Smoking Cessation Interventions in Indigenous North Americans: A Meta-Narrative Systematic Review

Abstract

Introduction

Indigenous North Americans have the highest cigarette smoking prevalence among all racial and ethnic groups in the United States. We seek to identify effective components of smoking cessation interventions in Indigenous people in the United States associated with favorable cessation outcomes.

Methods

A review of literature studying smoking cessation interventions in Indigenous North Americans (American Indians and Alaska Natives) from January 2010 through August 2021 was completed. The primary objective of this study was to identify components of interventions associated with positive smoking cessation outcomes in Indigenous people. The studies identified were synthesized in a meta-narrative approach.

Results

Ten studies out of 608 titles were included (6 randomized trials, 2 single-arm studies, 1 cohort study, and 1 prospective observational study). Five categories of smoking cessation interventions were identified; phone or web-based tools, culturally-tailored interventions, the inclusion of Indigenous study personnel, pharmaceutical cessation aids, and behavioral health interventions. Phone and web tools, cultural tailoring, and inclusion of Indigenous personnel conditions inconsistently influenced smoking cessation. Pharmaceutical aids were viewed favorably among participants. Individualized behavioral counseling sessions were effective at promoting smoking cessation, as was input from local communities in the planning and implementation phases of study.

Conclusion

A successful smoking cessation intervention in Indigenous North Americans includes Tribal or community input in intervention design and implementation; should provide individualized counseling sessions for participants, and offer access to validated smoking cessation tools including pharmacotherapy.

Implications

This study identifies a paucity of smoking interventions utilizing standard of care interventions in Indigenous North Americans. Standard of care interventions including individualized cessation counseling and pharmacotherapy were effective at promoting cessation. The use of novel culturally tailored cessation interventions was not more effective than existing evidence-based care with the exception of including Tribal and local community input in intervention implementation. Future smoking cessation interventions in Indigenous North Americans should prioritize the use of standard of care cessation interventions.

Introduction

Smoking prevalence in North American Indigenous people (American Indians and Alaska Natives) is the highest of any race or ethnicity in the United States, estimated to be as a high as 42.1% nationally by the Centers for Disease Control.^1–5 Smoking commercial tobacco products is known to increase morbidity and mortality.^6,7 Smoking in Indigenous North Americans has also been recognized as a contributor to disparities in cancer prevalence, cardiovascular disease, and all-cause mortality.^2,6,8,9 There are over five million Indigenous North Americans in the United States represented by 574 federally recognized Tribal communities, with roughly 54% of the population residing in rural areas.^1,5,10 The cause of prominent smoking prevalence in this population is complex and multifactorial with variability among the diverse Tribal communities in the United States and Canada.^2–4,11,12 In addition to social factors influencing smoking behaviors in the general population such as social determinants of health, stable housing, transportation, medical literacy, and healthcare access, there are multiple unique factors contributing to smoking behaviors in Indigenous North Americans.^2,9,13,14 Tobacco is viewed by many Tribes as a traditional plant with spiritual, medicinal, and cultural significance.^3,15–17 The important role of traditional tobacco remains important for many communities today.^3,15–17 Historical trauma due to colonization remains a contributor to adverse health outcomes in modern Indigenous people.^14,18,19 Colonization lead to tremendous loss of life, land, language, and cultural practice and identity in every Indigenous Nation in the United States. The health impacts of this intergenerational trauma today can be measured by disparities as wide as mental health and stress coping indexes, substance use and abuse, structural racism, lifespan, and even epigenetic measures of methylation and stress.^14,18-21

Cessation interventions created for the general public not only do not acknowledge the traditional role of tobacco in Indigenous communities, but also create a negative image of tobacco that is incongruent with traditional views of tobacco for many Indigenous people.^{12,14,15,22,23} Development of smoking cessation interventions specifically tailored to Indigenous people has become an area of study in the past two decades.^2,13 Examples of culturally tailored cessation interventions include acknowledgement of the traditional role of tobacco, hiring Indigenous study staff, and collaboration with Indigenous communities. There remains a significant knowledge gap regarding the effectiveness of complex behavioral, community, and combined pharmaceutical interventions to address smoking prevalence in Indigenous people.¹³ Our objective was to conduct a systematic review of the literature to synthesize current evidence regarding smoking cessation interventions for Indigenous adults in North America with special attention towards culturally tailored interventions.²⁴

Materials and Methods

Eligibility Criteria

The target population was individuals over age 18 who identified as American Indian, Alaska Native, Indigenous or First Nations. If the primary population studied was not explicitly Indigenous, but a subset of the cohort included an Indigenous population, these studies were included. Studies conducted in the United States and Canada were included. Interventions conducted from 2010 through most current publications were included in primary search conducted January 22, 2020 with subsequent update in search completed August 2, 2021. Languages included were English and French. Ahead of print studies were considered if contacted authors released data for analysis. Authors of studies meeting criteria without specific Indigenous results were contacted to determine if an Indigenous subgroup analysis was completed. Randomized controlled trials, qualitative studies, cohort studies, and retrospective studies were included. If pediatric patients were targeted in the cohort but there were individuals over age 18, these trials were included. Trials limited to pediatric patients under age 18 were excluded. A review protocol registration was created for this study and is under review with PROSPERO, record ID number 271710. The data underlying this article are available in the article and in its online Supplementary Material.

Literature Search

A comprehensive literature search of several databases from inception to January 22, 2020, limited to English language, was conducted. Databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid APA PsycINFO, Ovid EBM Reviews – Cochrane Central Register of Controlled Trials, Ovid EBM Reviews – Cochrane Database of Systematic Reviews, Ovid Embase and Scopus. On August 2, 2021, the search was updated and re-run to include French language. A new strategy was created and run in the CINAHL (EbscoHOST) database from inception to August 2, 2021 and included both English and French language. The search strategies were designed and conducted by an experienced librarian (LCH) with input from the study’s investigators. Controlled vocabulary supplemented with keywords was used to search for relevant studies. Upon screening, case reports, case series, and review articles were excluded. The full search strategy listing all search terms used and how they are combined is available in Appendix 1, Supplementary Material.

Study Selection and Data Collection

Two independent reviewers (AR and AK) selected the studies and completed a critical appraisal with disagreements resolved by a third reviewer (CCK). Search terms were created to identify interventions intended to promote smoking cessation. Data were abstracted utilizing Covidence.org.²⁵ Data abstracted included study design, demographics, enrollment, cessation end points, retention, and efficacy data. Intervention details were also abstracted.

Methodological Quality Assessment

Randomized trials were assessed for risk of bias with the Cochrane Risk of Bias tool.²⁶ Cohort studies were evaluated with the Newcastle-Ottawa Assessment Scale.²⁷ The Tool for Methodological Risk of Bias in Case Reports and Case Series was utilized to evaluate single arm studies.²⁸

Definitions

Smokers were defined as consumers of commercial inhaled combustible tobacco products. This study was designed to capture specifically cigarette use, although cigar smokers and electronic cigarette device users were considered smokers for the purpose of this study. Exclusive users of chewing tobacco were not included. Ceremonial tobacco use was not considered smoking.

The primary outcome examined by this review was cessation from smoking commercial tobacco products. Smoking cessation was defined as abstinence from commercial cigarette smoking. Valid methods for the definition of smoking cessation were patient self-report, biochemically confirmation (exhaled carbon monoxide, salivary cotinine, urinary cotinine, and other evidence-based biologic markers), and provider collected cessation information. The minimum duration of smoking cessation considered valid for inclusion in this review were those defining cessation as greater than 24 h of abstinence.^29,30 This duration was utilized to minimize early exclusion of studies in the screening process. Duration of cessation and method for confirming cessation as defined for each study was recorded. Self-report and biomarker cessation confirmation methods were considered valid for the purposes of this review.³¹ When reported in primary literature, attitudes regarding smoking cessation interventions were reviewed.

Behavioral cessation interventions were considered any counseling intervention involving interaction with study personnel or a healthcare practitioner regarding promotion of smoking cessation. Behavioral interventions could be conducted in an individual or group setting.

There is no standard definition of a culturally tailored tobacco cessation intervention. We considered an intervention to be culturally tailored if either of the following conditions was met; (1) any existing cessation intervention modified to include Indigenous beliefs, language, or specific Tribal stories or (2) a novel cessation tool created with integrated Indigenous beliefs, language, or specific Tribal stories.

Analysis

The primary outcome was smoking cessation. We pursued a meta-narrative review approach examining complex interventions that focused on determining which components of the interventions are essential and/or necessary to promote smoking cessation. All data generated or analyzed during this study are included in this published article and its Supplementary Information files.

Results

Search resulted in 608 titles and abstracts without duplicates, with 84 studies included in full text review. Ten studies met criteria for inclusion. Exclusion criteria can be seen in Figure 1. The Cohen’s kappa statistic between reviewers was 0.87, indicating almost perfect agreement. Interventions evaluated included use of pharmaceutical cessation aids, behavioral interventions, culturally tailored interventions, text message and phone interventions, web-based interventions, and use of Indigenous study personnel. Primary outcomes and study demographics are outlined in Table 1.

Figure 1.

PRISMA diagram outlining inclusion and exclusion criteria.

Table 1.

Demographics of Included Studies

First author	Sample size	Year	Design	Intervention	Outcomes	Duration
Patten	N = 35	2012	Randomized control trial	Pregnant tobacco users < 24 weeks gestation randomized to culturally tailored counseling sessions or control.	Primary: Biochemically confirmed tobacco abstinence in late pregnancy	Late pregnancy
Smith	Study n = 50 Control n = 53	2014	Randomized control trial	Culturally tailored intervention versus control intervention. Both included varenicline.	Primary: 7-day self-reported and biochemically confirmed PPA Secondary: Medication use and reasons for relapse	6 months
Choi	Study n = 243 Control n = 220	2016	Randomized control trial	Participants randomized to culturally tailored intervention or control condition.	Primary: Cotinine verified smoking abstinence Secondary: Reduction in number of cigarettes used per day	6 months
Patten	Study n = 30 Control n = 30	2019	Randomized control trial	Randomized control pilot study enrolling patients to biomarker feedback intervention or control.	Primary: Double abstinence rate for study group versus control	1 year
Livingston	N = 1623 Control n = 588	2018	Randomized control trial	Community intervention trial with 6 communities randomized to 1 of 4 study conditions.	Primary: Self-reported use/misuse of non-alcohol substances including cigarettes, chewing tobacco, marijuana, prescription drugs, or other illegal drugs.	3 years
Dignan	N = 254	2019	Randomized trial	A multi-component intervention study randomizing subjects to one of 15 groups exposed to minimal or intense levels of 4 intervention components.	Primary: Self-reported smoking abstinence verified by carbon monoxide measurements Secondary: Impact of level of participation on smoking cessation	18 months
D’Silva	N = 141	2010	Single arm trial	Four culturally tailored individual or group counseling sessions and option for free pharmaceutical cessation aid of choice.	Primary: Abstinence, quit attempts, and daily smoking behaviors. Secondary: Demographics and participants satisfaction	90 days
Moore	N = 3373	2014	Single arm trial	Patients enrolled in intensive case management to reduce cardiovascular disease risk with individualized culturally centered care.	Primary: Blood glucose control, blood pressure control, lipid control Secondary: Smoking status, aspirin use, medication list review	1 year
Neri	N = n/a	2016	Cohort study	Questionnaires of smokers participating in either telephone Quitline’s or web-based tobacco cessation services.	Primary: 30 day abstinence Secondary: Abstinent and non-abstinent user characteristics and demographics	7 months
Fu	N = 291	2010	Prospective Observational cohort	Secondary analysis of patients who received NRT enrolled in a patient assistance program.	Primary: Self-reported 7-day point prevalence abstinence	8 months

Methodological Quality Assessment

The six randomized trials were judged to have low risk of bias for most domains; however, considering nature of interventions blinding among groups was not possible for participants, and we were unable to ascertain methods for blinding study staff in multiple trials.^32–37 The two cohort studies had good methodological quality.^38,39 The two single arm had overall good quality, with potential ascertainment bias regarding the outcomes measures as the primary concern.^40,41 Details of the methodological quality assessment are available in Appendix 2, Supplementary Material. Due to heterogeneity in methodology with crossover of pharmaceutical cessation aids between control and intervention groups, meta-analysis was not feasible.

Characteristics of Smoking Cessation Interventions

Five themes of smoking cessation interventions were identified during review; use of pharmaceutical cessation aids, behavioral health interventions, culturally tailored interventions, telephone calls or texting and online media interventions, and inclusion of Indigenous study personnel. A graphical summary of interventions described can be found in Table 2.

Table 2.

Interventions and Outcomes

Quit rate at conclusion of study as per each protocol.

See Table 1 for outcomes defined for each study.

Cigarette use, when assessed separately, was not a significant outcome.

Primary outcome was smoking rate and not compared to other outcomes.

Pharmaceutical Cessation Aid Interventions

Five studies supplied a pharmaceutical cessation aid or studied the effect of an existing prescription for a pharmaceutical cessation aid.^32,33,37,38Appendix 3 (Supplementary Material) outlines details of studies utilizing pharmaceutical cessation aids.

In a study conducted by Dignan et al. randomizing recruited patients to one of fifteen study conditions with four interventions of varying intensity, conditions including NRT were found to be associated with cessation.³³ Although NRT was found to be associated with cessation, this study had significant loss to follow up, with 16 of 254 patients remaining at the conclusion of the 18-month study.³³ In an observational cohort study of Indigenous individuals conducted by Fu et al., smoking cessation was 14.1% for the Indigenous cohort prescribed NRT, with cessation associated with a favorable perception of NRT, older age, and an adoption of a home smoking ban.³⁸ A single-arm, mixed methods, multi-site study by D’Silva et al. included use of a free pharmaceutical cessation agent of choice in conjunction with a culturally tailored cessation intervention.⁴² The self-reported cessation rate at study conclusion was 21.8% with 67% of participants using a pharmaceutical cessation aid (52% varenicline, 42% NRT, 6% bupropion).⁴² Cessation data specific to participants using a pharmaceutical cessation aid was not reported. A total of 47% of the participants completing the study reported using a pharmaceutical cessation aid was the most useful resource provided by the study.⁴² Two studies conducted by Smith et al. and Choi et al. compared control groups (standard of care counseling by a healthcare provider and pharmacotherapy) to a culturally tailored counseling intervention with pharmacotherapy.^32,37 Both studies did not reveal significant differences in tobacco cessation between the control and study cohorts when examining primary end points.^32,37 These findings support increasing access to pharmaceutical cessation aids free of cost to promote smoking cessation.

In summary, although use of a pharmaceutical aid was associated with cessation, it is difficult to estimate the effect as pharmaceutical agents were used in multiple study conditions. The use of pharmaceutical cessation aids for participants with a positive perception of these agents were effective in the promotion of cessation. Access to free or low cost pharmaceutical smoking cessation aids was an effective methods of promoting smoking cessation.

Behavioral Health Interventions

Eight trials described behavioral health interventions to promote smoking cessation.^{32–37,42,43} There was heterogeneity in methods of behavioral health interventions. Four studies offered group sessions combined with individual counseling sessions.^32,34,37,42 Four offered only individual counseling sessions.^33,35,36,43

Two randomized control trials enrolled patients in a culturally tailored group with individual counseling conditions and pharmacotherapy, compared to a control condition with similar nonculturally tailored interventions.^32,37 There was no difference in proportion of individuals who achieved smoking cessation comparing control groups to the study groups in either study, suggesting counseling was associated with cessation and not augmented by addition of cultural elements. Two randomized control trials conducted by Patten et al. utilized counseling interventions for pregnant Alaska Natives. The first involved a culturally tailored counseling intervention compared to an evidence-based nonculturally tailored intervention, and the later compared a counseling intervention including biomarker feedback compared to a group without biomarker feedback.^35,36 There was no difference in smoking cessation between control groups and novel behavioral interventions, suggesting the use of counseling interventions can promote cessation. One study implemented a counseling intervention consisting of individualized intensive case management to address cardiovascular disease risk factors at multiple Indian Health Service sites.⁴³ Self-reported cigarette smoking was reduced from 19.5% to 16.3% (p < .05). In a study enrolling patients to one of 15 study conditions including various intensities of multiple interventions, frequent behavioral interventions were not found to be highly associated with cessation.

In summary, individual counseling session interventions were effective at promoting smoking cessation. None of the four studies including combined group and individual counseling interventions reached significance at promoting smoking cessation.

Culturally Tailored Interventions

Eight studies were considered culturally tailored for the purposes of this review. All eight studies considered culturally tailored included collaborative efforts with Tribal communities in planning and implantation of interventions.^{32–37,42,43} Three studies included a cultural activity incorporated in counseling sessions, such as berry picking or story telling.^32,37,42 Three utilized tailored multimedia tools including written materials, phone and text message contact, or incentives without a specific cultural activity completed.^33,35,38 Details of elements of culturally tailored interventions are outlined in Appendix 4, Supplementary Material.

Two of the four prospective studies utilizing culturally tailored interventions did not obtain significance when considering the primary endpoint of smoking cessation.^32,33,35,37 Although D’Silva and colleagues demonstrated a favorable cessation rate of 21.8%, the participants reported the most useful aspect of the program was access to free pharmaceutical cessation aids.⁴² The authors of Choi et al. postulated inclusion of culturally relevant interventions may result in other favorable outcomes, such as study retention.³² Retention was not found to be improved in other studies with the addition of cultural elements to cessation interventions.³⁷ Of note, one study intentionally did not modify existing curriculum to the local tribal community to prevent singling out Indigenous communities, potential stereotyping of substance use, and allow generalization of intervention to communities outside of the study population.³⁴ Heterogeneity among conditions including culturally tailored interventions and the influence of unmeasured, external study factors, limit definitive conclusions regarding the effect of culturally tailored interventions. Furthermore, only the study by D’Silva and colleagues reported a participant perspective surrounding response to interventions.

In summary, collaboration with the local communities was the most effective component of culturally tailored smoking cessation interventions. Three of the eight studies including input from Tribal or local communities reached significance in accordance with primary outcome of smoking cessation. Including a cultural activity was inconsistently associated with smoking cessation.

Telephone Calls, Text Messages, and Online Interventions

Phone, text, and online media interventions were used in five of the included studies. Four studies included phone contact including use of text messages, and one examined web based or phone Quitline use.^{32,33,35,36,39}

Phone calls were utilized by Patten et al. in 2012 as part of an outreach intervention to rural Alaska Native women, and as a component of a biomarker feedback pilot intervention in 2019.³⁶ Neither of these interventions reached significance for the primary outcome of smoking cessation as defined by each study protocol.^35,36 Choi et al. provided telephone-based motivational counseling as an adjunct to in-person group-based counseling,³² without reaching significance for the primary outcome. Dignan et al. used mobile health (mHealth) text messages to provide education and support.³³ Participants received up to four messages, including a morning query that required a response. This study also failed to reach significance at promoting cessation as the primary outcome. Neri et al. found Quitline users were 1.26 (1.00–1.58) times more likely to achieve smoking cessation than those using web-based interventions.³⁹ While the number of participants was large (n = 4086), only 2% of all Quitline users (n = 2238), and less than 1% of web users (n = 1848) self-identified as Indigenous. Telephone-based interventions did not positively impact participation or retention. Retention was a more significant issue in the telephone-based current best practice arm than the culturally tailored intervention arm in the trial conducted by Choi et al.³² In one of the studies by Patten et al., participation did not increase when study coordinators offered telephone counseling to a group of pregnant women who did not have time to commute to their in-person visits.³⁵

In summary, there is insufficient evidence to support the use of phone and text message interventions in Indigenous populations. The postulated benefit of retention was not supported by evidence.

Indigenous Study Personnel

The involvement of Indigenous study personnel or counselors from the community was noted in four of the studies.^32,34,35,37

The trial piloted by Patten et al. included counseling by an Alaska Native counselor.³⁵ This trial failed to promote smoking cessation compared to a standard pregnancy cessation counseling intervention. In Smith et al., counseling was offered by the study coordinator, an enrolled tribal member.³⁷ Smith failed to reach significance in promoting greater cessation than standard of care interventions. The study by Livingston et al. partnered with school district superintendents, school principals, teachers, social workers and local citizen of the Cherokee nations, with each of these playing a pivotal role in the intervention.³⁴ While this intervention promoted alcohol and chewing tobacco cessation, smoking was not reduced with this intervention. Choi et al. were the only to have recruited an Indigenous group facilitator for their culturally tailored intervention and a non-Indigenous facilitator for their current best practice program.³² The study condition did not reveal significance compared to the control in promoting smoking cessation.

In summary, incorporating Indigenous study personnel as counselors or coordinators interfacing directly with participants was not associated with smoking cessation superior to existing best practice interventions.

Discussion

There are insufficient randomized control trials and prospective interventions to address disparities in smoking in Indigenous North Americans. We found only three studies representing 3768 Indigenous individuals that were effective at achieving smoking cessation.^33,42,43 These studies were heterogenous, but commonalities included individual counseling sessions, access to validated smoking cessation tools, and Tribal community collaboration in development and implementation of interventions. Seven studies representing 2545 Indigenous individuals did not result in significant smoking cessation.^32,34–39 Common challenges among all included studies were loss to follow up. This challenge has been previously described in Indigenous populations due to a variety of factors, including hesitancy to participate due to lack of Indigenous representation by study physicians, living geographically far from study sites with transportation challenges, fear of breach in confidentiality, and lack of personal experience with the disease being studied by study personnel.^20,44,45 The role of historical trauma and negative experiences with past research practices further influences the recruitment and retention of Indigenous people in clinical research.^19,46,47

Although novel smoking cessation interventions including a variety of culturally tailored interventions were completed, they were inconsistently more effective than control interventions at achieving the primary outcome of smoking cessation. Considering secondary effects of culturally tailored interventions such as retention and patient satisfaction, there were again inconsistent benefits associated with inclusion of culturally tailored interventions. Although Choi et al. postulated a secondary benefit of cultural tailoring would increase retention in studies, a similar study conducted by Smith et al. had one of the lowest percentages of retention of the included studies in this review despite inclusion of culturally tailored elements.^32,37 Although participants in D’Silva et al. found the use of cultural elements helpful, more participants found free pharmaceutical cessation aids useful to achieve cessation.⁴²

Individual counseling sessions to promote smoking cessation are effective interventions to augment smoking cessation counseling completed during a clinical encounter.⁴⁸ There is strong evidence suggesting use of individual counseling is effective when completed without other interventions in the general population, and moderate evidence suggesting individualized counseling methods in addition to pharmacotherapy are effective at promoting cessation.⁴⁸ In the Indigenous population, individual counseling interventions were effective when included in a smoking cessation program. Adding cultural elements to these interventions did not promote higher rates of smoking cessation compared to studies with a control. These findings suggest promoting evidence based counseling interventions with higher uptake in Indigenous North Americans may be required to promote greater rates of smoking cessation. Access to evidence based counseling interventions for this population requires further interventions including addressing social determinants of health, such as equitable care promoting referral to cessation programs, transportation for patients in rural settings, and other social barriers.⁹

Collaboration with Tribal communities to develop interventions resulted in improved smoking cessation outcomes among studies included. These findings suggest collaborative research methodologies in Indigenous populations result in favorable smoking cessation outcomes. Conducting studies in the framework of community based participatory research (CBPR) represents a methodology with prior success in Indigenous communities.^49,50 CBPR is a research method involving community members as stakeholders in the research process.⁵⁰ By involving local communities in planning and implementation, experiential knowledge from the community can enhance interventions. Limitations in recommending community collaboration include heterogeneity in populations examined among included studies. Some studies were conducted in collaboration with one specific Tribe, such as the intervention conducted by D’Silva et al.⁴² Language and Tribal stories were included in crafting interventions, limiting generalizability to other Indigenous communities. In the study conducted by Moore et al., use of a standardized counseling framework to address cardiovascular risk factors across multiple IHS facilities promoted smoking cessation.⁴³ This suggests increasing access to validated tools promoting smoking cessation may be sufficient to promote changes in health outcomes. These interventions may have insufficient uptake in Indigenous communities due to the influence of societal and social factors. The importance of assessing the needs of communities prior to implementation of an intervention are demonstrated by wide regional and Tribal variability in cigarette smoking prevalence. For example, adults of Northern Plains Tribes have estimated smoking prevalence in adults of 44%, compared to 21% of adults of Southwestern Tribes.^4,11,51 There are further regional variations in Indigenous adults residing in urban settings. An estimated 40% of Urban Indigenous people in Oakland, California smoke commercial tobacco products.¹² Conducting a thorough community needs assessment prior to design and implementation is critical to meet the unique needs of urban, rural, and reservation based Indigenous North Americans.

Although interest in developing novel smoking cessation interventions remains high, there are limitations in current data describing the impact of standardized smoking cessation interventions in Indigenous communities. This review demonstrates pharmacotherapy and standard of care counseling interventions are effective. None of the included studies focused on cessation maintenance or long-term tobacco use outcomes. Longitudinal effects of these interventions following study conclusion are unknown, and no study provided ongoing support to maintain cessation after study conclusion. Despite these limitations, there is evidence to support conducting a community needs assessments and collaboration with local communities when planning an intervention. An additional element of effective interventions included individualized plans and meetings with participants. Future trials studying smoking cessation in the Indigenous population should include three components based on current evidence, (1) community collaboration in planning and implementation of interventions and (2) individual meetings with participants, and (3) increasing access to standard of care smoking cessation interventions including pharmaceutical cessation aids.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

Dr. Rusk discloses disclose funding from the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and the Rochester Epidemiology Project Scholarship. Dr. Kennedy discloses funding from the National Institutes of Health, Mayo Funds, and the Department of Defense. Dr. Murad and Dr. Kanj have no funding to disclose.

Declaration of Interests

The authors have no conflicts of interest to disclose.