TOBACCO WHERE YOU LIVE: 

Native Communities
ACKNOWLEDGEMENTS

This brief was produced for the Centers for Disease Control and Prevention by 

the Center for Public Health Systems Science at the Brown School at Washington 

University in St. Louis. 

Primary contributors:

Rebecca Ballard, Stephanie Andersen, Laura Brossart, Amy Endrizal, Rachel Hackett, Chase Bryer 

(Chickasaw), Zara Petković, Douglas Luke

Input was provided by:

René Arrazola, Brian Armour, Kyla Beard (Ho-Chunk), Sarah Brokenleg (Sičáŋğu Lakota Oyate), Daniel 

Brown (Ho-Chunk), Elliot Christenson (Lower Sioux), Karen Conner, David Espey, Kya Grooms, Joshua 

Hudson (Ojibwe), Natasha Buchanan Lunsford, Michon Mabry, Deborah Houston McCall, Tammi 

Meissner (Tlingit; Naanyaa.aayi and Deisheetan clans), Ryan Sheahan, Karla Sneegas, Kellie Thompson 

(Seneca), Missy Tracy (Ho-Chunk), CoCo Villaluz (Hidatsa, Assiniboine, Chamorro), Renee Wright

Other contributions:

Photos on page 5 courtesy of UCSF Richard W. Pollay Cigarette Ads Collection

Photos on page 11 courtesy of Great Plains Tribal Leaders Health Board

Photo on page 14 courtesy of Chickasaw Nation Medical Center

Photo on page 22 courtesy of Clearway Minnesota

Photo on page 23 courtesy of Elliot Christensen, Lower Sioux Nation

Photo on page 24 courtesy of Ho-Chunk Gaming Madison

Cover photo: 

Pattern Red, Orange, White, Green, Black, and Blue Diamond Blanket/Rug—Diné (Navajo) Artist, made 

about 1885 of cotton and wool.

Suggested citation:

Centers for Disease Control and Prevention. Tobacco Where You Live: Native Communities. Atlanta, GA: 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2022.
TABLE OF CONTENTS

OVERVIEW........................................................................... 1

Read about the Tobacco Where You Live series, what you’ll find in this brief, and 

how it fits in with the Best Practices User Guides. 

MAKE THE CASE .................................................................... 2

Understand why a culturally focused approach is important to reduce 

commercial tobacco use disparities among American Indian and Alaska Native 

people. 

LEARN THE BASICS ................................................................ 3

Learn about characteristics of Native people, including where they live, 

governing structures, and patterns of commercial and traditional tobacco use.

GET READY .......................................................................... 6

Prepare to work with Native partners by building relationships and learning 

about Native communities.

TAKE ACTION ..................................................................... 11

Learn how to create commercial tobacco prevention and cessation strategies 

that resonate with Native communities.

EXPLORE COMMUNITY EXAMPLES ........................................... 23

Read about how the Lower Sioux and Ho-Chunk nations worked with state and 

local partners to reduce commercial tobacco use.

REFERENCES ...................................................................... 25
Tobacco Where You Live I NATIVE COMMUNITIES 1

OVERVIEW

Tobacco Where You Live

Clear evidence exists about what works to reduce commercial tobacco use at 

the population level.1 Yet, many states and communities across the country have 

not implemented effective strategies.2,3,4 Groups disproportionately impacted 

by tobacco industry targeting and social determinants of health continue to 

experience high rates of tobacco-related disease and death.5 Understanding 

community needs and using community-driven solutions can inform how to 

move toward closing these gaps in commercial tobacco prevention and control. 

The goal of Tobacco Where You Live is to empower tobacco control program 

managers, staff, and partners to understand how commercial tobacco use varies 

within their communities, overcome challenges, and reduce disparities. Each 

Tobacco Where You Live brief will cover a topic important to reduce commercial 

tobacco use in communities with the highest prevalence.

When this guide references commercial tobacco or tobacco products, it refers 

to products that are mass-produced and sold for profit. This is separate from the 

sacred and traditional use of tobacco by some American Indian communities.

In This Resource

The Native Communities brief focuses on how to reduce commercial tobacco use 

disparities among American Indian and Alaska Native (AI/AN) populations. This 

brief provides information to help you: 

 Develop strong relationships with Native leaders and members 

 Communicate the harms of commercial tobacco and respect the use of 

traditional tobacco 

 Work with tribes to tailor strategies to reflect their unique cultures, capacities, 

and challenges 

In this brief, use of the term Native applies to both American Indian and Alaska 

Native people, unless otherwise indicated.

About the Project

Tobacco Where You Live is a Best Practices User Guide resource. The Center for 

Public Health Systems Science at Washington University in St. Louis is 

developing a set of resources to translate research into practical guidance for 

states and communities. These resources expand on the evidence-based 

guidelines and funding recommendations in Centers for Disease Control and 

Prevention’s (CDC) Best Practices for Comprehensive Tobacco Control 

Programs—2014 (Best Practices 2014).6

The Best Practices User Guides project is funded 

by CDC contract 75D30120C09195. Its contents 

are solely the responsibility of the authors and 

do not necessarily represent the official views of 

CDC. References to non-CDC sites and the use 

of advertisements and images do not constitute 

or imply endorsement of these organizations or 

their programs by CDC or the U.S. Department 

of Health and Human Services. CDC is not 

responsible for the content of pages found at 

external sites. URL addresses listed were current 

as of the date of publication.
Tobacco Where You Live I NATIVE COMMUNITIES 2

MAKE THE CASE

As of 2019, nearly 30% of American Indian and 

Alaska Native (referred to collectively as Native 

in this guide) people used commercial tobacco, 

the highest commercial tobacco use rate of 

all U.S. racial and ethnic groups.

7

 Native adults 

also have the highest rates of heart disease, 

cancer, and stroke.8 Research has shown that 

Native youth also start smoking earlier than 

non-Native youth.8

Strategies leading to declines in commercial 

tobacco use overall have not worked for 

or been equitably implemented in Native 

communities.8

 Finding more effective ways to 

reduce commercial tobacco use among Native 

populations can help narrow resulting disparities. 

A culturally focused approach to commercial 

tobacco use prevention and cessation is 

important because:

 No two tribes are alike. 

Native populations have diverse traditions, beliefs, languages, and histories. 

Commercial tobacco use varies among Native populations.9 Respecting the 

individual sovereignty of tribes and investing time to understand a tribe’s 

unique history, commercial tobacco use patterns, and cultural practices can 

build community trust and help communicate effective commercial tobacco 

use prevention strategies. 

 Prevention and cessation strategies often overlook the role of traditional 

tobacco.

Traditional tobacco has been an important part of many tribes’ healing rituals, 

spiritual ceremonies, and celebrations for thousands of years.10 Honoring 

sacred tobacco use is essential in the face of generations of losses to Native 

lives, land, and culture as a result of colonization.11

 Native communities often lack funding and access to resources.

Native health resources, including commercial tobacco prevention and 

cessation programs, are severely underfunded.12 Native people often lack 

health insurance and live in geographically isolated ares. As a result, it is harder 

for them to access health resources.13

 Tribal sovereignty can support innovative approaches.

Federally recognized tribes are not subject to state regulation. Tribal nations 

are sovereign and have the authority to craft their own innovative commercial 

tobacco use prevention policies. Building strong partnerships with tribal 

governments can support this work.

In 2019, smoking rates among Native adults were the 

highest of all racial and ethnic groups

Source: Cornelius et al. MMWR; 20207
Tobacco Where You Live I NATIVE COMMUNITIES 3

LEARN THE BASICS

More than five million American Indian and Alaska Native (AI/AN) people live in 

the U.S.14 There are 574 federally recognized and more than 60 state-recognized 

tribes, each with their own traditions, beliefs, language, and history.15 Different 

tribes and individuals may prefer other terms such as Native, Native American, 

First Nations, Indigenous, American Indian, Alaska Native, Aboriginal, or their 

specific tribe’s name.12

Over 70% of Native people today live outside tribal lands.

16 Most of these tribal 

members live in urban areas.15 About 40% of Native people living on nontribal 

lands smoke cigarettes, compared with less than 30% of Native people who live 

on tribal lands.17 Native people living on nontribal lands are more likely to use 

commercial tobacco every day.17 The cultural connections and social support 

available on tribal lands may protect people who live there from harmful 

behaviors like commercial tobacco use.13

What Is Traditional Tobacco?

American Indian people have been using tobacco for sacred spiritual, 

ceremonial, and medicinal purposes for thousands of years.10 They prepare 

leaves and bark from a variety of plants, including native tobacco species, as part 

of their cultural practices. Most Alaska Native people do not have a tradition of 

ceremonial tobacco use.9

Traditional tobacco differs from commercial tobacco.18 It is:

 Used for sacred purposes rather than recreationally19

 Rarely inhaled into the lungs18

 Gathered or grown locally19

Early European settlers brought commercial tobacco, Nicotiana tabacum, from 

the Caribbean to North America. They traded it as they moved West, especially 

with tribes in the Northern Plains.20

Many tribes of the Upper Plains and Great 

Lakes use Kinnikinnick as a tobacco substitute, 

a mixture of leaves and bark from red willow, 

bearberry, and other plants, in ceremonies and 

as medicine

Most American Indian 

and Alaska Native 

people live outside 

tribal lands, in urban 

areas.

U.S. colonization and federal laws caused historical trauma for Native people, 

including loss of life, land, language, and customs.21,22 The Indian Religious Crimes 

Code of 1883 outlawed cultural and religious practices, including the use of 

traditional tobacco. Prohibitions on traditional tobacco and other Native cultural 

practices remained until the passage of the American Indian Religious Freedom 

Act in 1978.

Commercial Tobacco Use

The outlaw of Native cultural practices led many Native communities to use 

dangerous commercial tobacco in their ceremonies. This helped them continue 

to practice their traditions and keep their cultural practices alive in the face of 
Tobacco Where You Live I NATIVE COMMUNITIES 4

restrictions.23 When the tobacco industry discovered that Native communities 

were using commercial tobacco in traditional ceremonies, it soon found a new 

way to make a profit.20 Industry tactics like coupons, pricing, and promotions 

lower the price of cigarettes and increase smoking.24 E-cigarette use has also 

become popular among Native populations.25 The industry has intentionally 

marketed e-cigarettes to Native people.26

W H AT I S I Q M I K ? 

Most Alaska Native people do not use ceremonial tobacco, but some use a 

form of smokeless tobacco called iqmik (also called blackbull) that is unique 

to Alaska.27 Iqmik is made by burning a fungus found in birch tree bark, then 

combining the ash with cut-up commercial tobacco.28

Like other smokeless tobacco, iqmik contains nicotine and increases the risks of 

gum disease and oral cancer.27 But iqmik is even more potent and addictive 

than commercial smokeless tobacco because the alkaline ash helps the nicotine 

be absorbed through the mouth more quickly.28 In remote villages of Alaska, 

even some young children use iqmik.

27 Adapting strategies to include iqmik can 

help encourage commercial tobacco cessation and prevention.27

Polypore mushroom (Phellinus igniarius) used in making iqmik. Source: zen under Creative 

Commons license CC BY-NC-SA 2.0

KEY RESOURCES

FastStats: Health of American Indian 

or Alaska Native Population (CDC)

Health statistics on AI/AN population, 

including using commercial tobacco

Traditional vs. Commercial Tobacco

(National Native Network)

Descriptions of traditional and 

commercial tobacco, with links 

to related topics such as tobacco 

industry marketing

LEARN THE BASICS 
Tobacco Where You Live I NATIVE COMMUNITIES 5

Commercial Tobacco Marketing

The tobacco industry has aggressively marketed its products to Native 

communities for decades.24 E-cigarette manufacturers have also targeted tribal 

communities with product promotions and price discounts.29 The tobacco 

industry’s marketing tactics for Native populations include:

 Misuse of Native imagery, symbols, and cultural pride messages24

 Donations to and sponsorship of Native causes and AI/AN-serving 

organizations24

 Price promotions and discounts on tobacco products sold on tribal lands30

 Advertisements and promotions for tobacco products at powwows and 

other tribal events24

 Meetings with Native leaders with the goal of weakening commercial 

tobacco control efforts24

The tobacco industry has used Native cultural imagery to promote their products since the 1930s. Left to right: Coupon Mild cigarette package; Natural 

American Spirit cigarette ad; Old Gold ad, P. Lorillard (1949); Velvet cigarette ad, Liggett (1939). Source: UCSF Industry Documents Library

Reducing Commercial Tobacco Use

Federally recognized tribes are self-governing, or sovereign.

31 Each tribal nation 

has its own constitution and laws. Tribal nations are subject to federal but not 

state regulations. 

State and local tobacco laws such as taxes and retailer licenses typically do not 

apply to retailers on tribal lands. Because of this, they can sell commercial tobacco 

at lower prices and are exempt from smokefree laws. 

Tribal sovereignty also gives tribes the opportunity to craft commercial tobacco 

control regulations that meet their needs and reflect their culture.

LEARN THE BASICS 
Tobacco Where You Live I NATIVE COMMUNITIES 6

GET READY

Understanding tribal culture is key to working effectively with tribal communities 

on commercial tobacco prevention and cessation. Building strong relationships, 

creating shared goals, and learning about local Native communities are essential 

first steps.

Build Relationships

Unethical treatment by non-Native people has led to a deep distrust in some Native 

communities.32 Building relationships with Native leaders can help earn trust to most 

effectively support the tribe’s commercial tobacco prevention goals.

Tribal leaders know their community’s strengths and weaknesses best.33 Many 

people could be leaders in the community, including elders, tribal health 

coordinators, tribal councilors, and spiritual leaders.

Working closely with urban AI/AN health organizations can help programs meet 

the unique challenges that Native people face.34

To identify leaders, begin with connections you already have.35 For example, ask 

Native organizations or clinics in your community to help identify leaders. 

I N D I G E N O U S WAYS O F 

K N O W I N G 

Integrating scientific evidence with practice-based evidence, local context 

and lived experiences can help in adapting innovative commercial tobacco 

use strategies that resonate with Native communities.36,37 Scientific research is 

rooted in the Western tradition of systematically collecting information to test 

hypotheses. Indigenous ways of knowing are based on lived experiences and 

observations from an early age.36 Non-native people and groups have often 

assumed that Indigenous knowledge is less important than Western scientific 

knowledge.38 But valuing Indigenous ways of knowing is key to meaningful 

partnerships with Native communities.

Every tribe has its own knowledge tradition—there is no single Indigenous way 

of knowing.36 Traditional Native knowledge is grounded in relationships and 

often passed generationally through stories and oral histories.39 Encouraging 

dialogue and relationship-building, with interview methods like focus groups 

and talking circles, can engage Native participants and identify areas of 

traditional knowledge.39

KEY RESOURCES

National Native Network (NNN) 

A federal network of tribes, tribal 

organizations and other health 

programs dedicated to supporting 

and improving Native health. NNN 

offers technical assistance and 

culturally relevant resources to 

decrease commercial tobacco use 

and cancer rates.

Tribal Epidemiology Centers

Organizations funded by the Indian 

Health Service that monitor tribal 

health issues and train community 

members to address them. The 

Centers also connect tribes to learn 

from each other and work together to 

address health problems. 

Tribal Public Health Resource Table 

(Network for Public Health Law)

List of organizations with experience 

in tribal and public health law, 

including epidemiology centers and 

academic, nonprofit/public, and legal 

service organizations
Tobacco Where You Live I NATIVE COMMUNITIES 7

Once you have connected with leaders, maintain regular communication. 

Ongoing engagement respects tribal sovereignty by sharing information and 

responsibility for decision making.40

GET READY

 TRIBAL PARTNER ROLES IN COMMERCIAL TOBACCO PREVENTION

Partner Examples Role Helpful Resources

Businesses 

serving Native 

communities

• Businesses on or near 

Native lands

• Businesses owned or 

operated by Native people

• Make businesses smokefree

• Post information about cessation services

• Provide cessation services to employees

• American Nonsmokers’ Rights 

Foundation

• FDA’s Engagement with AI/AN 

Tribal Governments web page

Commercial 

tobacco control 

programs

• Local programs

• State programs

• Collect, analyze and disseminate data

• Provide training and technical assistance

• Strategically plan commercial tobacco control 

strategies

• City of Milwaukee Health 

Department

• Minnesota Department of 

Health

Communications 

professionals

• Health communications 

specialists 

• Local journalists, radio hosts, 

and other media actors

• Develop media campaigns promoting 

traditional tobacco and discouraging 

commercial tobacco use and exposing industry 

targeting

• Promote available cessation services

• Native Public Media

• Indian Country Today

• Native American Journalists 

Association

• National Native News

Community 

members

• Native youth 

• Other members of the 

community

• Educate about the benefits of smokefree places

• Talk to retailers about the harms of tobacco 

marketing and sales, especially for youth

• Center for Native American 

Youth

Elders and spiritual 

leaders

• Tribal members recognized 

for cultural knowledge and 

wisdom

• Develop definition of traditional tobacco 

• Share teachings promoting traditional tobacco 

and discouraging commercial tobacco use

• Culture Card: A Guide to Build 

Cultural Awareness

Health 

professionals

• Tribal health board members

• Healthcare providers 

and staff

• Create smokefree tribal health settings

• Make health systems changes to integrate 

cessation into tribal health settings

• Align cessation with other health programs

• CDC’s Tribe and Indian 

Organizations web page

• Association of American 

Indian Physicians

• Indian Health Service

Organizations 

serving tribal 

communities

• Community organizations 

and groups 

• Cultural centers

• Give insight on feasibility of strategies

• Collect tribal-specific health data

• Design media campaigns for Native audiences

• Provide cessation resources for Native people

• American Indian Cancer 

Foundation

• National Native Network

• Tribal Epidemiology Centers

Technical 

assistance 

providers

• State tobacco control staff

• Public health experts

• Train community members how to implement 

commercial tobacco prevention strategies

• Help collect surveillance and evaluation data

• Native Wellness Institute

• SAMHSA Tribal Training and 

Technical Assistance Center

Tribal officials • Tribal president, governor, 

chief, councilors, or chair

• Tribal education, legal, and 

health department officials

• Build support

• Monitor tobacco product sales 

• Allocate resources 

• Enact commercial tobacco use policies 

• CDC’s Tribal Advisory 

Committee

• Tribal Leaders Directory

Tribal regulatory 

agencies and law 

enforcement

• Gaming, financial, and 

environmental authorities

• Tribal police

• Help define commercial tobacco restrictions

• Inform enforcement approaches

• Enforce smokefree and commercial tobacco 

retail restrictions

• The National Indian Gaming 

Commission

• The National Native American 

Law Enforcement Association
Tobacco Where You Live I NATIVE COMMUNITIES 8

Create Shared Goals 

Shared goals are important to work together effectively, maintain community buyin, and respect the community’s expressed priorities. Tribal community members 

and partners can play different roles to advance shared goals. 

Create shared goals through consensus-based decision making. In this type of 

decision making, discussion continues until everyone’s most important needs are 

met. Parts of the agreed-upon decision may not be ideal for each participant, but 

they can live with the outcome and will support the decision. Consensus-building 

helps everyone get on board and have a chance to participate.

Make sure everyone agrees on the expected outcomes of the work, what 

the work will look like, and why it is important.41 Understanding goals helps 

community leaders who may not have experience in commercial tobacco 

control make informed decisions. 

Work with tribal leaders to create a plan to carry out the work. A work plan

engages participants and builds support for your new partnership.41

Respect Native Culture

Act with humility and integrity in your interactions with tribal members. Familiarize 

yourself with their values and culture, understanding that their priorities and 

timelines may differ from yours.36 Remember that you are there to learn from them 

as much as they are to learn from you. Don’t come in as an “expert.”32

Learn about Native protocol, such as codes of conduct or expectations for nonNative partners, and respectfully follow them.42 For example, some tribes consider 

offerings of sweet grass or sage a sign of respect when forming partnerships.40

WHAT IS CULTUR AL HUMILIT Y?

Our experiences and culture influence how we think and act. Cultural humility is 

an ongoing process of self-reflection and learning about others’ culture to foster 

respectful attitudes, actions, and policies.43 This process includes:

• Reflecting on your own beliefs and assumptions35

• Learning about tribes’ current and historical social norms, governance, and 

language, including practices from before forced removal by settlers43

• Understanding tribal histories which can provide insight into the relationship 

between states and tribes43

Use tools to help you and your staff assess your biases, privileges, and 

perspectives.

32,44 Anti-bias training can complement other tools and cultural 

humility practices.

32,45

Source: Artem Beliaikin from Pexels

M A K E A W O R K P L A N 

Creating a work plan can help make 

sure everyone understands: 

• The roles and responsibilities of 

your staff and the tribal leaders42

• The scope of the work you are 

proposing41

• What will be done with data and 

personal information41

• The Native norms and values that 

will guide the work39

GET READY
Tobacco Where You Live I NATIVE COMMUNITIES 9

Be mindful of language you use. Avoid language that disregards tribal 

sovereignty, or that could be associated with historical trauma.11 Avoid terms and 

phrases like: 

 “We’re helping you”36

 “Property”46

 “Ownership”46

 “Control”11

For example, the term “tobacco control” can imply restrictions on traditional 

tobacco.11 Instead, use “prevention and cessation” and specify commercial tobacco 

to emphasize health goals while respecting traditional tobacco use.

Attend tribal social events, like open powwows and community celebrations, 

when you have been invited to do so. Being present helps you learn more about the 

community and helps community members understand who you are.39 It shows you 

have an investment in the tribe beyond your own personal gain and work.32

Learn about Local Native Communities

Understanding the local Native community while practicing cultural humility will 

help commercial tobacco control tribal partnerships accomplish their goals.47

Learn which tribes inhabit the land you occupy.48 Native populations vary in 

geographic location, government, language, customs, and commercial tobacco 

use. Each tribe has its own strengths and capacity to carry out commercial tobacco 

control strategies. Some may benefit from tobacco education, while others may 

already have comprehensive regulations in place. 

GET READY

Tribes vary in 

governance, 

language, customs, 

and tobacco use.

KEY RESOURCES

Cultural Humility: Essential 

Foundation for Clinical Researchers 

(Yeager et al.) 

The role of cultural humility in 

research

Culture Card: A Guide to Build 

Awareness—American Indians 

and Alaska Natives (Tribal Nations, 

Montana) 

Information on tribal communities 

and culture to provide general 

information to non-Native people 

In a Good Way: Indigenous 

Commercial Tobacco Control 

Practices (ClearWay Minnesota et al.) 

Strategies to reduce commercial 

tobacco use in AI/AN communities

Self Assessments (National Center 

for Cultural Competence) 

Online and PDF assessments to 

facilitate self-reflection and develop 

cultural awareness

CONDUCT A COMMUNITY ASSESSMENT 

Ask permission from tribal leaders to conduct a community assessment before 

beginning any assessment efforts. Taking care to collect and use accurate, tribalspecific data can improve and better inform commercial tobacco prevention and 
Tobacco Where You Live I NATIVE COMMUNITIES 10

cessation efforts.8 Information about one tribe is not representative of another. 

Conducting a community assessment in collaboration with the local tribe will 

help you understand their needs and find solutions. Work directly with Native 

communities to understand:49

 Existing resources and needs 

 Commercial and traditional tobacco use 

 Perspectives and attitudes toward tobacco use 

 Concerns and priorities

Community assessment methods are summarized below. Ask tribal leaders and 

community members to review questions for cultural appropriateness and help 

assess findings.50

 COMMUNITY ASSESSMENT METHODS

Method Description Good for Examples Information to collect

Oral histories Traditional way for 

tribal members to share 

information that may be 

better received than surveys

Learning about 

experiences and 

perspectives 

through 

reflective 

dialogue

• Storytelling

• Talking circles51

• Focus groups

• Interviews

• Information “beyond the numbers,” such 

as experiences and practices

• Perspectives on community needs and 

strengths

• Personal experiences with tobacco

Surveys Set of standardized questions 

that provide a profile 

of a community; can be 

adapted to reflect cultural 

characteristics

Understanding 

community 

characteristics, 

concerns, and 

priorities

• Alaska Native Adult 

Tobacco Survey 

Guidance Manual (CDC)

• American Indian Adult 

Tobacco Survey (CDC)

• Tribal BRFSS Toolkit

(National Native 

Network) 

• Demographics

• Perceptions and use of commercial and 

traditional tobacco use

• Willingness to quit commercial tobacco

• Policies in place to reduce commercial 

tobacco use

• Prevention and cessation services 

available in the community

Observations Visual method to better 

understand the local tobacco 

use environment; often 

conducted by community 

members themselves

Capturing 

experiences 

of people in 

their own 

communities

• Photovoice52

• Walking Tobacco Audit

(Counter Tobacco)

• STARS (Counter Tools)

• Tobacco product marketing and 

promotion

• Smokefree environments and nosmoking signs

• Locations of ashtrays or cigarette disposal 

bins

PROTECT TRIBAL DATA OWNERSHIP 

Non-Native researchers have exploited Native people by collecting their data 

without providing meaningful exchange of information.32 To protect their 

information and to ensure that states meet their obligations to respect tribal 

sovereignty, many tribes have created data sharing agreements.

50,53

Data sharing agreements describe how data will be used, where it will be shared, 

and who owns the data. They also help overcome privacy concerns and ensure 

research benefits the tribe.50

GET READY
Tobacco Where You Live I NATIVE COMMUNITIES 11

TAKE ACTION

The best approach to support commercial tobacco prevention strategies will 

be different for each American Indian/Alaska Native (AI/AN) community. Tribal 

members know what works in their community and are central to developing 

effective programs and policies. A key first step for state programs is building 

relationships with tribes. States can then meaningfully work with tribes to 

implement strategies that are community-driven, culturally specific, and 

tailored to local context. 

To support tribal commercial tobacco prevention efforts, share best practices with 

Native communities while encouraging flexibility to adapt strategies to their local 

environment.54

Focus on working with tribes to:

 Promote smokefree Native communities

 Build awareness of the impact of tobacco products in retail stores

 Support efforts to increase commercial tobacco prices

 Increase commercial tobacco cessation in Native communities

 Communicate with Native audiences about commercial tobacco use

 Monitor and evaluate commercial tobacco use, prevention and cessation 

activities, risk factors, and outcomes in Native communities 

Flexible funding enables tribes to drive the direction of commercial tobacco 

control work based on their unique needs. Learn more about how Minnesota 

provides flexible grants for tribes to reduce commercial tobacco use in culturally 

appropriate ways on page 23. 

Signs that say No Smoking in the Dakota 

language featuring art by local artists. Source: 

Great Plains Tribal Leaders Health Board website

Promote Smokefree Native Communities 

Many Native communities are passing smokefree laws for government buildings, 

workplaces, elder housing, casinos, powwows, and foster homes. For example, 

in November 2021, the Navajo Nation passed an act banning use of tobacco 

products indoors and within 25 feet of all indoor areas.55 But most tribes still do 

not have comprehensive smokefree laws.11

Building community support and addressing concerns early is critical to create 

smokefree Native communities.56 Tribes and partners can: 

 Poll community members about smokefree environments. The Sault Ste. 

Marie Tribe conducted a survey that showed that 70% of tribal housing 

residents preferred smokefree homes.57

 Address economic concerns by talking to tribal gaming officials about the 

dangers of commercial tobacco and developing a business case for smokefree 

environments.58

Tribal members know 

what works in their 

communities. 
Tobacco Where You Live I NATIVE COMMUNITIES 12

 Distinguish traditional from commercial tobacco and make clear that 

restricting commercial tobacco use can help promote sacred tobacco. Elders 

can develop a definition of traditional tobacco.59

Engaging the community in creating smokefree environments can help develop a 

policy that is easier to enforce.60 Continuing to share information with the public 

after the changes go into effect can further increase the community’s comfort 

with a new policy.60

To raise awareness about new smokefree laws, ask the tribe what 

communications strategies work best for their community. State and local 

tobacco control staff can help develop tailored educational materials such as: 

 Smokefree signage

 Fact sheets with tribal-specific data to support key talking points56

 Mass media campaigns to promote available commercial tobacco cessation 

services, such as the National Native Network’s media resources61

KEY RESOURCES

Commercial Tobacco Smoke-Free 

Tribal Policy Toolkit (National Native 

Network)

Information and tools for 

implementing smokefree policy in 

tribal communities 

Media Campaign Resource 

Center (CDC)

Hub of media resources, including 

existing smokefree campaigns and 

other tribal specific materials, that 

can be purchased and edited to fit 

local context

S M O K E F R E E C A S I N O S 

Although many states have smokefree policies for public places, these laws don’t 

apply to casinos on tribal lands.

62 Secondhand smoke exposure remains a threat to 

casino visitors and employees, many of whom belong to tribal communities.63

Creating smokefree environments in casinos can actually attract more casino 

visitors and revenue.

63,64 In a study of a Midwestern tribal casino, three times as 

many casino patrons reported that they would visit more often with a smokefree 

policy than without (54% versus 18%).63

Voluntary smokefree policies can help create a healthier environment for 

customers, employees, and the wider tribal community.65 Learn how Ho-Chunk 

Gaming Madison became Wisconsin’s first 100% smokefree tribal casino on 

page 24.

Reduce Tobacco Industry Influence in 

Native Retail

Tobacco products, promotions, and advertising are highly visible in and around 

many Native communities.8 The tobacco industry has used inequitable practices 

in Native communities by aggressively marketing cigarettes, sold at deep 

discounts, on tribal lands.24 Products sold on these lands are exempt from state 

taxes in many states.24

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 13

As sovereign nations, tribes can take action to reduce tobacco industry influence 

in retail stores, including:30

 Restricting price promotions and advertising

 Limiting retailers near schools through licensing and zoning

 Restricting flavored products (including menthol)

 Raising the minimum age for tobacco sales to 21

In December 2019, the federal Tobacco 21 law raised the legal age for tobacco 

product sales from 18 to 21. Because it is a federal law, it applies to tribal nations 

within the United States. Tribal governments can also pass or strengthen their own 

tribal laws with a higher minimum age or stricter enforcement requirements.66

Several states also have laws regulating commercial tobacco sales on tribal lands.67

To help plan retail strategies and increase awareness of tobacco industry tactics 

in Native communities, first collect information on tobacco product availability 

and marketing in tribal stores.30 Ask tribal leaders permission before collecting 

any data. States can work with tribes to map the locations of stores and adapt 

store assessment tools, such as the Standardized Tobacco Assessment for Retail 

Settings (STARS), for local use.68

T R I B E S TA K E AC T I O N TO R E D U C E 

E-CIGARETTE USE

 In 2019, tribes acted in response to lung injury outbreaks and the marketing of JUUL devices 

on reservations with Tobacco 21 policies and e-cigarette restrictions:69

• The Lac Courte Oreilles Tribe and Oglala Sioux Tribe permanently banned the sale and 

use of e-cigarettes. 

• The Turtle Mountain Band of Chippewa Tribe banned the sale of e-cigarettes but will 

permit use.

• The Muckleshoot Tribe and Saint Regis Mohawk Tribe permanently banned the sale of 

flavored e-cigarettes and increased the minimum purchase age for vaping products to 21. 

The Muckleshoot tribe also restricted the sale of all tobacco products to those who are 21 

or older.

• The Iipay Nation of Santa Ysabel and Puyallup Tribe temporarily suspended sales of 

certain e-cigarettes.

Source: CDC

KEY RESOURCES

Cigarette and E-cigarette Retail 

Marketing on and Near California 

Tribal Lands (Begay et al.)

The availability and promotion 

of tobacco products on and near 

tribal lands

Point-of-Sale Strategies: A Tobacco 

Control Guide (Center for Public 

Health Systems Science)

Strategies to limit the sale, display, 

and advertising of tobacco products 

in the retail environment 

Store Assessment Tools (Counter 

Tobacco)

Tools to assess tobacco retail settings

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 14

Support Tribal Efforts to Increase 

Tobacco Prices

Raising tobacco product prices reduces commercial tobacco use, especially 

among price-sensitive youth.2 Non-Native people who visit tribal reservations 

often do so to buy cheaper, tax-free tobacco products.20 Tribes can align prices for 

tobacco products on tribal lands with state sales prices by:

 Raising tribal taxes on tobacco products

 Setting a minimum price for tobacco products

 Limiting price promotions and discounting

 Applying state pricing laws to products sold on tribal lands

Some states have entered into special agreements in which the tribe agrees 

to collect state tobacco taxes on all tobacco product sales on reservations. In 

exchange, the tribes may keep the tax revenue.47

Tax revenue generated from tobacco product sales can help sustain commercial 

tobacco control efforts. For example, the Sault Ste. Marie Tribe of Chippewa 

Indians in Michigan increased their cigarette tax by $0.25 to $2.50 per carton. 

They used the additional revenue to fund youth health education and cessation 

medications for tribal members.8

Increase Cessation in Native 

Communities 

Many Native people who use commercial tobacco want to quit but have less 

success quitting than non-Native people in the U.S.2 They often face challenges 

that make it harder to quit, such as: 

 Geographic isolation70

 Limited access to technology70

 Cross-cultural communication barriers70

 Mistrust of healthcare professionals71

 Being underinsured or uninsured13

 Limited access to adequate cessation services13

Native people are also less likely to get advice to quit from a healthcare provider 

or be aware of treatment options.13,72

Tribes can use three key cessation approaches to reduce commercial tobacco use 

among their members, tailoring strategies to their own communities:73

 Promote health systems change to integrate commercial tobacco use 

treatment into routine clinical care 

 Improve insurance coverage for evidence-based cessation treatment

 Connect tribal members to state tobacco quitlines

T R I B A L H O S P I TA L 

S U P P O R TS Q U I T L I N E 

REFERRAL

Chickasaw Nation Medical Center in 

Oklahoma became the first tribal 

hospital in the U.S. to implement a 

bi-directional quitline referral.74 The 

hospital worked with the Hospitals 

Helping Patients Quit initiative to 

create the system so providers can 

refer patients to the quitline and 

receive information back to follow up 

with patients.75

Source: Chickasaw Nation Medical Center 

TAKE ACTION

Non-Native people 

who visit tribal 

reservations often 

do so to purchase 

cheaper, tax-free 

tobacco products. 
Tobacco Where You Live I NATIVE COMMUNITIES 15

PROMOTE HEALTH SYSTEMS CHANGE

Health systems change strategies aim to screen every patient for 

commercial tobacco use and offer help to quit at every visit.

73

Implementing these strategies in tribal health systems can help 

ensure more Native people get help to quit commercial tobacco.

State and local tobacco control programs can work with tribes to 

build commercial tobacco cessation into their health system by: 

 Training providers in culturally appropriate cessation 

treatment, such as how to adapt the 5 A’s brief tobacco 

intervention model for counseling patients about 

commercial tobacco use76

 Forming a workgroup of partners and experts to focus on 

increasing commercial tobacco cessation in tribal healthcare 

settings

 Creating a network of cessation support through clinical-community 

linkages among healthcare providers, community organizations, and public 

health agencies76

 Helping Native health systems build information technology (IT)

infrastructure needed to promote commercial tobacco cessation, including 

electronic health record technology77

ADAPTING THE 5 A’s IN NATIVE HEALTH SYSTEMS

ASK about commercial tobacco use • Identify appropriate communication styles, such as formal or informal. 

• Be respectful in how you ask and be mindful of cultural and social norms.

ADVISE to quit • Learn about commercial tobacco use in the community, so you can 

educate others on the dangers of commercial tobacco. 

• Understand how traditional tobacco is used in the community. Talk to an 

elder or community member to learn about traditional tobacco use.

ASSESS readiness to quit • Use motivational interviewing to learn about clients’ values, beliefs, and 

reasons for quitting.

ASSIST the quit attempt • Draw on the patient’s values like personal strength, family support, 

traditional practices, or community involvement. 

• Think about existing cessation resources in your community and how you 

can help your clients access them.

ARRANGE follow-up • Confirm contact information and identify best way to follow-up with clients, 

such as texting.

Adapted from Red Star Innovations. More Than the 5 A’s: Implementing a Commercial Tobacco Cessation Intervention in Tribal Communities; 201478

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 16

IMPROVE CESSATION COVERAGE 

Comprehensive cessation coverage increases the number of people who 

try to quit commercial tobacco, use evidence-based treatment, and quit 

successfully.6,79,80

Most Native people are eligible for healthcare services through the Indian Health 

Service, tribal programs, or urban Indian health programs. Medicaid programs also 

provide needed healthcare services for many Native people. 

Tobacco control programs can work with Medicaid agencies to improve cessation 

coverage and increase awareness of benefits for Native communities.73 Tribal 

businesses can also play an important role in improving coverage. For example, 

tribal casinos can provide comprehensive cessation benefits for employees.

CONNECT NATIVE MEMBERS TO QUITLINES 

State tobacco quitlines offer free, effective, and widely available counseling 

to help people quit commercial tobacco.6,79 Some states already have quitline 

services for Native populations, while others offer access to tailored commercial 

tobacco cessation services through the American Indian Commercial Tobacco 

Program, operated through National Jewish Health, or The American Indian 

Quitline, available for residents of Minnesota.61,81

To better serve Native callers, use culturally tailored protocols and hire Native 

trainers to teach quitline staff.82 Include training topics like:83

 Connecting callers with Native coaches

 Respecting traditional tobacco use and encouraging commercial tobacco 

cessation

 Understanding a tribe’s cultural preferences, which may include reducing 

intake questions and increasing time for coaching

 Focusing on the overall journey rather than a specific quit date

Make sure to consider the needs of each Native community served by the state 

quitline. Quitlines may not be accessible for Native people living on tribal lands, 

which have the lowest number of telephone subscribers in the U.S.73

Quitline poster from Minnesota’s American Indian Cessation Campaign. Source: 

CDC MCRC

KEY RESOURCES

Best Practices User Guide: 

Cessation (CDC)

How to promote health systems 

change, improve cessation coverage, 

and support state quitlines

American Indian Commercial 

Tobacco Program (National 

Jewish Health)

Online tools to support American 

Indian people in quitting commercial 

tobacco use

Considerations for Tobacco 

Programs for Tribal Populations

(Rural Health Information Hub)

Native-specific information, 

resources, and materials for 

commercial tobacco use cessation 

and prevention programs

More Than the 5 A’s: Implementing 

a Commercial Tobacco Cessation 

Intervention in Tribal Communities

(Red Star Innovations) 

Workbook with step-by-step 

guidance for planning a cessation 

intervention in Native communities 

and supporting activities

Million Hearts Tobacco Cessation 

Change Package (CDC)

Quality improvement tool to help 

healthcare professionals implement 

strategies to improve care for patients 

who use commercial tobacco

The Power of Possibility... Fostering 

Strong Healthy Native Communities

(University of Arizona Healthcare 

Partnership) 

Resources to support cessation in 

tribal healthcare settings, including 

the Basic Tobacco Intervention Skills 

Certification for Native Communities

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 17

Communicate with Native Audiences

Commercial tobacco prevention messages and strategies often don’t resonate 

with Native populations. Messages may lack relevant language, include non-Native 

images, or be shared through channels not used by tribes.8

Design communications campaigns to resonate with Native communities by: 

 Addressing serious health consequences of commercial tobacco use

 Respecting traditional tobacco use

 Reflecting tribal culture

 Encouraging quitting out of responsibility and respect for others, 

especially family 

 Sharing messages through channels used by Native populations

Poster from Black Hills Center for American 

Indian Health Keeping our Children Safe! 

Campaign. Source: CDC MCRC

ADDRESS SERIOUS HEALTH CONSEQUENCES

Humorous messages about commercial tobacco use are often not effective, 

especially among Native populations.84 Neither are messages using spiritual 

or poetic language.85 Instead, craft hard-hitting messages that include the 

following elements:

 Facts about the serious effects of commercial tobacco use86

 Graphic images to convey the severity of commercial tobacco harm86

 Stories from tribal members to resonate with Native audiences84

RESPECT TRADITIONAL TOBACCO

Messages about “quitting tobacco” can lump together harmful commercial 

tobacco use with the sacred and medicinal use of traditional tobacco. These 

messages may be ineffective with, or even offensive to, American Indian audiences.84

Instead, develop messages that: 

 Explain the difference between traditional and commercial tobacco8

 Discourage commercial tobacco use, including the use of iqmik by Alaska 

Native communities8

 Promote restoration of traditional tobacco (for example, educate audiences 

on harvesting traditional tobacco)58

Diné (Navajo) man collecting white sage. 

Source: Chuck Coker under Creative Commons 

license CC BY-ND 4.0

B E T R I B E - S P E C I F I C 

When developing messages, ask 

Native partners about the appropriate:

• Language

• Symbols

• Colors

• Images

REFLECT LOCAL TRIBAL CULTURE 

Effective messages reflect the local tribe’s culture. Make sure that data included 

in messages are tribe-specific.8

Ask tribal members to design and review communications materials. Their input 

increases the chance that words and images will resonate with the community.87

It also respects tribal sovereignty when community members choose which 

messages are shared.88

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 18

ENCOURAGE QUITTING OUT OF RESPONSIBILITY 

TO OTHERS 

Messages that promote looking out for one another are successful in discouraging 

commercial tobacco use.89 Create a sense of togetherness in a call to action, such 

as rallying the community around reclaiming Native images from the tobacco 

industry.10

Intergenerationalism, the idea of caring for elders and children in the 

community, can be a powerful motivator in messages.8 This can include messages 

about quitting to protect those around you, such as preventing secondhand 

smoke exposure.8

SELECT COMMUNICATIONS CHANNELS THAT 

NATIVE PEOPLE USE

Many Native communities prefer face-to-face communication.90 Messages coming 

from trusted members, like spiritual leaders, will be more authentic, meaningful, 

and impactful.

13

Community spaces and social gatherings are great places to share messages. 

Since tribes are community-focused, social norms are crucial to Native culture.11

Share information directly with attendees at community and cultural events like:

 Powwows

 Health fairs

 Tribal council meetings

 Gatherings at Native colleges

Lakota man in traditional dress at powwow. Source: Unsplash/Andrew James

KEY RESOURCES

Best Practices User Guide: Health 

Communications in Tobacco 

Prevention and Control (CDC)

How to develop effective health 

communications

Effective Tools for Communications 

and Leadership in Indian Country

(National Congress of American 

Indians)

Effective communications techniques, 

like the 5 M’s of messaging, and 

insights on working with tribal 

populations

Promising Practices for Commercial 

Tobacco Prevention in Indian 

Country (National Native Network)

Guidance on building relationships 

and developing effective messages 

for tribal communities

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 19

When in-person communication isn’t possible, look into using other types of 

media to share messages. Social media and e-newsletters have been effective, 

particularly with Native youth.91,92 For example, during COVID-19 gathering 

restrictions, some Native communities created social media groups to host virtual 

powwows.93 Tribes may also have local newsletters and radio stations.

Monitor and Evaluate 

Monitoring activities track commercial tobacco use, quitting behaviors, and 

health outcomes in a population. Collecting these data with Native populations 

can help all partners:

 Understand commercial tobacco use, disparities, and risk factors among Native 

populations8

 Work toward eliminating commercial tobacco-related disparities in Native 

populations and communities12

 Plan activities to reduce commercial tobacco use among Native populations8

 Build support for commercial tobacco prevention and cessation in Native 

communities8

Evaluation helps tribes assess effectiveness and improve strategies. Although 

there are proven strategies to reduce commercial tobacco use among non-Native 

populations, we know less about what works for Native people.12

Ask permission from tribal leaders before beginning any monitoring and evaluation. 

Staff can work with tribes to conduct these activities by adapting existing 

monitoring and evaluation efforts to collect tribal data and align with Native values.

C H E C K L I S T F O R 

A DA P T I N G S U R V E YS 

& INTERVIEWS

• Have community members 

conduct the survey or interview

• Reach out beforehand to introduce 

yourself

• Limit questions that impose values 

or personal opinions

• Make it a conversation instead of 

only a question/answer format

• Use correct Native terms and check 

your spelling

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 20

ADAPT MONITORING TOOLS

State and national surveys often have incomplete or imprecise data on 

tribal commercial tobacco use. For example, Native people are consistently 

underrepresented in Census data.94 The American Indian Adult Tobacco Survey

and Alaska Native Tobacco Survey assess commercial tobacco use, exposure to 

secondhand smoke, and beliefs about commercial tobacco and quitting.49,50

You can also adapt these surveys or work with tribes to develop tools. You can 

use questions from these surveys on tools you develop. Include questions about 

traditional tobacco use in surveys of American Indian tribes or iqmik use in Alaska 

Native communities.8,95

In addition to survey tools, use Indigenous ways of knowing, such as story telling, 

to better connect with the local culture and context.96

Placing data ownership with tribes adds accountability and trust to the process of 

data collection and use. The Urban Indian Health Institute, one of the 12 Tribal 

Epidemiology Centers, collaborated with the Lummi Nation to develop an 

Indigenous evaluation process.97 They define what change means to the 

community by encouraging face-to-face feedback from tribal members, using 

images or art to illustrate change, identifying community strengths, and culturally 

translating findings to funders.98

ALIGN EVALUATION WITH NATIVE VALUES 

Some Western research and evaluation practices may be unfamiliar to Native 

populations or viewed as incompatible with Native culture. Aligning evaluation 

with Native values can help tribal members trust and act on the results. Use the 

following principles to guide evaluations in Native communities:97

 Ground the evaluation in traditional ways of knowing 

Learn about and incorporate traditional ways of knowing, such as creation 

stories, individual and communal experiences, and history handed down 

through the generations. 

 Incorporate community values

Understand the community’s core values, such as being people of a place, 

the centrality of family and community, and tribal sovereignty. Ask how these 

values affect the evaluation goals and methods.

 Engage the community in evaluation

Meaningfully collaborate with community members in all phases of evaluation 

to make decisions about the evaluation process and communicate results. 

Community members can help plan the evaluation, develop tools, collect 

information, interpret data, and write and disseminate reports. 

 Tell their story

Incorporate the Native tradition of storytelling into evaluation by considering 

what questions are necessary to tell the community’s story. Collect both 

quantitative and qualitative information to explore the story, including 

individual and communal experiences. 

KEY RESOURCES

A Roadmap for Collaborative 

and Effective Evaluation in Tribal 

Communities (Children’s Bureau)

Guidance for working with tribes to 

conduct culturally respectful and 

appropriate collaborative evaluations 

in Native communities

Indigenous Evaluation Framework

(American Indian Higher Education 

Consortium)

Workbook for building an evaluation 

framework that reflects Native 

American values and culture

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 21

 Focus on strengths

Focus on exploring community strengths instead of solving a problem. Use 

methods that build on those strengths, such as empowerment evaluation.

99

 Share findings 

Share findings in ways that are meaningful to Native audiences. Before sharing 

evaluation results outside the community, encourage tribal ownership of 

data and evaluation products by asking the tribe for permission to share and 

confirm that you are accurately representing their stories and experiences.100

 Celebrate what you learned

Celebrate what you learned with the community and use results to benefit the 

community. 

Start all Native evaluation efforts by consulting tribal leaders, your program 

Institutional Review Board, and any tribal internal review processes.97 Some tribes 

may have their own review process to protect tribal members and traditional 

knowledge. If not, you can work with tribes to develop one.90 Learn more about 

data sharing agreements on page 10.

Sustain Progress 

Programs can play a key role in working with tribes to build capacity to continue 

commercial tobacco prevention work. You can help sustain commercial tobacco 

use prevention in Native communities by:

 Supporting community-driven strategies, including those to promote 

education and restoration of traditional tobacco11

 Setting shared goals with Native partners and checking in regularly about 

progress10

 Dedicating staff to provide culturally appropriate training and technical 

assistance39

 Ensuring that staff share responsibilities with tribal members, such as 

presenting to others, writing reports, or completing grant applications39

 If resources allow, working with tribes to create a permanent community 

advisory board to lead efforts after the implementation period ends36

 Acknowledging progress and recognizing accomplishments to keep Native 

partners engaged39

Programs can also connect tribes with partners. Native work groups and 

coalitions create a place for tribal representatives to come together to identify 

local needs, share strategies, and engage in peer-to-peer mentoring.95 It is 

important that work groups both reinforce ongoing local efforts and introduce 

new commercial tobacco prevention knowledge and skills. 

Participants at the Midnight Sun Intertribal 

Powwow in Fairbanks, AK. Source: user 

Frostnip907 under Creative Commons license 

CC BY-NC-SA 2.0

KEY RESOURCES

National Native Network

Tailored trainings, toolkits, and 

webinars on reducing commercial 

tobacco use and health disparities 

among Native people

Program Sustainability Assessment 

Tool (Center for Public Health 

Systems Science)

Online tool describing and assessing 

key factors related to sustainability of 

programs with key resources that has 

been used with tribal populations

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 22

Planning for sustainability can help increase capacity for maintaining efforts. From 

2020 to 2021, the Network Coordinating Center at the Tribal Epidemiology Centers 

Public Health Infrastructure Program partnered with the Center for Public Health 

Systems Science to support Tribal Epidemiology Centers in assessing and 

building program sustainability capacity using the Program Sustainability 

Assessment Tool.

101 The tool identifies eight domains that influence program 

sustainability: Environmental Support, Funding Stability, Partnerships, 

Organizational Capacity, Program Adaptation, Program Evaluation, 

Communications, and Strategic Planning.

Program Sustainability Domains. Source: 

sustaintool.org

Eastern wall of Minneapolis American Indian Center, created by Gregg Deal and Votan Henriquez, and funded in part by ClearWay Minnesota. Source: Jaime 

Martinez–ClearWay Minnesota

TAKE ACTION
Tobacco Where You Live I NATIVE COMMUNITIES 23

EXPLORE COMMUNITY EXAMPLES

Lower Sioux Nation—Minnesota

Located in southwest Minnesota, the Lower Sioux Reservation has 

around 1,200 members, about half of whom are youth. When the 

tribe learned that many of their members used commercial tobacco, 

they knew that addressing the problem began with educating their 

members about traditional tobacco.

The Lower Sioux Nation receives a Tribal Tobacco Grant from the 

Minnesota Department of Health (MDH). The MDH Tribal Grants 

Program is based on the foundational belief that culture drives 

prevention in tribal communities.102 “The previous iteration of this 

program had been asking tribes to implement evidence-based practices 

that mainstream tobacco prevention and control implements regularly. 

MDH consistently heard from tribal grantees that these strategies 

wouldn’t work in our communities,” says Sarah Brokenleg, Acting Health 

Equity and Tribal Grants Supervisor and member of the Sičáŋğu Lakota 

Oyate. The program worked with tribal and urban American Indian 

partners and the Great Lakes Inter-Tribal Epidemiology Center to include more 

flexible cultural work and traditional activities.103

Restoring traditional tobacco is now a focus of the Tribal Grants Program, 

alongside addressing secondhand smoke exposure and commercial tobacco use. 

In fact, Minnesota was the first state tobacco prevention program in the U.S. to 

provide resources for growing traditional tobacco. 

Minnesota also hired specialists like Brokenleg, who understood the nuances 

of working with tribal nations, to lead the work. “That face-to-face time in the 

community really allows us to be specialists for the communities we are working 

with. Each tribal nation is unique—and so is their commercial tobacco prevention 

work,” she says.

Working with the Lower Sioux’s Tribal Health Coordinator, Elliot Christensen, 

Brokenleg connected the tribe to MDH partners, the American Indian Cancer 

Foundation, and ClearWay Minnesota. These partners provided culturally 

relevant resources like toolkits, webinars, and training to develop a commercial 

tobacco prevention program that works for the Lower Sioux. 

The Lower Sioux then tailored a set of commercial tobacco prevention strategies 

for their tribe. They involved youth in traditional outdoor activities and sports in 

place of commercial tobacco use. Activities included collecting and harvesting 

cansasa, the tribe’s sacred tobacco, while educating on the differences between 

this traditional medicine and harmful commercial tobacco. 

In the past five years, the Lower Sioux Nation has seen its commercial tobacco 

use drop. But the numbers don’t tell the whole story. “There’s no number that you 

can put on the experience or the knowledge that the community has gained,” 

Christensen says.

Members of the Lower Sioux Nation collect cansasa, the tribe’s 

sacred tobacco. Source: Elliot Christensen

Each tribal nation 

is unique—and so 

is their commercial 

tobacco 

prevention work. — Sarah Brokenleg
Tobacco Where You Live I NATIVE COMMUNITIES 24

Ho-Chunk Nation—Wisconsin

The Ho-Chunk Nation has operated gaming facilities in 

Wisconsin since the late 1980s. “Casinos buoy us and keep 

us employed,” says Dan Brown, a Ho-Chunk member and 

Executive Manager of Ho-Chunk Gaming Madison. During 

most of his years in the gaming industry, Brown had accepted 

smoking as part of the casino environment.

The idea to go smokefree began in 2013. As Brown read 

through customer comment cards, cigarette smoke was a 

common complaint. Patrons said that the smoke kept them 

from fully enjoying the casino with friends and family. 

When Brown proposed a smokefree policy to his staff, they 

supported it. Delving further, he found patrons could be 

more likely to visit a smokefree casino. Buy-in from the tribal 

government was key.63 “This was a financial risk,” says Missy 

Tracy, Municipal Relations Coordinator at the casino and 

member of the Dane County Alliance Against Commercial 

Tobacco.

Brown partnered with the Wisconsin Native American Tobacco Network

(WNATN) to lead the smokefree effort. State and local agencies were also 

important partners, offering resources and financial support. “We were just there 

to offer our support, and tribal members really led the effort,” says Ryan Sheahan, 

Coordinator for the Dane County coalition. Karen Conner, Health Disparities and 

Treatment Coordinator with the Wisconsin Department of Health Services, 

agreed, “Tribes are the experts—they know their nation best.” 

The casino prepared its customers for the new policy with newsletters, 

promotional items, and advertising, including a TV commercial highlighting the 

facility as “the cleanest casino air in Wisconsin.” Ho-Chunk Gaming Madison officially 

became Wisconsin’s first 100% smokefree casino at midnight on August 1, 2015. 

Although the casino did not see instant success, it bounced back to set revenue 

and attendance records. Over the past five years, customer feedback has 

been overwhelmingly positive. “We get comments constantly from our guests, 

especially our middle-aged guests, who want to bring their folks in. Before, they 

could not. It’s safe, they can stay longer,” Brown says.

Brown says staff recruitment and retention have also improved, and some 

employees have quit smoking commercial tobacco. As of December, 2021, nearly 

160 tribal casinos are now smokefree.104

Tribal member and Cage Manager Kyla Beard says smokefree environments 

promote the health and well-being of the Ho-Chunk Nation. “Going smokefree is the 

most Indigenous thing you can do,” she says. “It’s the best way we can continue to 

show our sovereignty to other Nations and take care of ourselves, our elders, and 

our future generations.”

Ho-Chunk Gaming Madison has been 100% smokefree since 2015. Source: 

Ho-Chunk Gaming Madison

EXPLORE COMMUNITY EXAMPLES

Going smokefree 

is the most 

Indigenous thing 

you can do.

— Kyla Beard
Tobacco Where You Live I NATIVE COMMUNITIES 25

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