Tami Sullivan, PhD, associate professor of psychiatry at Yale School of Medicine, and Patricia Nez Henderson, MD, MPH, vice president for the Black Hills Center for American Indian Health (BHCAIH) and the first Indigenous woman to graduate from Yale School of Medicine, have been awarded a grant from the National Institutes of Health (NIH) to pilot a mindfulness-based, culturally-tailored smoking cessation intervention for Indigenous women who experience intimate partner violence (IPV).
The study, funded under the NIH’s National Institute of General Medical Sciences (NIGMS) Native American Research Centers for Health (NARCH) award, aims to fill a practical need among Indigenous women who experience IPV, a population of which 70% smoke.
The project capitalizes on BHCAIH’s long-standing relationship with the Rapid City, South Dakota Indigenous community, which is principally Lakota. The idea germinated in 2016, when one of Nez Henderson’s staff members proposed developing a culturally-specific smoking cessation intervention after noticing that more than half of the women at a domestic violence shelter in South Dakota, the majority of whom were Lakota, were smoking.
Nez Henderson, a Navajo Nation tribal citizen, has extensively researched smoking in American Indian tribes and communities and her work has largely focused on implementing commercial tobacco control policies on tribal lands. Sullivan is a leading expert on IPV and is one of the few investigators who has studied smoking among women who have experienced IPV.
Nez Henderson and her team received an NIH grant to fund a series of focus groups and key informant interviews to determine what type of intervention would work best. When it was time to test the feasibility of the newly created smoking cessation intervention, Nez Henderson applied for an NIH grant. While the NIH loved the idea, Nez Henderson said, the team was directed to identify someone knowledgeable in IPV. That’s when Nez Henderson reached out to Sullivan to collaborate.
“This is the first intervention that incorporates mindfulness, Lakota mindfulness, and Lakota culture for smoking cessation,” Nez Henderson said. “This is a pilot study and we are seeking to test its feasibility and likeability. Then, hopefully, we will be able to move forward with a randomized trial to really test the intervention itself and its impact on smoking cessation.”
The Lakota, like many Indigenous tribes in United States, use various plants for cultural and ceremonial purposes. When the government banned all forms of ceremonial practice, including the use of any type of plants, among Indigenous tribes in 1883, many tribes went underground and replaced the plants with cigarettes to avoid persecution. By the time the ban was lifted in 1978, the tobacco industry had already targeted native communities to use their products and over 50% of Indigenous men, women, and children of the Northern Plains had high rates of cigarette smoking.
“There are layers and layers of historical trauma that Indigenous people have experienced and we have to consider those factors when developing any type of intervention,” Nez Henderson explained.
And when it comes to women who have experienced the trauma of IPV, there are significant barriers to quitting, Sullivan said, which range from their partners not wanting them to quit, to not being in a supportive environment that helps them quit.
“The autonomy of some of women who experience IPV is limited, and they can’t do what they otherwise might.”
If the intervention isn’t matched to the needs of the group, there is actually the potential for it to do more harm than good. There really hasn’t been trauma-informed smoking cessation interventions. This intervention will integrate mindfulness, which is consistent with American Indian cultural values and has been shown to reduce stress and other problematic health behaviors.
Tami Sullivan, PhD, associate professor of psychiatry, Yale School of Medicine
Sullivan said there is an association between post-traumatic stress disorder (PTSD) and smoking, and that women who experience IPV also experience higher rates of PTSD, making it more difficult for these women to quit smoking. Without integrating trauma-informed care into interventions for women who experience IPV, she said, interventions can ultimately come across as blaming women for their abuse.
“If the intervention isn’t matched to the needs of the group, there is actually the potential for it to do more harm than good,” Sullivan said. “There really hasn’t been trauma-informed smoking cessation interventions. This intervention will integrate mindfulness, which is consistent with American Indian cultural values and has been shown to reduce stress and other problematic health behaviors. This is consistent with Lakota culture and Northern Plains tribal culture, and it’s coupled with a trauma-informed intervention that recognizes the IPV but, in this, population also recognizes the historical trauma and ongoing trauma that Native Americans experience.”
The study funded by NIGMS began in September. The team is working with a community advisory board and others embedded in the culture and community of tribal groups who will inform every step of the process from finalizing the intervention to developing recruitment materials, Sullivan said.
The intervention is an eight-session series, each based around seven Lakota values: fortitude, generosity, kinship, prayer, respect, wisdom, and compassion. Researchers developed a story to incorporate, which tells about the journey of a Lakota woman who lived in Rapid City and was taught the Lakota values by her grandparents, and experienced IPV. The story chronicles the woman’s journey of healing and ultimately quitting commercial tobacco cigarettes.
The intervention also incorporates an understanding of the difference between ceremonial tobacco and commercial tobacco, and commercial tobacco’s fraught history with the tribe, so participants can understand their own historical trauma and how that has led to smoking.
“We were very, very careful in the development of this intervention not to trigger the women in each of the sessions we’ll be providing,” Nez Henderson said. “We came in from more of the cultural side of it.”
Sullivan explained further: “Tailoring interventions to specific populations really speaks to the unique needs of each group. If something doesn’t feel relevant to you or you are made to feel bad about yourself, it can be a victim-blaming experience.”
Researchers were mindful to help participants understand, without triggering them, what has happened in their lives and what it means for them and ultimately for their families, as an important piece of Lakota culture is not just about healing oneself, but healing one’s family as well, Nez Henderson said. Women who participate in the intervention will receive tips on what they need to do to become more mindful and steps they can take when they’re under stress or begin to think about the past, such as prayers and statements recorded in Lakota.
“Ultimately the goal is that, by the sixth week, they have begun to develop a toolbox of things they can use for themselves and that they can set a date for quitting,” Nez Henderson said.