1623 Patient and Smoking Patterns in Northern California American Indian Clinics Urban and Rural Contrasts Felicia Schanche Hodge, D~.P.H.’!* Larri Fredericks, Ph.D.2 Patricia Kipnis, Ph.D.2 ’ llniversity of California at Berkeley, School of PiJbliC Health, Berkeley, California. Center for American Indian Research and Education, Berkeley, California. BACKGROUND. This article elaborates on an earlier article about a smoking cessation program conducted in Northern California Indian clinics. Whereas the previous article discussed Indian smoking rates in general, this article compares the smoking patterns of Indians who live in urban and rural settings. The differences between the two populations are described, and the implications of these differences for planning, policy, and education are discussed. METHODS. A self-report questionnaire was administered to 1369 adult Indians seeking health services at 18American Indian health care clinics in Northern California. Data were collected on demographic characteristics; smoking behaviors; readiness to quit smoking; knowledge, behavior, and attitude; and a social support and “hassles” measures. RESULTS. Urban Indians were more mobile and reported higher smoking rates, a higher level of education, less social support, and more hassles than rural Indians. CONCLUSIONS. Indians living in urban areas continue to experience a high degree of stress. Long-term isolation from reservations and traditional homelands may have contributed to the breakdown of social support systems among urban Indians. These and several other factors should be considered when designing tobacco control programs. Cancer 1996; 781623-8. 0 1996American Cniicer SocicTy. KEYWORDS smoking cessation, tobacco, North American Indians, urban health, urban health services, urban population, rural health, rural health services, rural population. A Supported by a grant from the National Cancer Institute. UO1-CA52270. Presented at the Native American Cancer Conference 111: Risk Factors, Outreach and Intervention Strategies, Seattle, Washington, June 1619, 1995. Address for reprints: Felicia Schanche Hodge, [)r.P.H., Center for American Indian Research and Education, 1918 University Avenue, Suite :!-A, Berkeley, CA 94704. Received May 31, 1996; June 18, 1996 i’ 1996 American Cancer Society ccording to the 1990 census figures, 242,000 American Indians and Alaska Natives live in California’; this is the second largest concentration of Indians in the United States. This population doubled between 1970 and 19852 and has increased by 20.3% since the 1980 census. California’s Indians are widely dispersed, highly mobile, and frequently move back and forth between their rural reservations of origin and the major urban areas. Also, many Indians relocate to California from other parts of the country. There are 85 reservations and rancherias scattered throughout the state. The two largest, Hoopa and Round Valley, are located in Northern California. Approximately 30% of California’s Indian population reside in rural counties, and the remaining 70% are concentrated in five major urban sites.’ Morbidity and mortality statistics for the population of American Indians in California are fragmented and fraught with problems. Indians represent less than 1%of the state’s residents and are often categorized as “other” on vital statistics records and reports (Crouch J. Personal conversation, 1993).Vital statistics are unreliable due to racial misclassification (A. Hahn, L. Muline, K. Tuetsch; unpublished 1624 CANCER Supplement October 1, 1996 / Volume 78 / Number 7 data, 1992).4-6For example, because of the underreporting of the Indian race on the state's death certificates, the National Center for Health Statistics does not individualize California data in reports of Indian Also, due to eligibility restrictions, years-of-life-l~st.~ the Indian Health Service provides health care to less than half of the Indians in the state; thus, the Indian population in California is underrepresented in the Indian Health Service data (Crouch 7. Personal conversation, 1993). American Indian health status is generally far worse than the general population. The causes of morbidity have shifted from the acute conditions prevalent 30 to 40 years ago to chronic problems that are largely behavioral in origin. Compared with the United States as a whole, Indians report higher rates of tuberculosis (770% higher), alcoholism (634% higher), accidents (259%higher), diabetes mellitus (259%higher), homicide (101% higher), and suicide (96% higher).8 Reported rates of cigarette smoking vary significantly from tribe to tribe and region to region. For example, smoking prevalence is highest among Northern Plains Indians (42-70%) and Alaska Natives (56%)and is lowest in the southwest (13-28%).' In California, 40% of Indians smoke (47% of males and 37% of females)." This is almost double the current rate of all adults in California (23.8% of males and 18.8% of females)." The national rate for adult smoking for all races in 1991 was 25.7%.'* There are very few studies analyzing the high smoking rate of American Indians. There are even fewer studies of the differences between urban and rural Indians with respect to smoking and other risk behaviors, social support systems, etc. This article elaborates on an earlier article about a smoking cessation program conducted in Northern California Indian clinics.'" Whereas the previous article discussed Indian smoking rates in general, this article compares the smoking patterns of Indians who live in urban and rural settings. The differences between the two populations are described, and the implications of these differences for planning, policy, and education are discussed. METHODS Background The Center for American Indian Research and Education is dedicated to the improvement of health and social welfare of American Indians and Alaska Natives. It is governed by an all-Indian advisory board and is staffed primarily by Indian professionals. In 1989, the center polled tribal leaders in California to identify priority areas for research. Smoking cessation was identified strongly as an area of need for planning, intervention, and cessation programs. The smoking cessation project reported in this paper was funded by the National Cancer Institute. The program was clinic based and took place in 18 American Indian outpatient clinics in Northern California over a 5-year period. The data for this analysis come from a smoking prevalence survey conducted during the first 20 months of the project in 18 clinics located in the northern half of the state. The evaluation of the efficacy of the program has not yet taken place. The target population was 75,000 rural and urban Indians residing in Northern California. Indians living in rural areas are generally members of native California bands and tribes, whereas the majority of those in urban sites come from out-of-state, reservation-based tribes. Sample Depending on the size of the clinic, 30 to 120 adult Indians older than 18 years of age were asked to complete a self-administered questionnaire when registering for a medical or dental appointment. Respondents were provided information on the project, were asked to read and sign a participation consent form, and were told that medical care was not contingent on their participation in the project. Also, they were told that they could refuse to answer any question. A total of 1369 of those asked (90%) agreed to participate. However, for a variety of reasons, many of the respondents (30%)did not complete the survey in its entirety, primarily those questions about religiosity and traditional behaviors (not reported in this article). Reasons given for failure to complete the questionnaire totally included the survey's length and difficulty, the sensitive nature of some its questions, distractions by the respondents' children, and the need to leave the waiting room when summoned by the provider. Measurement The study collected data on demographics, smoking behaviors, readiness to quit smoking, and a number of other characteristics involving knowledge and attitudes. It also included a social support scale. Participants were classified as current smokers, former smokers, or persons who had never smoked. Current smokers were defined as those who reported smoking at the time of the survey. Former smokers reported not smoking at the time of the survey but having smoked at least 100 cigarettes in their lifetime. Respondents who neither smoked at the time of the survey nor had smoked 100 cigarettes were classified as having never smoked. We rated current smokers' readiness to quit on 1625 American Indian Smoking Contrasts/Hodge et al. the Prochaska scaleI3 according to three categories: the precontemplative stage (not interested in quitting), the contemplative stage (thinking of quitting within the next 6 months), and the active stage (willingto quit within 30 days). A Lickert scale was used to measure individuals’ knowledge of the health risks associated with smoking and chewing tobacco, and to identify smoking-related behaviors and attitudes. A series of questions concerned the number of close relatives and friends on whom respondents felt they could rely as well as the participants’ social support network. There were also questions designed to determine the number of “hassles” experienced during the previous 3 months. Statistical methods used for multiple comparisons were done by chi-square test. The significance level of all tests were compared at an alpha level of 0.05. Results were reported for both significant and nonsignificant results. In this preliminaiy examination of the urban and rural differences of American Indians, only descriptive statistics were used for explanatory purposes. TABLE 1 Residence in California and the Local Area Amount of time lived in California (Percent) ~ Less than 6 months 6 to 12 months 1 to 2 years 3 to 5 years 6 to 10 years 11 to 20 years More than 20 years Lifetime ~~ ~ Urban (339) Rural (1029) Overall (1368) 4 1 1 1 2 4 4 5 8 11 23 40 2 2 5 16 72 1 2 3 4 6 18 64 Amount of time lived in the local area (Percent) Urban (339) Rural (1029) Overall (1368) Less than 6 months 6 to 12 months 1 to 2 years 3 to 5 years 6 to 10 years 11 to 20 years More than 20 years 9 5 4 3 8 11 11 3 7 8 16 11 20 23 Lifetime 18 41 5 3 4 8 8 12 22 35 RESULTS Demographic Characteristics In California, 70% of the American Indian population reside in urban areas and 30% reside in rural areas. Our sample reflected more closely the proportion of Indians in the northern portion of the state, where there are larger numbers of rural residents (30%urban and 70% rural). Twenty-five percent of the sample in this study were urban residents, and 75% were rural residents. Participants were affiliated with 120 different tribes, 69% with native California tribes and 31% with out-of-state tribes. More than 60% had lived in California their entire lives, and 36% of these had always lived at their current residence. As expected, urban Indians were more transient than the rural population ( P < 0.001) and reported having lived less time in California and even less in their current residence (Table 1). There was a difference among age groups between urban and rural sites ( P < 0.006). The differences in age group distribution between the urban and rural populations were minor, with one exception: 23% of the rural population was older than 50 years of age compared with 15% of the urban population ( P < 0.004). Overall, 80% of the sample was between the ages of 20 and 60 years. Thirty-seven percent of the urban sample was male versus 34% of the rural sample. Overall, the sample contained almost twice as many women as men, most likely because women visit clinics more often than men. For both California and community iP < 0 001, ~’-1est1 Urban Indians reported a higher level of education than their rural counterparts. A total of 17% of urban Indians and 13% of rural Indians had some college; 32% of urban Indians and 19% of rural Indians had completed a trade or vocational program. This was statistically significant ( P < 0.001). Overall, the educational attainment of Indians in Northern California was similar to that of Indians nationwide. Sixty-nine percent of those in the sample who were 25 years or older had at least graduated from high school compared with 65.5% of the national Indian population.’ Only 8%of Northern California Indians had completed a bachelor’s degree compared with 9% of Indians nationwide and 25% of California’s general p~pulation.~ Seventeen percent of the sample’s urban Indians were on welfare and/or unemployed compared with 14% of rural Indians; 3% of urban Indians were retired compared with 9% of rural. Thirty-six percent of both groups were employed full time. Forty-five percent of Northern California Indians were married, which is less than the 64% of Indians nationwide and the 54.7% of the general population in California.’ Compared with the rural sample, urban Indians were found to be significantly less likely to be married (chi-square, P < 0.01) and more likely to be divorced (Fig. 1). CANCER Supplement October 1,1996 I Volume 78 I Number 7 1626 60 50 c 40 C a, z0 a 30 20 10 0 1 nI found for Indians in Northern California (47% of males and 37% of females). Sixty percent of the sample reported having at least one smoker in the household. Urban Indians were more likely to be at the active, “ready to quit in 1 month” and “ready to quit” stage than rural Indians-29% compared with 20%. Twentyfive percent of both groups were contemplating quitting within the next 6 months, and 45% of urban Indians and 55% of rural Indians were at the precontemplative stage or “not interested in quitting.” Married Divorced Widowed Single 1 0Urban IRural 1 (pc0.01) FIGURE 1. Marital status by site. None One to five More than six 1 0Urban I Rural (p<o.0001) FIGURE 2. Number of close relatives Smoking Behaviors Analysis of the smoking behaviors of urban and rural residents showed a significant difference in gender groups; urban Indian males were more likely, statistically, to smoke cigarettes than rural Indian males (57% versus 43%; P < 0.011). There was no corresponding significant difference ( P > 0.05) for American Indian women. Thirty-eight percent of urban Indian women smoked, compared with 37% of rural Indian women. Overall, more of the Indians using urban clinics were smokers than their rural counterparts, 44% compared with 38% ( P > 0.05) (Fig. 2). The national prevalence rate for the general population is 25%.” When comparing the individual urban Indian clinics, we found that two of the four urban sites had extremely high smoking rates. The San Francisco clinic reported that 56% of Indian clients were smokers (59% of males and 50% of females), and San Jose reported 48.5%. This is much higher than the 40% average 1 Knowledge, Attitudes, and Behavior There was little difference between urban and rural participants’ knowledge about the detrimental effects of smoking. As a whole, more than 90% of both groups did not know that using chew was as dangerous as cigarettes, but 95% of urban Indians and 91% of rural Indians knew that, “tobacco whether chewed or smoked can cause cancer.” Also, most respondents knew that smoking while pregnant harms the fetus (94% urban and 91% rural). However, this knowledge of the detrimental effects of smoking had little impact on smoking behavior and attitudes. Although 61% of urban Indians and 62% of rural Indians would “try to avoid sitting next to someone who is smoking” in a restaurant, 73% of urban and 68% of rural would not “ask other people to put out their cigarettes.” Fiftysix percent of both groups would “let visitors smoke cigarettes in their home.” Fifty-two percent of urban Indians and 49% of rural believed it was “Okay to smoke in most places” in their community. Thirtynine percent of urban and 45 percent of rural Indians indicated that “tobacco companies should be allowed to advertise tobacco products.” Social Support Because social support is an important element of a smoking cessation program, the survey examined the types of social organizations to which the participants belonged and the number of their close friends and relatives. Urban Indians consistently reported having fewer friends and relatives on whom they could depend. Sixty-seven percent of rural participants had three or more relatives they regarded as “close,” compared with 58% of urban respondents. Thirty-one percent of rural Indians had 10 or more close relatives, as opposed to 15% of urban (Fig. 2). This difference may be a result of the historical relocation of Indians to urban areas in the early 1950s. Participants from rural areas lived near their immediate families, whereas those in urban sites were more likely to have left their families in distant reservations or locations. When comparing the smokers and nonsmokers in American Indian Smoking ContrastdHodge et al. T.IZBLE 2 "Hassles" ExDerienced During the Past Three Months Problem Urban Rural Being out of work for a month or longer' Haiing a serious illness or accident Not having enough money for food, clothing, housing, or other necessities of life" Being concerned about getting credit Having a problem with getting things repaired around the house' Having a check late or lost in the mail' Having something stolen or having the house or car broken into" Having a violent argument with a friend or relative Having some kind of trouble with family members Fleing concerned about living in an unsafe aread 54% 33% 51% 34% 49% 30% 44% 30% 31% 32% 38% 26% 29% 33% 4i% 41% 19% 31% 44% 23% both groups, there was little difference in the type and amount of social support. A significant difference was found between urban and rural Indians with respect to the number of problems experienced during the previous 3 months (Table 2). Forty-one percent of urban respondents were concerned about living in an unsafe area versus only 23% of rural. Twenty-nine percent of urban Indians had had their house robbed or car stolen in the previous 3 months compared with 19% of rural. Indians also reported other problems such as monetary problems (49% of urban and 44% of rural), problems getting repairs around the house (31% of urban and 38% of rural), and difficulties getting paychecks or other income (32% of urban and 26% of rural). CONCLUSIONS This study is significant for planning and developing policy for smoking cessation programs as well as for developing social support programs. For example, American Indians often move from rural areas to the major urban sites and then back again; they also relocate from other states. As a consequence, the tribal composition of California's Indian population is quite varied. Also, urban Indians tend to live dispersed within the larger population, rather than clustered together in homogeneous neighborhoods like many other ethnic and racial groups. Because the Indian community is not located in one part of the city, it is difficult to target intervention. However, urban Indians are often linked by a strong network of service organizations that provide medical and social aid to 1627 adults and children and that facilitate contact and ongoing communication. Effective smoking cessation programs must make use of this network. Also, programs should recognize the difference in living conditions between urban and rural sites. Life in large metropolitan areas is more often bleak and stressful. Almost half of urban Indians in our sample (49%) did not have enough money for food, clothing, housing, or other necessities of life (P < 0.087). They also reported more fears about the safety of their neighborhoods and having been the victims of theft more frequently than Indians living in a rural areas ( P < 0.0001). Beyond that, urban Indians were more likely to be unemployed (P > 0.051, 54% having been out of work for 1 month or longer in the previous 3 months. On the other hand, urban Indians were generally better educated. This is probably because large universities and colleges are usually located in the cities, attracting American Indian students seeking higher education. However, when controlling for education, unemployment in the urban and rural sites showed no differences except for those who had trade/ vocational schooling; this showed that the urban sites had less unemployment than the rural sites ( P < 0.02). In addition to these contrasts, the difference in urban and rural attitudes toward quitting smoking is significant when considering what antismoking programs should emphasize. Although the clients of urban clinics had higher smoking rates, these smokers were more willing to stop, perhaps because the message of the antismoking movement is stronger in cities than in rural settings. Because urban Indians, as a group, are beyond the precontemplative stage, urban programs should emphasize cessation strategies. Rural programs should aim at increasing awareness and motivation. Any tobacco control program within the American Indian community will be successful and accepted only if tailored to the population. This requires designing strategies that take account of the demographic characteristics, the specific patterns of tobacco use and abuse, the community's attitude of tolerance toward smoking, and the sources of both stress and support in rural and urban settings. REFERENCES 1. American Indians and Alaska Native areas: 1990 census. Washington, DC: Racial Statistics Branch, Population Division, Bureau of the Census, 1991:June. 2. Hodge F. Analysis of American Indian health care needs in northern California. Report to the Sierra Foundation. University of California, Berkeley. May 8, 1989. 3. Health status and health care needs of American Indians in California. Report to Congress on Indian Health Service. Public Law 100-713 (Section 709), November 1991. 4. Passel JS, Berman PA. Quality of 1980 census data for American Indians. Soc Biol 1986;33(3-4):163-82. 1628 CANCER Supplement October 1, 1996 / Volume 78 / Number 7 Passel IS. Provisional evaluation of the 1970 census count of American Indians. Demography 1976; 13(3):397-409. 6. Alonso W, Starr P, editors. The politics of numbers. New York: Russell Sage Foundation, 1987:187-233. 7. Lob0 S. American Indian community in a multi-tribal setting. Presented at the American Anthropological Association meeting, New Orleans, December 1990. a. 1993 Regional differences in Indian health. Indian Health Service, U.S. DHHS, PHS, IHS, Office of Planning, Evaluation, and Legislation, Division of Program Statistics. 9. Toward a tobacco-free California master plan. Submitted to the California State Legislature by the Tobacco Education Oversight Committee, January 1, 1991, page 57. 5. 10. Hodge F, Cuinmings S, Fredericks L, Kipnis P, Williams M, Teehee K. Prevalence of smoking among adult American Indian clinic users in Northern California. Prev Med 1995;24:441-6. 11. Tobacco use in California, 1990: a preliminary report documenting the decline of tobacco use. University of California, San Diego, and California Department of Health Services, San Diego, California. 12. Centers for Disease Control and Prevention. MMWR 43(19), May 20, 1994. 13. Prochaska J, Diclemente C, Velicer W, Zwick W. Measuring processes of change. Presented at the annual meeting of the International Council of Psychologists, Los Angeles, August 1981.