Nicotine Use Among Reservation-area American Indian Adolescents Compared With a National Sample

Abstract

Background:

Past research has found significant nicotine use disparities for reservation-area American Indian adolescents when compared to national levels. However, adolescent nicotine use has changed markedly, with reduced smoking and rapid increases in nicotine vaping. This study presents 2021–2022 prevalence estimates of tobacco product use, perceived harm and availability for reservation-area American Indian youth, with comparisons to the Monitoring the Future (MTF) national study.

Methods:

Participants were 8^th, 10^th and 12^th grade students. American Indian data were 33 reservation-area schools in 2021–2022 (n=2,420); MTF data were 308 schools in Spring 2022 (n=31,438). Measures were lifetime, 30-day cigarette smoking, smokeless tobacco use, and nicotine vaping; past-year nicotine vaping; daily smoking; perceived harmfulness and availability of these tobacco products. Prevalence and 95% confidence intervals were computed by grade.

Results:

Estimated prevalence of lifetime, monthly and daily cigarette smoking among American Indian 8^th and 10^th graders was higher than national levels. Nicotine vaping prevalence was similar between samples. American Indian students were less likely to report tobacco product use poses great risk, but also less likely to report tobacco products are easily available.

Conclusions:

Although estimated smoking prevalence among American Indian 8^th and 10^th graders was higher than national levels, prevalence appears lower than reported in earlier studies, suggesting declining disparities. Prevalence of nicotine vaping among Reservation-area American Indian adolescents generally mirrors the national population; however, a lower percentage reported regular nicotine vaping poses a serious risk. This discrepancy suggests a need for prevention and intervention efforts culturally tailored for this population.

1. Introduction

Adolescent nicotine use in any form is associated with significant physical and mental health ramifications (Becker et al., 2021; Livingston et al., 2022; Yuan et al., 2015). Adolescents are especially vulnerable to nicotine dependence (DiFranza et al., 2007); even infrequent smoking in adolescence correlates with smoking in adulthood (Riggs et al., 2007). Although adolescent nicotine use has been declining for several decades (Meza, Jimenez-Mendoza and Levy, 2020), a sharp rise in nicotine vaping occurred less than a decade ago. Nationally, 30-day nicotine vaping prevalence more than doubled among 8^th, 10^th and 12^th graders from 2017 to 2019 (Brody, 2020; Miech et al., 2019), and nicotine vaping has now become one of the most common forms of substance use among adolescents in the general population (Miech et al., 2023).

National data on the prevalence of nicotine vaping and other tobacco use within American Indian adolescent age-groups are sparse, partly because national samples lack adequate data to calculate reliable estimates—especially for specific tobacco products or usage timing. The National Youth Tobacco Survey (NYTS) recently released a surveillance report detailing ethnic/racial nicotine use disparities within a national sample of U.S. middle and high schoolers (Park-Lee et al., 2022). Based on the combined middle and high school data, 13.5% of non-Hispanic American Indian and Alaska Native (AIAN) adolescents, compared to 11.3% of the full sample, reported past-month use of any tobacco product (including e-cigarettes), while 4.6% of AIAN adolescents reported past-month use of any combustible tobacco product compared to 3.7% of the full sample. Past-month prevalence specific to e-cigarettes was roughly equivalent between the AIAN and the overall sample at ~10%. Unfortunately, specific estimates for the past-month prevalence of cigarette smoking and smokeless tobacco use among AIAN adolescents in this sample is unknown due to a lack of sufficient data (Park-Lee et al., 2022).

Notably, most national surveys, including NYTS, aggregate Alaska Native youth, reservation-area American Indian youth and urban American Indian youth into a single category, despite the distinct sociocultural factors that impact each subpopulation’s substance use (Yu, Stiffman and Freedenthal, 2005). “Reservation-area” in this context denotes youth residing on or near federally recognized U.S. reservations, which are federally designated lands managed by American Indian tribes that are generally exempt from state jurisdiction. Reservations (and the surrounding communities) are overwhelmingly geographically remote areas that face substantial socioeconomic challenges (Burton et al., 2013).

Nicotine use among Reservation-area American Indian youth is related not only to the significant social determinants of health (SDOH) inequities that impact reservation communities (Empey et al., 2021; Wang & Wu, 2020) but also to sociopolitical factors unique to reservation communities. As sovereign nations, tribal members are exempt from state excise taxes on tobacco sold on reservations, which lowers the cost of tobacco products sold there (Wang et al., 2017). Additionally, tobacco industries employ calculated promotional strategies targeting reservation-area American Indians, including misappropriating Native cultural symbols and imagery for their marketing campaigns (D’Silva, O’Gara and Villaluz, 2018) and instituting steep discounts for tobacco products sold on tribal lands (Begay et al., 2020; Lempert and Glantz, 2019). Reservation-area American Indian youth may be particularly vulnerable to these pricing tactics, as discounting campaigns have been associated with increased nicotine use among adolescents in the general population (Slater et al., 2007).

Comparing reservation-area American Indian adolescent substance use levels during 2016–2017 to the 2016 levels from the Monitoring the Future (MTF) national sample of 8^th, 10^th and 12^th grade students, Swaim and Stanley (2018) reported that estimated prevalence of lifetime and last 30-day cigarette smoking for 8^th, 10^th, and 12^th grade students were significantly higher for the American Indian sample. For example, last 30-day estimates were 10.6%, 15.1%, and 23.1% for 8^th, 10^th, and 12^th grade American Indian students, respectively, compared to 2.6%, 4.9%, and 10.5% nationally. Nicotine vaping was not measured for the American Indian sample during this time period.

The findings of Swaim and Stanley (2018) point to significant disparities in the prevalence of smoking for Reservation-area American Indian adolescents. However, adolescent nicotine use has changed markedly since the time of this study. Nationally, nicotine vaping rose rapidly in the late 2010s (Miech et al., 2019; Miech et al., 2021). On the other hand, post-pandemic prevalence for all types of nicotine use fell (Miech et al., 2023). In light of the national changes in adolescent nicotine use over the past decade, updated estimates of nicotine use prevalence among Reservation-area American Indian adolescents are needed to determine whether the disparities observed by Swaim and Stanley (2018) persist. Notably, data on the prevalence of nicotine vaping in this population is also lacking.

Using 2021 – 2022 data, this paper provides updated national prevalence estimates of nicotine use among Reservation-area American Indian adolescents, including the first-ever reported estimates of nicotine vaping prevalence in this population, and compares these estimates to those of the United States general adolescent population. The Our Youth, Our Future (OYOF) study annually surveys a nationally representative sample of 6^th–12^th grade Reservation-area students to obtain estimates of substance use prevalence and associated risk and protective factors. Estimates of cigarette smoking, smokeless tobacco use and nicotine vaping, along with perceived availability and harm, for 8th, 10th and 12th grade reservation-area American Indian students are compared to those of MTF.

2. Methods

Both MTF and OYOF surveys were approved by their respective university Institutional Review Board (IRB; MTF protocol: HUM00217920; 07/08/2022; OYOF protocol: IRB#3130, August 2023). In addition, OYOF received tribal IRB approvals, as appropriate.

2.1. Sample and recruitment

2.1.1. American Indian sample

Study data are from 33 schools participating in OYOF fall 2021 and spring and fall 2022. Each year, a geographically stratified random sample of middle and high schools on or within 25 miles of a reservation in the contiguous United States is drawn from a comprehensive sampling frame, and for participating schools, all students enrolled in grades 6–12 are surveyed. A description of sampling frame, sample procedures, and recruitment are provided in the online supplement.

2.1.2. MTF sample

Study data are from 308 schools that participated in MTF in 2022. MTF is an annual substance use epidemiological study that is nationally-representative of the 48 contiguous U.S. states (Miech et al., 2023). Each year, the project selects three independent, geographically stratified random samples of 8^th grade, 10^th grade, and 12^th grade schools from a sampling frame of all public and private schools in the U.S. Please refer to Bachman et al. (2015) and Miech et al. (2023) for a description of sampling frame, sample procedures, and recruitment.

2.2. Procedures

2.2.1. American Indian sample

Parents could opt their child out of the survey; less than 1% did so. Surveys were administered online with Qualtrics software during classroom hours to all 6–12^th grade students attending school on survey dates. Responses were anonymous, and students were instructed to skip questions they did not wish to answer. Response rates averaged 76% across schools. Non-response was primarily due to absenteeism on administration day.

2.2.2. MTF sample

Parents could opt their child out of the survey; less than 1% did so. Surveys took place in school, where students used electronic devices to complete a web-based questionnaire powered by Illume software. Responses in 8^th and 10^th grades were anonymous; 12^th grade students were asked to provide contact information for follow-up questionnaires. Students were instructed to skip questions they did not wish to answer. Response rates were 86% in 8^th grade, 84% in 10^th grade, and 75% in 12^th grade; non-response was primarily due to absenteeism on administration day.

2.3. Participants

Participants in both samples are 8^th, 10^th and 12^th grade students attending school during survey administration, assenting to the survey, and whose parents did not opt them out. For the American Indian sample, participants self-identified as American Indian.

2.4. Measures

2.4.1. Nicotine use.

MTF and OYOF investigators collaborated to include the same nicotine vaping and other tobacco use measures. Survey items included lifetime and 30-day cigarette smoking, smokeless tobacco use, as well as lifetime, 30-day, and past-year nicotine vaping. Study measures were constructed to parallel commonly cited measures in nicotine epidemiology research.

Thirty-day cigarette use responses ranged from none to 2 packs or more a day. Smoking 1 to 5 cigarettes or more a day was designated as daily use; smoking one half-pack or more a day was designated as half-pack daily use. Thirty-day smokeless tobacco responses ranged from no use to more than once a day. Using about once per day or more was designated as daily use. Responses for 30-day nicotine vaping ranged from 0 days to 20 or more days; nicotine vaping on 20 or more days was designated as daily use.

2.4.2. Perceived harmfulness

Respondents were asked how much people risk harming themselves if they: 1) smoke one or more packs of cigarettes per day; 2) use smokeless tobacco regularly; and 3) vape nicotine regularly. Responses ranged from no risk to great risk; those responding ‘great risk’ are presented.

2.4.3. Perceived availability

Respondents were asked how difficult it would be to get cigarettes, vape pens or e-cigarettes, and smokeless tobacco (for American Indian sample only), with responses ranging from probably impossible to very easy and an option “can’t say”. Those responding fairly or very easy are presented.

2.5. Statistical Analysis

In order to examine disparities in cigarette smoking, smokeless tobacco and nicotine vaping between the two groups, prevalence estimates for each measure were tested for significant differences between the American Indian sample and the MTF sample. For each measure at each grade, prevalence and 95% confidence intervals (CI) were computed. Stata^® survey commands accounted for clustering of students within schools, with weighting to correct for regional over- or underrepresentation. Missing data were excluded from the analysis. For the American Indian sample, percentage of missing values for all use measures was 5.6% or less across the three grades, for harmfulness ranged from 3.5% to 8.7%, and for availability ranged from 11.3% to 21.5%. For the MTF sample, the percentages of respondents with missing data were 10% or less for the nicotine use measures, 6% or less for the harmfulness measures, and 14% or less for the availability measures. A z-test for independent proportions was used to test for significant differences between samples, where effective sample sizes were computed as actual sample size divided by a measure’s design effect to take into account student clustering within schools (Kish, 1965).

3. Results

For OYOF students identifying as American Indian, 848 were 8^th graders (45.5% female; 49.6% male; 4.4% another; M_age = 13.6); 911 10^th graders (47.0% female; 48.2% male; 4.7% another; M_age = 15.7); and 661 12^th graders (51.7% female; 43.7% male; 4.4% another; M_age =17.5). MTF sample sizes were 9,889 (grade 8); 11,950 (grade 10); and 9,599 (grade 12), with a demographic distribution mirroring that of the nation.

Table 1 presents prevalence for tobacco product use by grade and sample. For both samples, nicotine vaping prevalence was several times higher than measures of cigarette smoking or smokeless tobacco use for the same reporting period.

Table 1.

Prevalence of tobacco product use and nicotine vaping comparing reservation AI (2021–2022) and MTF (2022) students

	8th grade		10th grade		12th grade
Type of nicotine use	AI (%) (95% CI)	MTF (%) (95% CI)	AI (%) (95% CI)	MTF (%) (95% CI)	AI (%) (95% CI)	MTF (%) (95% CI)
Cigarettes
Lifetime	8.3* (7.6, 9.0)	6.1 (5.3, 7.1)	15.2** (14.4, 16.2)	10.2 (9.0, 11.6)	21.4* (20.2, 22.6)	16.8 (14.6, 19.3)
30 day	1.7* (1.4, 1.9)	0.8 (0.6, 1.1)	3.5** (3.2, 3.9)	1.7 (1.2, 2.3)	4.8 (4.2, 5.3)	4.0 (3.1, 5.1)
Daily	0 9** (0.8, 1.0)	0.3 (.2, .5)	2.1** (1.8, 2.5)	0.7 (0.5, 0.9)	2.0 (1.7, 2.2)	1.6 (1.2, 2.1)
½+ pack/daily	0.0 (NA)	0.1 (0.1, 0.2)	0.8** (0.6, 1.0)	0.3 (0.2, 0.5)	0.7 (0.6, 0.9)	0.9 (0.7, 1.3)
Vaping Nicotine
Lifetime	18.5 (17.4, 19.6)	17.0 (15.0, 19.1)	27.7 (26.6, 28.9)	28.2 (25.1, 31.5)	32.6* (31.3, 34.0)	38.8 (35.4, 42.3)
Annual	12.8 (13.0, 13.7)	12.0 (10.5, 13.7)	22.4 (21.2, 23.7)	20.5 (17.8, 23.3)	23.7 (22.5, 24.9)	27.3 (24.3, 30.5)
30 day	9.3* (8.7, 10.0)	7.1 (6.0, 8.3)	16.4 (15.6, 17.3)	14.2 (12.1, 16.6)	20.1 (19.0, 21.2)	20.7 (18.2, 23.5)
Daily	1.4 (1.2, 1.6)	1.2 (0.8, 1.6)	5.8** (5.2, 6.4)	3.3 (2.6, 4.1)	6.8 (6.2, 7.5)	6.2 (5.0, 7.7)
Smokeless Tobacco
Lifetime	5.4* (5.1, 5.9)	3.9 (3.2, 4.9)	8.8** (8.0, 9.7)	5.8 (5.0, 6.8)	12.1 (11.4, 12.8)	10.3 (8.2, 13.0)
30 day	0.9 (0.8, 1.1)	1.2 (0.8, 1.6)	1.8 (1.6, 2.0)	2.5 (2.0, 3.1)	2.4 (2.1, 2.7)	3.2 (2.2, 4.7)
Daily	0.3 (0.2, 0.4)	0.3 (0.1, 0.5)	0.6 (0.5, 0.7)	0.7 (0.5, 1.0)	0.9 (0.8, 1.0)	1.1 (0.6, 2.2)

^*p < 0.05;

^**p<.01

AI = American Indian

MTF = Monitoring the Future

CI = confidence interval

NA = not asked

3.1. Cigarette smoking

Lifetime, 30-day, and daily smoking prevalence were significantly higher among 8^th and 10^th grade American Indian (AI) students versus the national sample (MTF). This was also true for 10^th grade ½+ pack smoking (0.8%, 95% CI [0.6 to 1.0] vs. 0.3%, 95% CI [0.2 to 0.5]), though prevalence was below 1.0% for all grades. Only lifetime smoking was significantly different between 12^th grade samples, where prevalence was higher among American Indian youth (AI: 21.4%, 95% CI [20.2 to 22.6]; MTF: 16.8%, 95% CI [4.6 to 19.3]).

3.2. Nicotine vaping

Thirty-day nicotine vaping was significantly higher in the 8^th grade American Indian sample versus the national sample (AI: 9.3%, 95% CI [8.7 to 10.0]; MTF: 7.1%, 95% CI [6.0 to 8.3]), while daily nicotine vaping was significantly higher among 10th grade American Indian students (AI: 5.8%, 95% CI [5.2 to 6.4]; MTF: 3.3%, 95% CI [2.6 to 4.1]). Lifetime nicotine vaping among 12^th graders was significantly higher in the national sample (38.8%, 95% CI [35.4 to 42.3]) than the American Indian sample (32.6%, 95% CI [31.3 to 34.0]).

3.3. Smokeless tobacco use

There was a significant difference for 8^th and 10^th graders, with American Indian youth reporting higher lifetime prevalence levels compared to national levels.

Table 2 compares harmfulness and availability for each sample by grade.

Table 2.

Percentage responding great risk of harm and easy to fairly easy availability for tobacco products and nicotine vaping, comparing reservation AI (2021–2022) and MTF (2022) students

	8th grade		10th grade		12th grade
	AI (%) (95% CI)	MTF (%) (95% CI)	AI (%) (95% CI)	MTF (%) (95% CI)	AI (%) (95% CI)	MTF (%) (95% CI)
Harmfulness a
Smoke one or more packs of cigarettes per day	49.5** (48.6, 50.5)	61.9 (59.5, 64.3)	49.8** (48.9, 50.7)	71.0 (69.0, 72.9)	58.4** (57.4, 59.3)	71.6 (67.9, 75.0)
Vape nicotine regularly	33.7** (32.7, 34.7)	53.2 (49.9, 56.5)	31.8** (30.6, 33.0)	51.5 (49.1, 53.8)	46.4 (45.5, 47.3)	45.2 (42.8, 47.7)
Use smokeless tobacco regularly	23.5** (22.7, 24.4)	36.5 (34.3, 38.8)	26.8** (25.8, 27.8)	44.1 (42.5, 45.7)	36.9 (35.8, 38.1)	NA
Availability b
Cigarettes	22.5** (21.8, 23.3)	33.8 (31.3, 36.4)	35.2** (33.7, 36.6)	47.5 (45.2, 49.7)	42.8** (41.3, 44.3)	54.2 (50.7, 57.6)
Vape pens or e-cigarettes	26.9** (25.9, 27.9)	34.6 (31.5, 37.8)	42.2** (41.0, 43.5)	51.9 (48.4, 55.3)	46.7** (45.5, 47.9)	69.3 (65.9, 72.4)
Smokeless tobacco	15.9 (15.0, 16.8)	NA	26.5 (25.6, 27.5)	NA	36.8 (35.4, 38.2)	NA

^*p < 0.05;

^**p<.01

^a:Percentage responding “great risk”.

^b.Percentage responding “fairly easy” or “very easy”.

AI = American Indian

MTF = Monitoring the Future

CI = confidence interval

NA = not asked

3.4. Harmfulness

Fewer American Indian 8^th and 10^th grade students reported great risk from smoking, vaping nicotine, or using smokeless tobacco regularly compared to their national counterparts. For example, for 10^th graders, 49.8% American Indian students (95% CI [48.9 to 50.7]) reported smoking regularly posed a great risk versus 71.0% (95% CI [69.0 to 72.9]) of their national counterparts, and 31.8% (95% CI [30.6 to 33.0]) reported nicotine vaping posed great risk compared to 51.5% (95% CI [49.1 to 53.8]) of their national counterparts.

Fewer American Indian 12^th graders reported smoking posed a great risk (58.4%, 95% CI [57.4 to 59.3]) compared to their national counterparts (71.6%, 95% CI [67.9 to 75.0]) while there was no significant difference for vaping nicotine regularly.

3.5. Availability

American Indian students at each grade were significantly less likely than their national counterparts to report cigarettes and vape pens/e-cigarettes were easy to obtain. For 12^th grade students, the difference in percentage reporting vape pens/e-cigarettes were easy to obtain was over 20 percentage points greater for the national sample (AI: 46.7%, 95% CI [45.5 to 47.9]; MTF: 68.3%, 95% CI [65.9 to 72.4]).

4. Discussion

Comparing 2021–2022 prevalence estimates of reservation-area American Indian adolescent nicotine use to national estimates revealed several persisting disparities in nicotine use, particularly cigarette smoking. In addition, compared to their national counterparts, a lower percentage of American Indian adolescents in each grade reported that cigarette smoking, smokeless tobacco use and nicotine vaping poses a great risk —with the exception of 12^th grade nicotine vaping. However, there was also a significantly lower percentage of American Indian students reporting cigarettes and vape pens/e-cigarettes were easy or fairly easy to obtain, as compared to their national counterparts. The following sections will review these findings and contextualize them within the extant research addressing nicotine use disparities in the reservation-area American Indian adolescent population.

4.1. Cigarette smoking

Eighth and 10th grade American Indian students reported a higher prevalence of lifetime, monthly and daily cigarette smoking than their national counterparts, which is consistent with past findings (Swaim and Stanley, 2018). However, based on the current results, 2021 – 2022 disparities in lifetime and 30-day cigarette smoking between the two groups appear to be considerably smaller than the 2016 disparities reported in Swaim and Stanley (2018). For example, the estimated prevalence of 30-day cigarette smoking among 8^th, 10^th and 12^th grade American Indian youth during the 2021– 2022 school year was 0.9, 1.8, and 0.8 percentage points higher, respectively, than national estimates. However, the estimated prevalence of 30-day smoking among American Indian youth in 2016 were 8.0, 10.2, and 12.6 percentage points higher, respectively, than national estimates.

Although these apparently diminished disparities may reflect declining levels of cigarette smoking in both samples, a rough comparison between current prevalence estimates and previously published estimates (Swaim & Stanley, 2018) points to a striking reduction in American Indian youth smoking since 2016–2017. Nationally, smoking levels among adolescents have been declining steadily since the late 1990s. Thus, the notably lower prevalence estimates found among American Indian youth in this study, relative to those reported in 2016–2017, may mirror national trends in adolescent smoking, as well as unique factors affecting reservation communities (Cunningham et al., 2019; Miech et al., 2023). Statistical analyses of nicotine use trends over time, particularly trends in use post-COVID, will be essential to confirm potentially reduced disparities.

4.2. Smokeless Tobacco

Only two significant differences between the samples were found, with 8^th and 10^th grade American Indian students reporting higher lifetime use of smokeless tobacco compared to the national sample. Although Swaim and Stanley (2018) did not provide prevalence estimates for smokeless tobacco use, an informal comparison of current prevalence estimates with earlier estimates reported in Beauvais et al. (2007) suggests smokeless tobacco use has declined among reservation-area American Indian youth over the last two decades.

4.3. Nicotine Vaping

Although statistically significant in some cases, differences in nicotine vaping prevalence between the American Indian and MTF adolescent samples were relatively small. However, mirroring national patterns of e-cigarette use (Miech et al., 2023), the current results suggest that nicotine vaping among reservation-area American Indian youth is much more prevalent than cigarette smoking and smokeless tobacco use. Both findings are consistent with those of the National Youth Tobacco Survey of U.S. middle and highschoolers (Parker-Lee, 2022), which found that 9.6% of AIAN youth and 9.3% of the overall sample reported past-month e-cigarette use, whereas 4.6% of AIAN youth and 3.7% of the overall sample reported past-month use of any combustible product.

Despite a markedly elevated prevalence of e-cigarette use relative to other tobacco products among adolescents nationally, an MTF report on national nicotine vaping trends from 2017 to 2022 found that levels of past 30-day nicotine vaping peaked in 2019 (Miech et al., 2023). Unfortunately, nationally-representative nicotine vaping data for reservation-area American Indian adolescents are not available prior to 2021. Whether reductions in nicotine vaping levels in the general adolescent population post-2019 are due to pandemic-related factors, changes in policy, and/or prevention and intervention efforts remains to be seen (Miech et al., 2023). Continued monitoring of nicotine vaping among reservation-area American Indian youth and national youth is critical to better understand the forces at play.

The high levels of nicotine vaping among Reservation-area American Indian youth, compared to cigarette smoking and smokeless tobacco use, points to a critical need for anti-vaping campaigns. However, conventional anti-smoking campaigns are shown to be less effective within American Indian adolescent populations (Yzer et al., 2021), and this limitation may generalize to anti-vaping campaigns. In response to the lack of culturally tailored nicotine vaping prevention resources, the FDA recently launched Next Legends, a social-media based anti-vaping campaign designed to educate AIAN youth about the potential harms of nicotine vaping through the incorporation of important values shared by many American Indian cultures (Federal Drug Administration, 2022).

4.4. Perceived Harm

Compared to their MTF peers, a significantly lower percentage of the American Indian adolescent sample perceived cigarette smoking and smokeless tobacco use poses great risk, which parallels earlier findings from Beauvais et al. (2007) that showed American Indian youth perceived less harm from regular use of these products relative to adolescents in the general population. Results for nicotine vaping indicate a similar disparity, where only about one third of 8^th and 10^th grade American Indian students reported regular nicotine vaping poses great risk, compared to about half of their national peers. Educating American Indian youth about the harms of nicotine vaping is critical to reducing nicotine vaping prevalence in this population. However, the discrepancy in perceived harm between reservation-area American Indian adolescents and their national counterparts suggests existing educational programming may be less effective for this population—again highlighting a critical need for anti-vaping education and prevention efforts that are culturally tailored to this population.

Although American Indian youth continue to report lower levels of perceived harm for cigarette and smokeless tobacco use than their national peers, a rough comparison of current study estimates to those found by Beauvais et al. (2007) suggests that this disparity may be shrinking. Levels of perceived harm for smoking and smokeless tobacco among American Indian youth appear to be considerably higher in the current study compared to those found by Beauvais et al. (2007) two decades ago, a finding that coincides with a potential decline in nicotine use in this population. By contrast, reported levels of perceived harm for tobacco product use within the general adolescent population have remained largely unchanged since 2004 (Miech et al., 2023). The possible increases in perceived harm among reservation-area American Indian youth in 2021–2022 relative to two decades ago, coupled with stable national levels over the same time period, may indicate that culturally grounded anti-smoking campaigns are having a uniquely positive impact on American Indian youth (Crump et al., 2020). Nevertheless, present findings indicate that reservation-area American Indian adolescents continue to perceive less harm in cigarette smoking and smokeless tobacco use than their national peers— pointing to an ongoing need for effective, culturally tailored educational resources.

4.5. Perceived Availability

Despite their elevated prevalence of tobacco product use, coupled with their lower levels of perceived harm, fewer reservation-area American Indian adolescents reported cigarettes and e-cigarettes were easily available relative to the national sample. Notably, Miech et al. (2023) have found decreases in perceived availability among the national adolescent population, which may relate to regulatory changes impacting tobacco sales and marketing (Public Health Law Center, 2020), including a federal increase in the age limit for tobacco product sales (“Tobacco to 21”; H.R.2411, 116^th Congress, 2019–2020). Policies specifically impacting reservation communities may also be affecting reservation-area American Indian adolescents’ access to tobacco products, as many tribes are passing restrictive regulations that limit use of these products on tribal lands (CounterTobacco.org, 2023). For instance, the Navajo Nation enacted the Niłch’ Éí Bee Ííná – Air is Life Act of 2021, prohibiting use of conventional cigarettes, e-cigarettes, cigars and similar products in enclosed, indoor workplaces, public places and within 25 feet of any indoor area. Furthermore, some tribes have banned or are working to ban the sale and use of nicotine vaping products on reservations. For example, the Oglala Sioux Tribal Council banned the sale, possession, and use of e-cigarettes on Pine Ridge Reservation in 2019 (Associated Press, 2019). As more data are gathered, the relationships between federal regulations, specific tribal policies and nicotine vaping prevalence among reservation-area American Indian youth should be examined.

4.6. Limitations

These findings should be considered in light of their limitations. First, while data represent stratified random samples from comprehensive sampling frames, schools were not obligated to participate. If nicotine use differed between participating schools and non-participating schools, estimates are biased; however, factors impacting participation have historically been unrelated to student characteristics. Second, not all enrolled students participated in the survey due to absenteeism on administration day. Students with high absenteeism may be more likely to use substances compared to those with low absenteeism (Dupont et al., 2013; Swaim et al., 1997). However, this issue applies to both studies such that comparison validity should be preserved. Third, youth who dropped out of high school were not included in either sample. Given high dropout rates among AI youth, OYOF estimates may underestimate nicotine prevalence for adolescents in grades 10 and 12.

5. Conclusion

This study found several persisting disparities in nicotine use between reservation-area American Indian adolescents and the general adolescent population. However, their lower prevalence of cigarette smoking relative to 2016–2017 estimates (Swaim & Stanley, 2018), higher levels of perceived harm compared to levels reported two decades ago (Beauvais et al., 2008), and significantly lower perceptions of tobacco product availability than the national sample is encouraging. Still, while the estimated prevalence of nicotine vaping is relatively similar between the two groups, a significantly lower percentage of American Indian adolescents believe nicotine vaping poses a serious risk compared to the general population. This finding not only underscores the need for culturally-tailored anti-vaping campaigns, but also for additional research assessing the relationships between nicotine product use and factors affecting use in this population. Importantly, because the findings herein represent the first estimates of nicotine vaping prevalence in a nationally-representative sample of reservation-area American Indian youth, long-term monitoring of nicotine vaping in this population is critical to address the needs of reservation-area communities.

Highlights.

• Estimated tobacco use prevalence in Reservation-area American Indian adolescents during 2021–2022 appear to be markedly lower than previously reported estimates.

• Nicotine vaping prevalence among American Indian adolescents mirrors national prevalence.

• Nicotine vaping is more prevalent than other tobacco use among American Indian adolescents.

• American Indian adolescents perceived less risk from nicotine vaping compared to a national sample.

• Culturally-tailored education about harms of vaping is critical to lowering use.

Glossary

AI

American Indian

MTF

Monitoring the Future

CI

confidence interval

NA

not asked