American Indian Persons’ Perspectives on Various Smoking Cessation Aids and Approaches: A Community-Engaged Qualitative Research Study

Abstract

Introduction

Increasing smoking cessation among American Indian (AI) persons is a critical equity goal.

Aims and Methods

During 2022, AI persons (N = 46) were interviewed on perceptions of existing and novel cessation approaches. Intention to use each approach was assessed and questions started with “cold turkey” and then queried about the following: nicotine patches, gum, lozenges (NRT); prescription medications; plant-based medications; personalized medicine; e-cigarettes; and nicotine reduction standard (NRS).

Results

Perspectives informed the identification of six crosscutting themes which were (a) environmental constraints, (b) addictiveness and side effects, (c) effectiveness of approach, (d) interpersonal influence, (e) duration or requirements of approach, and (f) novelty. Plant-based medications were viewed as natural, less likely to cause side effects, and aligned with AI cultures. Regarding NRT, many participants talked about positive word-of-mouth but noted concerns about effectiveness, side effects, and price. Regarding personalized medicine, many indicated curiosity, but some noted it would delay treatment and was too extreme to share a sample. Common perspectives for cold turkey were its drug-free nature and cost savings, but some noted it does not address cravings. Regarding the NRS, many were supportive, although some were concerned with compensatory smoking and what else remains in the cigarettes.

Conclusions

Themes translated to the greatest proportion of participants stating they would use plant-based medications followed by NRT and personalized medicine. Fewer participants reported intent to use prescription medications and e-cigarettes which reflect greater concerns with these approaches.

Implications

Results can inform tribal and other public health programming and communication efforts to increase smoking cessation among AI persons and help drive down disparities.

Introduction

For generations, American Indian (AI) persons have maintained a relationship with traditional tobacco including use in ceremonial practices and cultural protocols, as described elsewhere.^1,2 Due to U.S. colonization efforts, including the prohibition of traditional tobacco use until 1978, and the tobacco industry’s targeted marketing tactics, commercially made tobacco has become more prevalent among AI persons than persons of any other racial/ethnic group in the United States.^1,3,4 Contributing this disparity is that despite AI persons expressing interest in quitting smoking at similar levels as others, AI persons have one of the lowest levels of lifetime quitting (43.3% of AI ever smokers in 2016–2017 were former smokers versus 59.1% among White ever smokers).⁴

Cessation pharmacotherapy (medications) approved as safe and effective by the U.S. Food and Drug Administration (FDA) include over-the-counter nicotine replacement therapies (NRT; eg, nicotine gum, lozenges, and patches) and prescription medications such as varenicline.⁵ These medications seek to reduce nicotine withdrawal and are proven to increase chances of quitting when compared to quitting without pharmacotherapy (“cold turkey”).^5–7 A U.S. representative study found that one in four AI persons who smoke (PWS) and made a quit attempt used a cessation medication.⁴ A study in a county of Minnesota found that 35% of AI people who ever smoked had used a cessation medication.³ Eliciting perceptions and preferences for FDA-approved cessation medications among AI persons could inform public health programming and communication efforts to further increase medication utilization among AI persons as a way to increase smoking cessation in this population.

Another cessation pharmacotherapy being evaluated for use in the United States is a plant-based medication (ie, Cytisine which has been used in Eastern Europe as a cessation pharmacotherapy and is in clinical trial testing for future use in the United States).^8–11 Additional approaches to helping people quit smoking being considered include personalizing pharmacotherapy selection to a biological marker,^12–14 and for those uninterested in pharmacotherapy encouraging complete switching from cigarettes to e-cigarettes.^15,16 The latter being largely based on the evidence that e-cigarettes, while not harmless, result in less harmful exposures than cigarettes^17–19 and a 2024 Cochrane Review that concluded high certainty that e-cigarettes increase smoking cessation over NRT.^20,21 It is also important to note the Review’s finding regarding a potential greater risk among those who quit smoking for prolonged use (ie, at 1 year follow-up) of e-cigarettes versus NRT.²¹ Another approach to smoking cessation pertains to product standards in the cigarette itself, such as the FDA’s announcement that they are considering requiring manufacturers to reduce nicotine to minimally- or non-addictive levels.^22–26

The primary objective was to use qualitative methods to identify themes in perceptions of available and FDA-approved pharmacological approaches (ie, NRT, prescription medications) to smoking cessation among AI persons and quantitatively summarize intent to use each approach. We also leverage this study to identify themes in perceptions of the following novel approaches/aids: plant-based pharmacotherapy, personalizing pharmacotherapy selection to biomarkers, e-cigarettes, and a nicotine standard in cigarettes.

Materials and Methods

Collaborators and Participants

Participant recruitment occurred at AI-serving clinics from the Midwest (ie, Minnesota, Wisconsin; N = 26) and the West (ie, California; N = 20) regions of the United States. The Minnesota- and California-based clinics are located in urban areas and serve a diverse population of AI persons. Leadership at both the Minnesota and California clinics agreed to allow their population to participate in this study. The Wisconsin-based clinic is affiliated with a sovereign tribe and thus its participation required tribal review and a signed memorandum of understanding (between the tribe and the University of Minnesota). Two of the three clinics had representation on the study’s community advisory board (CAB) which also included representation from the American Indian Cancer Foundation (a national nonprofit). None of the clinics had their own Institutional review Board (IRB), thus the IRB at the University of Minnesota served as the IRB of record.

Our approach to recruiting individuals for this study reflects purposive sampling.²⁷ Through partnership with the three clinics, study advertisements were disseminated via multiple avenues including via providers, on social media pages, and at community health events. To be considered eligible, individuals had to identify as being AI, be ≥18 years, smoke ≥ 3 cigarettes per day (CPD) in the past 30 days, and interested in quitting smoking.

Study Procedures and Measures

All study procedures were conducted over Zoom. After informed consent, the participant cultural identity was assessed via the Traditional Activities Scale, which measures one’s participation in traditional activities.²⁸ A single measure (ie, “How confident are you filling out medical forms by yourself?”²⁹) was used to assess health literacy, which has been shown to predict quitting smoking in prior studies.³⁰ Other quantitative assessments included cigarette dependence variables, CPD, and time to first cigarette.³¹ Then, the in-depth interview began.

The interview guide was crafted by a research team comprising members who identified as both AI and non-AI, and it received input from the CAB. The research coordinator (JN), who conducted interviews for all participants and was not AI, received oversight and training in all procedures conducted for this study from both AI (LM) and non-AI (DMC) supervisors.

All interviews utilized the same structured interview guide. A single slide on each cessation approach that included a visual and a brief overview was first shared (File S1). The interviewer started with questions on quitting without any aid (“cold turkey”). Questions included “What do you think or what have you heard about the ‘cold turkey’ approach to quitting smoking?” and “How likely would you be to use the ‘cold turkey’ approach to quitting smoking on a scale from very unlikely to very likely?” (response options: very unlikely, somewhat unlikely, neutral, somewhat likely, and very likely). The same two questions were repeated for the following along with sharing a visual for each: (a) nicotine patches, gum, lozenges; (b) prescription cessation medications; (c) personalized medicine approach; (d) e-cigarettes; and (e) a product standard resulting in all cigarettes having 95% less nicotine. To elicit perceptions about a plant-based medication, the following question was asked immediately after the discussion of prescription medications and while still showing the image of prescription cessation medications: “Now, if the medication was plant-based, meaning it was made from plants, how likely would you be to use it?”

Data Analysis

The data analysis had two, complementary, objectives. First, analysis, informed by grounded theory,³² of the qualitative data to determine major crosscutting themes regarding perceptions and opinions of each cessation approach. Audio recordings of interviews were transcribed by a third party (Research Transcriptions). An initial review of five transcripts was conducted independently by each member of a three-person team (JN, DMC, and LM). After the initial review, the team (JN, DMC, and LM) revisited the five transcripts to collectively identify any patterns in perceptions and experiences voiced by participants. If a perception or experience for a given approach was voiced by at least two participants, the perception was considered a code and was added to a preliminary codebook in the software Dedoose. The remaining transcripts were analyzed (each by two members of the team; eg, JN and LM) in Dedoose using the constant comparative techniques, which is used to find consistencies and differences in responses from the draft themes, which drive the development of new and/or more nuanced codes. Codes and their descriptions (see File S2) were refined iteratively through meetings and then all transcripts were re-reviewed individually by one member of the team (JN, DMC, LM) and recoded, if necessary, based on final codes. A series of meetings among the team members as well as members of the CAB were held to determine themes based on commonalities and differences between codes. The second objective of the data analysis was to summarize, via proportions, the quantitative measure on intent to use each approach.

Results

Characteristics of the sample are summarized in Table 1. In brief, the average age was 40.0 years, slightly more than one-half (52.2%) were female, and the vast-majority reported that they smudged or saged (93.5%) and offered tobacco (87%) in the past 12 months.

Table 1.

Characteristics of the Participant Sample (N = 46)

	Mean (STD) or percent
Age in years	40.02 (11.98) Range: 20–67
Female	24 (52.17%)
Male	22 (47.83%)
Hispanic/Latino ethnicity	15.2%
In the past 12 months…
Offered tobacco	40 (87.0%)
Participated in ceremonial songs	34 (73.9%)
Smudged or saged	43 (93.5%)
Participated in ceremonial dance	25 (54.3%)
Went to a traditional healer	22 (47.8%)
Sought advice from a spiritual advisor	31 (67.4%)
Participated or sang in a drum group	14 (31.1%)
How confident are you filling out medical forms by yourself?
A little bit	0 (0.0%)
Somewhat	1 (2.2%)
Quite a bit	7 (15.2%)
Extremely	38 (82.6%)
Number of past 30 days smoked	28.63 (3.72) Range: 15–30
Cigarettes per day on days smoked	9.89 (5.57) Range: 3–30
Duration of smoking in years	22.67 (14.46) Range: 1–50
How soon after you wake up do you smoke your first cigarette?
0–5 minutes	10 (21.7%)
6–30 minutes	12 (26.1%)
31–60 minutes	4 (8.7%)
>60 minutes	20 (43.5%)

In general, coded perspectives of each cessation approach fell under one of six themes: (a) Environmental constraints; (b) Addictiveness and side effects; (c) Effectiveness of approach; (d) Interpersonal influence; (e) Duration or requirements of approach; and (f) Novelty.

“Cold Turkey”

The most common themes from discussions of the “cold turkey” method were the (lack of) environmental constraints and addictiveness and side effects with approach. Specifically, its cost savings and drug-free nature. One participant explained, “Because I am not putting any additives of anything in my body for something that I should not be doing in the first place. And so, if I was going to try anything, I would try the cold turkey.” Another participant stated, “I did not have to be on medication. And I saved money. That was another benefit.” Likewise, participants reported a preference for “cold-turkey” since it was not replacing an addiction with another. “I just will not have any crutch. Like I will not have to replace one thing with another.”

Another theme that emerged with discussions of this method was the duration or requirements of the approach and specifically the simplicity was noted as a significant benefit by many participants, with one stating “I think it might be quicker to quit. Easier and quicker than taking medication.”

Regarding the theme effectiveness of the approach, prior success with quitting using the “cold turkey” method was mentioned by some:

Because I have quit smoking before. And I just did it. It was like a psychological thing. Like it was something that I was telling myself I was going to do in my head. And I just kept trying until one day I did it. And I stopped smoking for a few years. And I just kind of like started up the last few years again. But I know that it works really well.

On the other hand, concerns were voiced by some participants regarding the inability to mitigate cravings. For example, one participant said: “The addiction. To get out of the addiction. What prevents me from going cold turkey is I have small kids, and I know how snappy I can get.”

A final theme and one that was solely discussed with this approach was feelings of pride/accomplishment. For example, one participant stated “I mean, quitting cold turkey, the benefits would be like just an accomplishment, a great accomplishment.”

Overall, the “cold turkey” feedback from participants translated into slightly more than the majority (56%) reporting that they would be “likely” to use this approach to quitting smoking (see Figure 1).

Figure 1.

Participant responses to “How likely would you be to use (“cold turkey”/nicotine patches, gum, or lozenge/prescription medications Chantix or Zyban, a plant-based medication, personalized medicine, e-cigarettes/vapes) to quitting smoking on a scale from very unlikely to very likely?” summarized as proportion of total participants who provided a response. *For the approach to “cigarettes with 95% less nicotine” the following question was presented instead “How well do you think removing 95% of nicotine from all cigarettes would work for you to quit smoking?”

Nicotine Patches, Gum, and Lozenges

Positive word-of-mouth recommendations or observations of successful experiences by friends or family members were commonly discussed by participants when asked about nicotine patches, gum, and lozenges; which align with the themes of interpersonal influence and effectiveness of the approach. For example, one participant said:

I’ve never tried the patches, the gum, or any of those. But I’ve heard it’s helpful to cut down because it gives you the same effects like when you smoke a cigarette. That’s just what I’ve been told. I’ve never actually tried these products myself.

Regarding the same themes of interpersonal influence and effectiveness of the approach, another participant said: “I know someone that is taking the gum right now. And they said it is working. He has not smoked for two days.” On the other hand, one participant noted “I really have not heard anything. I heard of people taking them or wearing the patch. But I have not really heard like great success stories about them or anything.”

Effectiveness of the approach was further discussed by a minority of participants who expressed their own prior success with NRT such as this participant:

It really did help me get through the day. And not have withdrawals. It was more like I got like really bad moods like for lashing out like a bad man. I noticed that. That’s why I was like ‘oh, I better not try to quit because I mean I might be a psycho out here.’ Yeah it was really bad. So, and then I got the gum and I wasn’t having that. Every time I started getting all crazy feeling, I pop one of them Nicorettes or whatever and I was good.

On the other hand, some participants expressed that these products were ineffective due to past unsuccessful quit attempts. For example:

I tried gum once, but I still wanted to have a cigarette. I don’t think that really helps. People say the patch works but I just think having a cigarette would be there. I think cold turkey would be the best.

Participants also shared perspectives that aligned with the theme of addictiveness and side effects with approach. Specifically, many participants expressed apprehension about potential side effects of NRT such as skin irritation, headaches, and insomnia having experienced some form of side effect with past use. One participant noted:

My side effects weren’t the worst from what I’ve heard that can happen, but it made me sick. It gave me crazy, crazy dreams, but that was about it. I heard other people get like seizures or whatever so I don’t like that stuff.

Additionally, several participants were concerned about price, which relates to the theme environmental constraints. “Patches are kind of expensive, and I would have to make sure I have the supply.”

Overall, the feedback on NRT translated into 70% of participants reporting that they would be “likely” to use NRT (Figure 1).

Prescription Medications

Many participants expressed neither interest nor disinterest in the products, which seemed to be primarily related to the themes addictiveness and side effects and the effectiveness of the approach. Additionally like NRT, many comments were linked to word-of-mouth or observations of experiences by friends or family members (which aligns with the theme interpersonal influence).

Participants very frequently mentioned concerns with side effects (theme: addictiveness and side effects) such as reported by this participant: “What are the side effects of these pills? What are they going to do to me? Am I going to get addicted to these pills?.”

Regarding the theme effectiveness of the approach, a subtheme that prescription medications not being holistic and thus not culturally aligned emerged such as described by this participant:

I don’t trust that kind of medication because I’m traditional. I’m a traditional Native person. I try to take holistic remedies for when I’m sick or for any other reason. And I don’t believe that those kind of medications are holistic.

Also regarding effectiveness of the approach, a greater number of participants reported hearing ineffective than effective results such as “I have not actually – I have just heard that name, Chantix, before. But I do not know. It was a bad example of it. This girl was here taking that and she was still out there smoking. So, I do not know what the point of that was.”

Lastly, some participants were unfamiliar with prescription medications which relates to the theme novelty. “This is the first time I’m hearing about these prescription medications. And I have never tried these. I wouldn’t know much about it.”

Overall, the feedback translated to only 42% of participants reporting they are “likely” to use prescription medications to quit smoking (Figure 1).

Plant-Based Medication

The perception that the use of a plant-based medicine would be safer and have few side effects was expressed by nearly all participants which falls under the theme of addictiveness and side effects. For example, one participant stated:

Well, because you use a good safe word. Plants are a good safe word. Who knows what...I could get sick off of plants and die from plants, too, but when I hear the word plants, I hear safety. I hear something safe in that.

Similarly, another participant stated:

Well, because I like to believe in medicinal herbs and traditional medicines. I’d rather use traditional medicines than use Western medications, especially if they’re going to raise my blood pressure. You know, I get really nervous about taking medications anyway. I don’t like to take medications.

A few participants reported ambivalence due to a lack of knowledge and potential unknowns about this approach which relates to novelty. Overall, the feedback translated into three-quarters of participants reporting that they would be “likely” to use this approach to quitting smoking (Figure 1).

Personalized Medicine Approach

When presented with the concept of personalized medication, many participants expressed being ambivalent for a common reason that related to the theme novelty: “This is my first time hearing about the personalized approach. So, I’m not too sure how that would work.” There was a skew toward more positive than negative reactions to this approach. For example, one participant stated, “I haven’t heard anything about that, but that sounds pretty interesting.”

Concerns were expressed by some participants and included one quarter of participants expressing concerns about the length of time involved with this approach which relates to the theme duration or requirements of approach:

If the process was short and easy, people would be likely to do it. If it turns out to be a long thing, then people would -- if somebody is feeling one day that they want to quit and then your process takes eight days to complete, by the eighth day, that person may be like you know what? Forget it.

Also related to the theme duration or requirements of approach, a few participants expressed not being interested in the approach due to not wanting to provide a biological sample, with one participant stating “I wouldn’t give up my DNA and whatever else, no not for quitting smoking. That’s a little extreme.”

Finally, several participants expressed concerns about the side effects of the medications involved, which relates to the theme addictiveness and side effects, leading them to express a negative sentiment. These concerns resonated with those expressed during the discussions of NRT and prescription medications.

Despite most participants being ambivalent or expressing concerns, two-thirds of participants reported that they would be “likely” to use this approach (Figure 1).

Electronic Cigarettes

A common theme that emerged when discussing e-cigarettes pertained to addictiveness and side effects and specifically that they are more addictive than cigarettes:

I feel like they’re more addictive, to be honest, because the flavorfulness and everything like that is more like an addictive mind because it doesn’t taste bad. It has that flavor to it, and it has more puffs to it.

Another participant stated:

I think it’s an easier way than smoking a cigarette because you try to hide it and you try to smoke, just one button to press and you’re getting much more than you are in a cigarette.

Moreover, many participants also viewed use of electronic cigarettes/vapes as continuing an unhealthy addiction to nicotine:

It is not really a benefit because you are just switching out your addiction. And instead of inhaling smoke, you are inhaling vapor which I am sure goes deeper into like your lungs or something.

A few of the participants testified to past use with successful cessation from cigarettes which aligns with the theme effectiveness of the approach. For example one participant said:

I actually quit smoking cigarettes when I had the e-cigarettes. I quit smoking. I would just get the disposable kind. And there would be times that I would not even smoke the e-cigarette. I would not smoke it the last half of the day.

Participant responses translated to only 38% of participants reporting that they would be “likely” to use e-cigarettes for quitting smoking (Figure 1), making intent to use this approach the lowest among all considered in the study.

Nicotine Reduction Standard

Overall, the majority of participants were supportive of the approach, which tended to be conveyed as part of comments that related to the novelty of the approach. One participant stated:

That’s the first time I’m hearing about that. I think that would be helpful, that would work because after a while they’ll probably just start to think they’re smoking it and not getting much effect and then probably get tired of inhaling smoke. And that’s the way I feel about it. There’s no point in it, there’s less effects from it.

Similarly, “I have not heard about that specific approach. But I think that is a good idea.” was a nearly verbatim comment from one-half of the participants.

Nearly one-half of the 46 participants expressed a comment related to this approach being beneficial (theme: effectiveness of the approach). “Because there isn’t much nicotine, I wouldn’t want it anymore. So I would quit smoking.” It was also common for a participant to express a lack of interest in cigarettes with 95% less nicotine for themselves, but discussed its potential good value for others. For example, one participant stated:

I think that would be good for people who are just starting off to smoke. Say like if I had a cigarette whenever it was like 95% less when I was 17, I would have probably been less likely to develop that addiction.

The most common concern expressed by one quarter of the participants was when the nicotine is reduced, what else remains. For example, one participant said:

So, they are taking out 95% of the nicotine. But what other chemicals that are in regular cigarettes are still going to be in those ones? Like what other things are going to be in there besides nicotine?

These concerns align with the theme addictiveness and side effects.

Additionally, some stated concerns about the continuation of the habit: “Because I’d have to smoke more. I’m trying to chase that nicotine.”

Only two participants expressed past use, which is likely referring to the once available low nicotine cigarettes such as Quest, both with negative outcomes. “When they first came out, I did do the lowest dose of nicotine, and it didn’t help at all. Like, I felt like I was inhaling that thing 24/7. Like, it was a pacifier to a baby.” These perspectives relate to the theme effectiveness of the approach.

Due to the nature of this approach (ie, a policy), we did not ask about intent to use, but rather we asked participants “How well do you think this approach would work for you to quit smoking?” Approximately two-thirds (67%) responded with “likely.”

Discussion

This study elicited AI PWS’s perceptions about and intent to use FDA-approved cessation medications as well as various other potential approaches to smoking cessation. Perspectives informed the identification of six crosscutting themes which were environmental constraints, addictiveness and side effects, effectiveness of approach, interpersonal influence, duration or requirements of approach, and novelty. This study also found that 75% of participants stated they would be likely to use plant-based medications followed by NRT (70%), personalized medicine (66%), and cold turkey (56%). Only 38% and 42% of participants reported that they would be “likely” to use e-cigarettes or prescription medications, respectively.

Despite 25% of AI adults with a quit attempt in the past year who report using FDA-approved cessation medications,⁴ 70% of participants in this study reported that they would likely use NRT. Behavioral change theory posits that intent predicts actual behavior, as well as other factors like environmental constraints and the skills to perform the behavior.³³ High intent to use NRT relative to actual use suggests that reducing environmental constraints, such as through making NRT free and available, may increase usage. This is supported by participants discussing costs of NRT as a barrier. Providing free NRT would reflect an equitable public health effort given that AI persons experience the highest smoking prevalence among racial/ethnic groups in the United States. While intent to use NRT was high, our data also indicates room for improvement since 30% of participants reported being “not likely” or “neutral” in their intent. Some participants viewed NRT as “a crutch” and many noted side effects. A public health campaign promoting NRT via positive word-of-mouth from AI persons themselves as a way to end addiction to commercial tobacco coupled with free NRT may increase smoking cessation.

The concept of a plant-based medication received the most positive feedback. Common perceptions expressed by participants was that it is holistic and natural and less likely to cause side effects. These perceptions are likely not unique to AI PWS, but perhaps are more amplified in AI PWS given origin stories and use of plants for medicinal and spiritual practices among AI cultures. Moreover, given plants have life they are in many ways revered, in several AI communities, as “beings with purpose.” The loss of plant knowledge due to colonization has impacted AI communities tremendously, but the desire to strengthen the awareness and use of these beings is still there. These perspectives are timely given that Cytisine, a plant-based medication, is currently ongoing testing to inform future evaluation by the U.S. FDA.^8,11,34 The introduction of Cytisine into the marketplace coupled with a culturally tailored campaign promoting smoking cessation resources for AI PWS could have a significant impact.^35,36

Participants also provided their perspectives on the concept of personalized medicine for cessation, which to date has been mostly explored in research settings.^13,14 While most participants indicated curiosity due to the novelty of the approach, some thought it would delay receipt of treatment and was too extreme to provide a biological sample in order to quit. Another theme that arose was the concerns with side effects as described in the prior sections on NRT and prescription medications. Despite the mixed feedback, two-thirds of participants reported that they would be likely to use personalized medicine. This is in alignment with a prior study among AI PWS¹² and emphasizes interest in this strategy among AI PWS should it become available.

Modeling has shown that if the U.S. FDA moves forward with a NRS, 4.3 million deaths could be prevented by 2100.³⁷ More than two-thirds of participants expressed that this approach would likely help them quit smoking and this seemed to stem from participants inferring that lowered nicotine would reduce desire to smoke, make quitting more manageable, and prevent youth from being addicted. Those who expressed concerns raised questions around what else would remain in the cigarettes and noted that they would likely just smoke more. Importantly, it has not been observed in any of the studies conducted on this topic that a NRS would lead to persistent increases in CPD among PWS.^{23–25,38–40} Additionally, evidence from a recent pooled analysis of eight clinical trials (N = 2,396) ranging from 3 to 20 weeks in duration found that fewer than 1% of all participants randomized to very low nicotine cigarettes (in efforts to mimic a potential NRS) increased their CPD.⁴¹ The misperception of increased CPD coupled with scientific evidence could be used to develop a tailored communication campaign to augment a NRS and provide accurate information to AI PWS, shall it be implemented.

This study has limitations. Participants were recruited from three states and so their views are not likely generalizable to all AI peoples. However, as discussed previously,¹² limitations of generalizability are likely balanced by potential impact. Additionally, while efforts were made to elicit a quantitative response on intent to use each approach, a response was not always provided given the flow of the conversation. Finally, right before discussing plant-based medications, prescription medications were discussed, which is one of the approaches supported by the fewest participants. While the plant-based medication was discussed when still sharing the image of the prescription medications, it was not explicitly mentioned that the plant-based medication in reference would be prescription only. Future studies should examine whether support for a plant-based medication remains high even if it is a prescription medication, which is likely to be the case for Cytisine in the United States.

In summary, plant-based medications were viewed as natural, less likely to cause side effects, and aligned with AI cultures. Regarding NRT, many participants talked about positive word-of-mouth, but noted concerns about whether NRT works, price, and side effects. Regarding personalized medicine, many indicated curiosity, but some noted it would delay treatment and was too extreme to share a biological sample. Regarding the NRS, many were supportive, although some were concerned with compensatory smoking and what else remains in the cigarettes. Fewer participants were interested in using e-cigarettes and prescription medications to quit. These findings offer guidance to public health initiatives and outreach campaigns aimed at lowering cigarette smoking in AI communities. Indeed, to facilitate the use of these findings the study’s CAB prioritized the creation of a publicly available community-facing report/infographic.⁴²

Funding

This research was funded by the National Cancer Institute of the National Institutes of Health grant number R21CA261078 (to DMC) and the National Institute on Minority Health and Health Disparities of the National Institutes of Health grant number K01MD014795 (to DMC). This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of Interests

None declared.

Author Contributions

Dana Mowls Carroll (Conceptualization [equal], Data curation [equal], Formal analysis [equal], Funding acquisition [equal], Investigation [equal], Methodology [equal], Project administration [equal], Resources [equal], Software [equal], Supervision [equal], Visualization [equal], Writing—original draft [equal], Writing—review & editing [equal]), Julie Ntegeye (Formal analysis [equal], Investigation [equal], Project administration [equal], Visualization [equal], Writing—original draft [equal], Writing—review & editing [equal]), Lou Moerner (Formal analysis [equal], Methodology [equal], Writing—original draft [equal], Writing—review & editing [equal]), Claradina Soto (Data curation [equal], Resources [equal], Writing—review & editing [equal]), Dorothy Hatsukami (Conceptualization [equal], Writing—review & editing [equal]), Antony Stately (Resources [equal], Writing—review & editing [equal]), Dylan Jennings (Resources [equal], Writing—review & editing [equal]), and Wyatt Pickner (Formal analysis [equal], Investigation [equal], Resources [equal], Writing—review & editing [equal])

Data Availability

Data have not been made publicly available. Any party interested in accessing the data should contact the corresponding author who will review the request with the community/tribal partners.