When Native Community Consultant Lou Moerner visited her colleague Claradina Soto, an American Indian behavioral health science professor at USC Keck School of Medicine at her office in the early 2000s, something caught her eye.
“I happened to look up on her bookshelf and I see, ‘Project EX, Youth Commercial Tobacco Cessation Curriculum’,” says Moerner. She asked Soto about it, who explained that it was developed by social psychology professor Steve Sussman, a colleague at the Keck School of Medicine. Moerner took a closer look. “I was flipping through, and I say, ‘why haven't we Nativized this?’”
Project SUN was born.
It took a few years from idea to completion, but Project SUN (Stop the Use of Nicotine) has now become the first evidence-based commercial tobacco cessation curriculum adapted for American Indian/Alaska Native (AIAN) youth. A pilot study funded by the Tobacco-Related Disease Research Program (TRDRP) found the program was extremely successful at helping Native youth throughout California quit smoking.[i]
They named it Project SUN because “every day the sun comes up, you get a new chance to try something and that's what quitting is about,” says Moerner. “You just keep trying, learn some new skills, try again.”
“This was the first time we engaged the American Indian/Alaskan Native community into this process to create something based on an evidence-based program,” says Soto. “It fills a need for an effective and culturally relevant smoking cessation program for our American Indian and Alaska Native youth given their high rates of smoking and nicotine use and commercial tobacco use.” AIAN youth have the highest commercial tobacco use of all ethnic and racial groups in the U.S., up to 42%.[ii] They also start at nearly a year younger, 11.5, versus 12.3 for the general population.[iii]
Every Day is a New Chance to Quit
From curriculum development to training facilitators and even conducting scientific research, the unique risk factors faced by Native communities and youth, including generations of historical trauma, discrimination, and marginalization, had to be considered.[iv]
Moerner and Soto, both Native American, collaborated with Sussman plus a team of AIAN individuals who work with Native youth to modify the original curriculum, which had previously been adapted to cultures in South Korea, Israel, and Thailand, among others. For Project SUN, the team selected themes common to many AIAN tribes, since the goal was to have a broad cultural resonance across the U.S.
These ranged from using Native artwork and Talking Circles to such as addressing the difference between commercial and sacred tobacco. “The previous curriculum says, ‘tobacco kills,’” says Moerner, “and if you're raised traditionally to understand that tobacco is medicine, and really what kills is commercial tobacco … you've already offended that student and now they won’t listen.” Project SUN addresses these issues.
Because some commercial tobacco uses AIAN names and images (such as American Spirit and Red Man) and some AIAN communities may use commercial tobacco when ceremonial tobacco is unavailable, youth may get the impression that recreational use of commercial tobacco is safe, acceptable, or spiritual. While each tribe has unique traditions, the use of sacred tobacco involves unadulterated growing techniques, natural processing, and ceremonial use that typically does not involve inhalation. “It's the reverence and the respect that we're trying to teach,” explains Moerner.
Implementing Project SUN
After the curriculum was finalized, the team recruited youth through the state’s 27 American Indian Education Centers (AIECs)[v], Urban centers, and other agencies that work with Native youth. The original plan was a 3-branch randomized control trial using Project EX, Project SUN, and a wait-list control. However, many Center personnel objected to using a non-Nativized curriculum with their students; others did not want to wait while other Centers had the project running. Thus, the study was adjusted to a single-arm trial. Non-native youth could join with their AIAN friends in the program. They trained fifty-seven facilitators and recruited 126 youth. Thirty-seven of them, ages 13 to 19, reported past-month commercial tobacco use so those were used for the analysis.
The program is implemented over 8 weeks, and includes various activities, ranging from ways to regulate behavior (such as deep breathing), listing out culturally relevant pursuits that students can try instead of smoking such as basket making or building fishing nets, as well as role playing and Talking Circles, which are traditional for many AIAN communities.
“Talking Circles put everybody heart to heart, face to face, quiet everyone, allow the person with the talking stick, or whatever implement they’re using, to guide the round,” says Moerner. “You’re treating them as Natives first, but you’re also letting young people have a voice and a power that they don’t often get in a Western classroom—even a Native classroom. The facilitator is asking you, the young person, questions about yourself and your response will not be judged. Your response will not be shocking to them. They’re just going to appreciate that you shared.”
Cessation Success Seen
Youth ranked their satisfaction with Project SUN at 7.35/10, with activity preference rankings ranging from 4.81 to 7.45. Interestingly, yoga ranked lowest of all activities, which often ranks higher in groups using Project EX. The Talking Circle, healthy breathing, and a floating relaxation exercise ranked highest among Project SUN participants.
Of the thirty-seven student participants, thirty-four completed the 3-month follow-up survey. Of those, twenty-four reported quitting. Confirmation of abstinence from tobacco was found in 7 of the 14 participants who provided a saliva sample, though this result could have been influenced by exposure to secondhand smoke. These values were used to calculate the adjusted cessation rate of 32%. Although there was no control arm in this study, quit rates in control groups is typically between 1% and 7% at 3-month follow-ups.
Scientists must recognize the unique challenges of working with Native communities, such as those that occurred with this project, including the AIEC staff working as facilitators without receiving additional compensation to implement the program, fitting these duties in with their current workloads, and understanding that AIAN community priorities may differ from those of scientists.
“We're asking them to do X, Y and Z, and that's a lot of hard work, and that's harming the bridges we're trying to build with our communities,” says Soto. “Yes, we're trying to develop something great, but we need to support them a lot more with resources and incentives and things like that.”
Saving Lives While Valuing Cultures
While implementing the study had its challenges, the team was able to produce a study showing that this curriculum successfully helps Native youth to stop commercial tobacco use while also honoring their own traditions, such as sacred tobacco and Talking Circles.
“This isn't about us writing papers,” says Moerner. “This is truly about saving lives and creating an opportunity for young people to be treated like Natives first, and the nicotine addiction is something they're going to learn about, and they'll learn some behavior modification and, if they so choose, they’ll be supported to quit.”
Based on the many requests the team has received to train facilitators in different communities outside of California, Project SUN is now much in demand. “People are hungry to finally have a pan-Indian, proven-effective, Western evidence-based standard for a Native youth curriculum quit program, developed with the input of Native youth, that includes vaping,” stresses Moerner. “It also acts as a prevention, intervention, and a cessation manual. It's got all three built in.”
Likewise, Soto has been hearing from Native colleagues, including recently at the nationwide Creating Connections Tobacco Coalition, how happy they were to have this curriculum to use with their own networks. “They were sharing how they appreciate Project SUN being out there, and our Native youth being reached with culturally relevant materials,” says Soto. “It’s so important.”
Ramos, G. G., Sussman, S., Moerner, L., Unger, J. B., & Soto, C. (2022). Project SUN: Pilot Study of a Culturally Adapted Smoking Cessation Curriculum for American Indian Youth. Journal of Drug Education, 51(1–2), 10–31. https://doi.org/10.1177/00472379221111542
MEDIA CONTACT
Wendee Nicole Holtcamp, wendeenicole@gmail.com
Korby L Skoglund, korlynne@gmail.com
References
[i] Ramos GG, Sussman S, Moerner L, Unger JB, Soto C. Project SUN: Pilot Study of a Culturally Adapted Smoking Cessation Curriculum for American Indian Youth. J Drug Educ. 2022;51(1-2):10-31. doi:10.1177/00472379221111542. https://pubmed.ncbi.nlm.nih.gov/35788160/.
[ii] Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance - United States, 2017. MMWR Surveill Summ. 2018;67(8):1-114. Published 2018 Jun 15. doi:10.15585/mmwr.ss6708a1.
https://www.cdc.gov/mmwr/volumes/67/ss/ss6708a1.htm?s_cid=ss6708a1_w
[iii] Hoffman L, Ganz O, Delahanty J, Jones C, Homsi G, Nonnemaker J. Tobacco Product Use Health Equity Among Non-Hispanic American Indian Alaska Native Youth in 29 States, 2007-2013. Am J Prev Med. 2019;57(2):e43-e50. doi:10.1016/j.amepre.2019.04.005.
https://www.sciencedirect.com/science/article/abs/pii/S0749379719301886
[iv] 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. doi:10.1016/j.addbeh.2015.06.005 https://doi.org/10.1016/j.addbeh.2015.06.005.
[v] For a full list of American Indian Educations Centers (AIECs) visit https://www.cde.ca.gov/sp/ai/re/aidirectory.asp
