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A CASE STUDY APPROACH
LESSONS LEARNED IN ONTARIO - ABORIGINAL TOBACCO CESSATION
______________________________________________________________________
ABORIGINAL TOBACCO STRATEGY
Aboriginal Cancer Care Unit
Cancer Care Ontario
January – March 2008
This material is copyright by the original publisher and provided by desLibris subject to the licensing terms found at www.deslibris.ca TABLE OF CONTENTS

Aboriginal
Strategy

Acknowledgements

Executive

Objectives

Research
Methodology
Identification

Aboriginal Tobacco Cessation Intervention Models
A Case Study Approach
Identification of Emerging Practices for consideration
Identification of Emerging Practices

Concluding

Appendices
A: Program Manager Interview Guide
Letter of Information – Program Managers
B: Program Participant Interview Guide
Letter of Information – Program Participants
Consent Form
C: Research Participation Consent

Endnotes
References
A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation Ce document est la propriété de l'éditeur original et est diffusé par desLibris suivant les termes de licence stipulés au www.deslibris.ca ABORIGINAL TOBACCO STRATEGY

The Aboriginal Cancer Care Unit, Aboriginal Cancer Strategy
The Aboriginal Cancer Care Unit (ACCU) is responsible for developing the Aboriginal
Cancer Strategy (ACS) and is based on a wholistic approach to cancer prevention,
screening and research.
The Aboriginal Tobacco Strategy (ATS) supports Aboriginal peoples on their path to
developing tobacco-wise communities. It honors the Aboriginal path of wellness and
adheres to the principles of the ACS within Cancer Care Ontario.

Guiding Principles
o We will take a wholistic, Aboriginal approach to healthy physical, mental, emotional, spiritual and cultural needs of the individual, family and community. o We will make a difference at the community level and be inclusive of Aboriginal o We will work in conjunction with natural, informal support networks within Aboriginal communities, understanding the Aboriginal worldview and recognizing community knowledge and assets. o We will be process-oriented and respectful of people first.
About the Aboriginal Tobacco Strategy
The ATS’s primary goal is the delivery of programming under the Aboriginal Programs
component of the Smoke-Free Ontario (SFO) Strategy, Ministry of Health Promotion
(MHP) based on the three pillars of prevention, protection and cessation.
Our program develops and implements a strategy that reduces the use of commercial
tobacco among Ontario’s Aboriginal communities and populations, including on-reserve
and urban/rural communities, and thereby mitigates associated health risks.
For further information please contact:
Caroline Lidstone-Jones, Director
Caroline.Lidstone-Jones @cancercare.on.ca A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation This material is copyright by the original publisher and provided by desLibris subject to the licensing terms found at www.deslibris.ca ACKNOWLEDGEMENTS

Aboriginal Cancer Care Unit, Cancer Care Ontario

Marlene Finn
Caroline Lidstone-Jones
Theresa Sandy
Anishnawbe Mushkiki
Melanie Jourdain
Lisa Wheesk
Centre for Addiction and Mental Health
Dr. Marilyn Herie
Sarwar Hussain
De dwa dehs nye>s Aboriginal Health Centre
Allan Pelletier

MAKWA Youth Action Alliance, Thunder Bay District Health Unit
Brent Fuhr

Smoke-Free Ontario, Ministry of Health Promotion
Michele Harding
National Native Addictions Partnership Foundation
Craig Abotossaway

Regional Cancer Program, Sudbury Regional Hospital
Dr. Amanda Hey
Brian Slegers
Union of Ontario Indians
Murray Maracle Jr.
Wabano Centre for Aboriginal Health
Carlie Chase
Alison Fisher
Connie-Gail Crowder
Youth Action Alliance of Manitoulin Island
Erica Hare
A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation Ce document est la propriété de l'éditeur original et est diffusé par desLibris suivant les termes de licence stipulés au www.deslibris.ca EXECUTIVE SUMMARY


Objectives of the Study:

The intention of this report initially was to identify promising practices in Aboriginal
tobacco cessation but due to various limitations, this report did not allow for the authors
to do this. Instead, the focus of the study examined two existing Aboriginal tobacco
cessation models in Ontario in order to identify lessons learned and potential emerging
practices for consideration by others.
The identification of emerging practices from the two case studies was based on the
following criteria:
• Minimization of barriers for implementation in Aboriginal communities. • Optimization of replication for the Aboriginal population. • Strength of evidence found within the literature to support case study findings.
Problem Identification:

Sixty percent of Aboriginal people in Canada are smokers: 72% of Inuit, 57% of Métis,
and 56% of First Nations (Health Canada, 2002). Recent statistics for off-reserve
Aboriginal peoples indicates that 39% of Aboriginal males and 37% of Aboriginal
females smoke.1 These rates are significantly higher when compared to non-Aboriginal
populations where 25% of non-Aboriginal males and 19% of non-Aboriginal females
smoke (CSQI, 2008).
When working with Aboriginal populations, tobacco control cannot be looked at in
isolation from the social determinants of health. Nicotine addiction, access to tobacco,
environment, tobacco cost, socio-economic status, education, and cultural norms are all
risk factors in Aboriginal tobacco control.2
Methodology:
A literature review and an environmental scan were conducted on Aboriginal tobacco
cessation efforts and formed the foundation of this study. Two intensive case studies
were conducted with Wabano Aboriginal Health Access Centre and Anishnawbe-
Mushkiki Aboriginal Health Access Centre.
A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation This material is copyright by the original publisher and provided by desLibris subject to the licensing terms found at www.deslibris.ca Case Studies:

In-depth investigation into two Aboriginal tobacco cessation interventions in Ontario are
presented along with analysis as to areas in which program design, coordination,
implementation and evaluation are supported by literature findings on Aboriginal
tobacco cessation. With respect to the design of the two programs, this section of the
report will identify where mainstream literature about cessation is supported as well as
where gaps exist within the current literature on Aboriginal tobacco cessation. Findings
from the literature will be compared and contrasted with the design and findings of each
program so that lessons learned can be identified.
Lessons Learned:

Of the very few Aboriginal cessation projects identified through the environmental scan,
two tobacco cessation programs were chosen: Sacred Smoke, operating at Wabano
Centre for Aboriginal Health, and Sema Kenjigewin Aboriginal Tobacco Misuse
Program, from Anishnawbe Mushkiki. It was discovered both Aboriginal and non-
Aboriginal health delivery agencies would find these cessation interventions of interest,
and though they were designed to address Aboriginal tobacco risk factors and cessation
intervention barriers in an urban setting, First Nations and other rural applications are
possible with modifications. In fact, staff from these programs would prefer increased
resources and networking opportunities between urban and First Nations communities
offering tobacco cessation programs to enhance their knowledge of lessons learned
from other organizations and communities in deploying tobacco cessation strategies.
In a wholistic sense, Sacred Smoke and Sema Kenjigewin Aboriginal Tobacco Misuse
Program present emerging practices as they attempt to address the emotional, physical,
social and mental needs of Aboriginal smokers. These projects were designed with
Aboriginal cultural and social relevance in mind and as such, incorporate Aboriginal
values into the curriculum, teaching strategies, counseling methodologies and paying
attention to participants literacy levels, lifestyle, community behaviour, and family
income levels.
Identification of Emerging Practices for Consideration in Aboriginal Program
Cessation Design:

The main lessons learned in Aboriginal tobacco cessation by program managers and
key staff at Wabano and Anishnawbe Mushkiki can be grouped in terms of program
design, administration, support, and evaluation.
Program Design
• Observe the diversity of participants and recognize their different interests: First • Be cognizant of the various client supports needed respecting individual situations, income, employment level, education and other social determinants of A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation Ce document est la propriété de l'éditeur original et est diffusé par desLibris suivant les termes de licence stipulés au www.deslibris.ca • Incorporating various aspects of culture into programming does have an impact • Keep the classes informal and ensure all participants have opportunity to speak. • Elder teachings about traditional uses of tobacco, giving thanks and respecting and caring for the body are important to those who practice traditional First Nations culture. • Factual knowledge about addiction and the process of change is essential. • The program must be positively framed and emphasize harm reduction. • Linkages with other health promotional activities provide opportune “teachable • Foster autonomy and self-efficacy among participants. • Accessibility to pharmacotherapies improves chances of success. • The development and implementation of a cessation program entails various substantive costs and resources such as dedicated facilitator/ staff, managerial and finance staff, administrative support, food and beverages, transportation, childcare, facility space, overhead, elder honoraria, and guest speaker fees. • Personnel are critical to the success of the program, and they should be Aboriginal, non-smokers, trained in tobacco cessation counseling, be able to develop health promotion strategies, harm reduction approaches, be knowledgeable about tobacco addiction and be familiar with the traditional uses of tobacco. • Wrap-around support is important. Opportunities to integrate smoking cessation programs with other chronic disease programs (youth, senior’s, healthy eating active living programs) should be explored. • Supportive infrastructure and capacity within the organization is essential. Each program supports one another via cross referrals, finance, administration and supervisory supports. • Social support is critical for success in any tobacco cessation effort. • Training healthcare workers in tobacco cessation techniques is necessary to • Programs should take a wholistic approach to behavioural change. • Capitalize on non-smoker role models, particularly among the youth: o Mentoring and role modeling opportunities. A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation This material is copyright by the original publisher and provided by desLibris subject to the licensing terms found at www.deslibris.ca • Qualitative data is equally important as quantitative data in evaluating program • Pre and post evaluations with clients should: o Examine current smoking behaviours before the interventions and outcomes o Ask participants questions about program design and supports (i.e., is there anything that can be improved upon within the program design itself?). Concluding Remarks:
Various lessons learned can be gleaned from the two tobacco cessation programs
studied at Wabano and Anishnawbe Mushkiki. To begin to identify promising practices
in this area, further investigation is required by other researchers. As a result of
examining both programs, the following research gaps are suggested for follow up:
• Implementation of the emerging practices identified in this study to determine if the practices identified are easily replicated in other Aboriginal communities or by mainstream cessation program counselors when working with the Aboriginal population. • Rigorous evaluation designs are recommended to analyze program results. Evaluation design needs to include qualitative as well as quantitative methods. • As identified in the literature, the impact of tobacco taxes, smoke-free policies and environments and the denormalization of smoking cannot be overlooked in the context of any smoking cessation initiative. • Tobacco cessation programs must be integrated within the larger tobacco control community. At this present time, the author is unaware of population-level strategies pertaining exclusively to the Aboriginal population therefore warranting further research and investigation to determine the impact provincial and federal legislation, jurisdictional issues affect the Aboriginal population. A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation Ce document est la propriété de l'éditeur original et est diffusé par desLibris suivant les termes de licence stipulés au www.deslibris.ca OBJECTIVES
Initially, the purpose of this study was to focus on identifying promising practices in Aboriginal tobacco cessation, specifically to: • Engage in an environmental scan to see what programs, services and resources currently exist in Aboriginal communities regarding tobacco cessation programming (identifying what is working well within these models and what challenges exist within these models). • Seek input from Aboriginal front-line service providers to discuss their strategies and challenges regarding the delivery of cessation activities at the grassroots level. • Examine two existing Aboriginal tobacco cessation programs as case studies to aid in identifying promising practices from which others can gain insight. • Identify mainstream interventions that might be adapted to fit Aboriginal needs for
Limitations to the Study

Some considerations in producing this report must be noted. While significant research
on tobacco cessation exists including culturally competent interventions for Australian
Aborigines, New Zealander Maoris, and Hispanic Americans, for instance, valid
research data on Canadian Aboriginal tobacco cessation services and policy is quite
limited. Thus, it is difficult to qualify any intervention or practice as “best or promising”
at this time.
While organizations that implement Aboriginal tobacco cessation interventions may
undertake an evaluation to determine what is effective and where improvements could
be made, this information is often not available in the published literature. Because
there is very little published literature found on best or promising practices in Aboriginal
tobacco cessation, the findings presented in this report on tobacco cessation
intervention models designed specifically for Aboriginal people are based on the
observations, experiences and perceptions of project managers and staff at two
Aboriginal tobacco cessation projects in Ontario.
Analysis and lessons learned are based on research and discussion with a variety of
practitioners and tobacco cessation experts in Ontario.
A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation This material is copyright by the original publisher and provided by desLibris subject to the licensing terms found at www.deslibris.ca Due to time and financial constraints, the scope of the project was limited to engaging in a case study approach through the following methods: • In-depth examination and discussion with two urban, Aboriginal community- based smoking cessation interventions in Ontario. • The facilitation of one small focus group involving participants who were involved While it is not possible to make broad recommendations based solely on the findings in this report, the qualitative information shared as a result of the case studies is valuable and insightful. The information is presented in a case study format and will highlight some lessons learned and emerging practices that show promise in Aboriginal tobacco cessation efforts. It should be noted that further research will be required in order to examine the long-term outcomes of the identified emerging practices in other communities. The authors acknowledge the literature clearly states in order for cessation interventions to be effective, it is important to ensure smoke-free environments are offered in combination with smoking cessation programming. Cessation services are proven to have less impact on high prevalence of tobacco unless they are combined with tax and price increases, advertising, promotion and sponsorship bans, and smoke free environments. Thus a “push and pull” strategy has more impact than either technique on its own. However, little information exists on Aboriginal communities that have developed and implemented smoking policies and by-laws which could serve as models for others. A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation Ce document est la propriété de l'éditeur original et est diffusé par desLibris suivant les termes de licence stipulés au www.deslibris.ca RESEARCH METHODOLOGY
A literature review and an environmental scan were conducted on Aboriginal tobacco
cessation efforts and formed the foundation of this study.
Definitions:

For the purposes of the study, tobacco related definitions remained broad in recognition
of the challenges of applying these terms to an Aboriginal context for which social and
cultural meanings for tobacco are implied. Several sources of information were
consulted for guidance. For instance, the Ontario government defines cessation as the
following:
• Cessation (helping Ontarians quit smoking) Despite the fact that Inuit do not share First Nations’ history in traditional tobacco usage, the Pauktuutit Inuit Women’s Association of Canada defines cessation as follows: • Cessation (encouraging and helping those who want to learn to live without Promising Practice In 2005, the Aboriginal Tobacco Strategy (Aboriginal Cancer Care Unit) developed a working definition for identifying promising or emerging practices for which emphasis is placed on the autonomy of community to evaluate success: • Community-based promising practices are ideas or actions that worked as defined by the community and are supported by evaluation outcomes. Emerging Practice As stated previously, the intention of this report initially was to identify promising practices in Aboriginal tobacco cessation but unfortunately the limitations of this study did not allow for the authors to do this. Instead the focus of the study examined two existing Aboriginal tobacco cessation models in Ontario in order to identify some potential emerging practices for consideration. The identification of emerging practices from the two case studies was based on the following criteria: • Minimization of barriers for implementation in Aboriginal communities • Optimization of replication for the Aboriginal population A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation This material is copyright by the original publisher and provided by desLibris subject to the licensing terms found at www.deslibris.ca • Strength of evidence found within the literature search to support each program
Sources of Literature

Literature searches included web-based information from government health sites,
academic centres specializing in health promotion, addictions and tobacco control, and
Aboriginal organizations and communities associated with tobacco control. Information
sources included “grey” literature as well as published and unpublished reports,
documents and studies.
More emphasis was placed on researching local Ontario and Canadian-based sources
rather than international documents and materials, however, use of search terms such
as “indigenous,” “Aboriginal,” and “Native,” were included, leading to valuable
information from the U.S., Australia, and New Zealand.
Environmental Scan

The scope of the environmental scan included cessation interventions implemented by
primary health care providers and smoking cessation specialists in a wide range of
health settings including general practice, hospitals, Aboriginal community health
centres, and Indian Friendship Centres.
The types of cessation interventions included in the search were behavioural,
pharmacological and alternative. Aboriginal priority groups for intervention considered
separately from the general population include youth and pregnant women.

Interviews

For the purposes of discussing and confirming research findings, the Aboriginal Cancer
Care Unit recommended interviews with staff and management from various
organizations involved in health and social services related to tobacco control including
tobacco cessation counselor training, youth tobacco control, smoke-free legislation,
substance abuse treatment, and Aboriginal tobacco cessation interventions. The
following organizations were contacted:
• Anishnawbe Mushkiki – Aboriginal Health Access Centre • Training Enhancement in Applied Cessation Counselling and Health (TEACH) Project, and Stop Smoking Therapy for Ontario Patients (STOP) Study, Centre for Addictions and Mental Health • De dwa dehs nye>s Aboriginal Health Centre • MAKWA Youth Action Alliance, Thunder Bay District Health Unit • National Native Addictions Partnership Foundation • Regional Cancer Program, Sudbury Regional Hospital A Case Study Approach Lessons Learned In Ontario - Aboriginal Tobacco Cessation Ce document est la propriété de l'éditeur original et est diffusé par desLibris suivant les termes de licence stipulés au www.deslibris.ca This%document%is%available%for%Preview%only,%and%%
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