribal College.
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