University of Southern California Dissertations and Theses

Cultural risk and protective factors for tobacco use behaviors and depressive symptoms among American Indian adolescents in California

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Cultural risk and protective factors for tobacco use behaviors and depressive symptoms among American Indian adolescents in California

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Content 1

CULTURAL RISK AND PROTECTIVE FACTORS FOR TOBACCO USE BEHAVIORS
AND DEPRESSIVE SYMPTOMS AMONG AMERICAN INDIAN ADOLESCENTS IN CALIFORNIA

By

Claradina Soto

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PREVENTIVE MEDICINE)

August 2013

Copyright 2013 Claradina Soto
2

DEDICATION
This dissertation is dedicated to my wonderful husband Daniel, my daughter Toya, my son
Talon and to my beautiful parents, Clarence Toya and Susie Whitey, for their faith, love and
everlasting support.

3

ACKNOWLEDGEMENTS
I would like to thank my committee members, Drs. Jennifer B. Unger, Lourdes
Baezconde-Garbanati, Jean Richardson, Chih-Ping Chou, and Karen D. Lincoln for your
expertise, guidance, and inspiration on this doctoral journey. Thank you to all the USC
faculty, staff, and doctoral students for your support and respected advice in getting me to
this point. I would like to extend a special thank you to Marny Barovich for her patience
and perseverance to help me reach my goals.
I would like to extend a huge thank you to all my friends and colleagues, who
believed in me, inspired me, supported me, and challenged me through all these years.
This dissertation would not be possible without the American Indian community in
California that provided their experience, guidance, and openness to allow a “researcher”
work together with their tribal and urban organizations to gather unique data for their
community. I am so grateful to all the Native youth that supported the project and
provided their invaluable input.
Finally, I would like to thank my family for making this process a reality. My
husband Daniel, where our life journey together has been 18 years strong has been my
biggest champion who has had the most patience. I could not have come this far without
you and our children, Toya and Talon. To my beautiful children, thank you for always
making me smile, laugh and dance. My dad and mom, Clarence and Sue, I would like to
extend a big thank you for paving this road for me and for always being there for me and
my family.
This research was supported by the Tobacco-Related Disease Research Program
(Grant #15RT-0111) and by the National Cancer Institute (#T32CA009492).
4

TABLE OF CONTENTS
DEDICATION 2
ACKNOWLEDGEMENTS 3
LIST OF TABLES 6
LIST OF FIGURES 7
ABSTRACT 8

CHAPTER 1: INTRODUCTION 10
Specific Aims
Background and Significance

CHAPTER 2: STUDY 1 42
“Recreational and Ceremonial Use of Tobacco at Cultural Events by
American Indian Urban and Reservation Youth in California”
Abstract
Introduction
Method
Results
Discussion

CHAPTER 3: STUDY 2 74
“Stressful Life Events, Ethnic Identity, Historical Trauma, and Participation in
Cultural Events: Associations with Smoking Behaviors among American Indian
Adolescents in California”
Abstract
Introduction
Method
Results
Discussion

CHAPTER 4: STUDY 3 110
“Stressful Life Events, Ethnic Identity, Historical Trauma, and Participation in
Cultural Events: Associations with Depressive Symptoms among American Indian
Adolescents in California”
Abstract
Introduction
Method
Results
Discussion

CHAPTER 5: CONCLUSION 140
Summary
5

Implications for Prevention
Limitation and Strengths
Future Research Directions

REFERENCES 152
6

LIST OF TABLES

TABLE 1: Study 1 Survey Items 66
TABLE 2: Demographics of American Indian California Youth 69
TABLE 3: Knowledge and Use of Ceremonial Tobacco by Smoking Status 71
TABLE 4: Cultural Activities and Prevalence of Tobacco Use 72
TABLE 5: Multiple Logistic Regression Models of Past-Month and 73
Experimental Smoking

TABLE 6: Study 2 -Correlations, Mean, and Standard Deviations 103
TABLE 7: Historical Trauma Measure and Distribution 105
TABLE 8: Ethnic Identity Measure and Distribution 106
TABLE 9: Stressful Life Event Questions and Percentages 107
TABLE 10: Study 3 -Correlations, Mean, and Standard Deviations 137
TABLE 11: Depressive Symptoms Distribution 139

7

LIST OF FIGURES

FIGURE 1. Theoretical Model for Study 2 15
FIGURE 2. Theoretical Model for Study 3 16
FIGURE 3. Final Structural Equation Model for Study 2 104
FIGURE 4. Final Structural Equation Model for Study 3 138

8

ABSTRACT

Background: American Indian (AI) populations suffer the greatest health disparities in the
United States. AI youth bear a larger burden both in terms of higher prevalence of mental
health problems and substance abuse. This dissertation investigates the specific challenges
and potential protective factors to behavioral and mental health disparities, specifically
smoking behaviors and depressive symptoms among a sample of AI adolescents in urban
and reservation areas of California. Study 1 documents AI adolescents’ exposure to
ceremonial and commercial tobacco use during five cultural practices, including the type of
tobacco used, who used tobacco, and how it was used, as well as the prevalence of
recreational cigarette use, other tobacco product use, and preferred commercial tobacco
brands. Associations of ceremonial tobacco use and social/environmental exposure with
cigarette smoking are examined. Study 2 and 3 examine AI adolescents’ thoughts of
historical loss as a mediator between three predictor (ethnic identity, participation in
cultural activities, and stressful life events) variables to depressive symptoms and smoking
behaviors.
Methods: AI youth in California (N= 940, ages 13-19, recruited from 49 different tribal
youth organizations and cultural events in urban and reservation areas of California)
completed a culturally-specific tobacco survey. In Study 1 variations across gender, age,
smoking status, and region (urban vs. reservation) were examined. Multiple logistic
regressions were used to determine associations between predictor variables and smoking
behavior outcomes. In Study 2 and 3, Structural Equation Modeling analysis was used to
assess the observed and latent variables.
9

Results: More than half of the participants were female (59%), mean age was 15.5 years,
and 60% were urban youth (i.e. lived in cities rather than on reservations). Twenty-five
percent were past-month smokers and 30% were experimental smokers. Findings from
study 1 indicated AI youth who smoke tobacco in a ceremonial way and use commercial
tobacco at ceremonies were at risk for recreational smoking. Additionally, having a
grandparent(s) who smokes served as a protective factor against smoking cigarettes.
Studies 2 and 3 results showed historical trauma to mediate the participation in cultural
activities and stressful life events to depressive symptoms and smoking outcomes.
However, an inconsistent mediated effect occurred with a negative direct effect from ethnic
identity to both study outcomes and a positive indirect effect from ethnic identity to
historical trauma to both study outcomes. As hypothesized, all exogenous variables
predicted historical trauma. A significant positive path emerged from historical trauma to
the outcome. Lastly, a significant positive path emerged from stressful life events to
depressive symptoms.
Conclusions: Taken together, findings from these studies indicate AI youth are at risk for
smoking cigarettes and depressive symptoms. Continued research is needed on the effects
of historical trauma to develop effective interventions to reduce emotional suffering and
risky behaviors. Interventions should be guided by the AI community to improve quality of
life, specifically behavioral health and well-being.

10

CHAPTER 1: INTRODUCTION
Specific Aims
American Indian (AI) youth in the United Stated currently experience numerous
health disparities and challenges that have persisted from social and political forces
exerted on AI communities. AI youth bear a larger burden both in terms of higher
prevalence of mental health problems and substance abuse (Goodkind, LaNoue, & Milford,
2010; Sarche & Spicer, 2008; K.L. Walters & Simoni, 2009). This dissertation investigates
the specific challenges and potential protective factors to behavioral and mental health
disparities, specifically smoking behaviors and depressive symptoms among a sample of AI
adolescents in urban and reservation areas of California.
American Indians (AI) have a long history with tobacco, and it is still considered a
sacred and powerful substance used for ceremonial and medicinal purposes today (C. Pego,
R. Hill, G. Solomon, R. Chisholm, & S. Ivey, 1995). Unfortunately, many AIs misuse
commercial tobacco for recreational purposes and have the highest smoking prevalence of
any ethnic group in the United States (CDC, 2011). According to the 2011 National Survey
on Drug Use and Health rates of past month cigarette use among youth aged 12 to 17 are
highest among American Indians/Alaska Natives (AI/AN) (12.3%), compared to Whites
(8.2%), Hispanics (6.1%), Blacks (4.9%), and Asians (3.3%). AI/AN youth also show the
most prevalent use of other tobacco products including cigarettes, smokeless tobacco,
cigars, and pipe tobacco (14.5%) (SAMHSA, 2012). Virtually no research has examined the
use of ceremonial tobacco in cultural activities and its association with recreational tobacco
use among AI youth. Therefore, Study 1 examines a number of psychosocial cultural risk
11

and protective factors to smoking behaviors, specifically the influence of ceremonial
tobacco use.
Depression is a major public and mental health problem among American Indian
(AI) youth. According to SAMHSA (2007), among adolescents ages 12 to 17, American
Indian/Alaska Natives had the highest lifetime (13.3%) and past-year (9.3%) prevalence of
major depressive episode (MDE). For depressive symptoms, AI youth (29%) reported
higher depressive symptoms as compared with 22% of Hispanic, 18% of white, 17% of
Asian American, and 15% of African American youth (Saluja et al., 2004). Depressive
symptoms generally appear in childhood, adolescence, or early adulthood (Thrane,
Whitbeck, Hoyt, & Shelley, 2004). Therefore, further examination of psychosocial
predictors to depressive symptoms is necessary.
A possible cause of the higher prevalence of depression among AI youth is their
experience of historical trauma (M.Y.H. Brave Heart, 2000; Whitbeck, Yu, McChargue, &
Crawford, 2009). Historical trauma has been defined as the “cumulative emotional and
psychological wounding over the lifespan and across generations emanating from massive
group experience” (Brave Heart, 2003; p. 5). Over generations, American Indians have
experienced a series of historical traumatic events including community massacres,
genocidal policies, pandemics from the introduction of diseases, forced relocation, forced
removal of children from their families and into boarding schools, and government bans
against practicing spiritual and traditional ceremonies (M.Y.H. Brave Heart & DeBruyn,
1998; Duran & Duran, 1995; Whitbeck, Walls, Johnson, Morrisseau, & McDougall, 2009).
AIs experienced these events for more than 500 years and still live daily with the economic
conditions of reservation life, discrimination, daily stressful life events, and a sense of
12

cultural loss (Baldwin, Brown, Wayment, Nez, & Brelsford, 2011; Whitbeck, Adams, Hoyt, &
Chen, 2004). Many AI youth are directly or indirectly faced with these negative social
factors in addition to the stressful life events (e.g. entering new high school, being
pregnant, friend or family member attempt suicide, gossip, or arguments with friends)
(Baldwin, et al., 2011), which may impact their mental health status and health behaviors.
Few studies exists that explore historical trauma and AI adolescents, therefore, we examine
the concept of historical trauma and its impact to mental and behavioral health outcomes.
Study 2 and 3 examine historical trauma as a mediating mechanism linking ethnic
identity, cultural activities, and stressful life events to depressive symptoms and smoking
behaviors. With the diversity and history of American Indian tribes, this information will
help understand the disparities that exist among AI youth and the implications for
intervention approaches to increase parity.
Study 1
Study 1 examines AI adolescents’ exposure to ceremonial and commercial tobacco
use during five cultural practices, including the type of tobacco used, who used tobacco,
and how it was used, as well as the prevalence of recreational cigarette use, other tobacco
product use, and preferred commercial tobacco brands. Associations of ceremonial
tobacco use and social/environmental exposure with cigarette smoking are examined.
Variation across gender, age, smoking status, and region (urban vs. reservation) are also
examined. Multiple logistic regressions were used to determine associations between
predictor variables and smoking behavior outcomes.

13

The Specific Aims of Study 1:
A1-1. Examine the type of tobacco (natural, commercial, or both) used for
ceremonial purposes by AI youth and its association to cigarette smoking
(experimental and past-month).
A1-2. Examine the perceptions of AI youth who attended the cultural events (i.e.
pow-wow, drum group, roundhouse, funeral/wake, and sweat lodge) to understand
how tobacco was used and by whom it was used (gender and age groups).
A1-3. Examine whether attendance at cultural events is associated with cigarette
smoking.
A1-4. Examine the prevalence of recreational cigarette use, the use of other tobacco
products, and the brands most preferred.
A1-5. Examine the risks of exposure to smoking in their social environments (i.e.
family and friends who smoke, household smoking rules, and second-hand smoke
exposures) and its association to cigarette smoking.
Study 2
Study 2 examines historical trauma as a potential mediator of the effects of ethnic
identity, participation in cultural activities, and stressful life events on smoking behaviors
among California AI adolescents. The structural equation model was estimated using the
MPLUS 7.1 statistical program (Muthén & Muthén, 2012). (See Figure 1)
The Specific Aim of Study 2:
A2-1. Examine all exogenous variables (ethnic identity, cultural activities, and
stressful life events) to historical trauma and in turn, impact to cigarette smoking.

14

Direct Effects
A2-1a. All exogenous variables will be positively associated with historical
trauma (path a).
A2-1b. Historical trauma will be positively associated with smoking outcomes
(path c).
A2-1c. Higher levels of ethnic identity will be negatively associated with past-
month and experimental smoking (path b).
A2-1d. More stressful life events and participation in cultural activities will have a
positive direct impact on past-month and experimental smoking (path b).
Indirect Effects
A2-2e. A negative mediating effect of historical trauma on the relationship between
ethnic identity and smoking outcomes.
A2-2f. A positive mediating effect of historical trauma on the relationship between
cultural activities and smoking outcomes.
A2-2g. A positive mediating effect of historical trauma on the relationship between
stressful life events and smoking outcomes.
15

Cultural
Events
Stressful Life
Events
Experimental
Smoking
Past-month
Smoking
Figure 1. Theoretical Model (Study 2)
a
c
c
b
b
b (-)
b (-)
b
a
a
b
Ethnic
Identity
Historical
Trauma

Study 3
Study 3 also examines historical trauma as a potential mediator of the effects of
ethnic identity, participation in cultural activities, and stressful life events on depressive
symptoms among California AI adolescents. The structural equation model was estimated
using the EQS 6.1 statistical package (Bentler & Wu, 2003). (See Figure 2)
The Specific Aim of Study 3:
A3-1. Examine all exogenous variables (ethnic identity, cultural activities, and stressful
life events) to historical trauma and in turn, the impact to depressive symptoms.
Direct Effects
A3-1a. All exogenous variables will be positively associated with historical
trauma (path a).
A3-1b. Historical trauma will be positively associated with depressive symptoms
(path c).
16

A3-1c. Higher levels of ethnic identity and participation in cultural activities will
be negatively associated with depressive symptoms (path b).
A2-1d. More stressful life events will have a positive direct impact on depressive
symptoms (path b).
Indirect Effects
A2-2e. A negative mediating effect of historical trauma on the relationship between
ethnic identity and depressive symptoms.
A2-2f. A positive mediating effect of historical trauma on the relationship between
cultural activities and depressive symptoms.
A2-2g. A positive mediating effect of historical trauma on the relationship between
stressful life events and depressive symptoms.

Ethnic
Identity
Cultural
Activities
Stressful Life
Events
Historical
Trauma
Depressive
Symptoms
Figure 2. Theoretical Model (Study 3)
(-)
(+)
(+)
(+)
(-)
(+)
a
a
a
b
b
c
(+)
b

17

Background and Significance
Public Health Significance of American Indian Youth Mental and Behavioral Health
Health disparities exist with American Indian adolescents. American Indian (AI)
youth are among the most vulnerable population in the United States with high rates of
poverty, exposure to violence, mental health issues, high rates of substance abuse and
smoking cigarettes(Spero M Manson, 2004; US DHHS 2001; West, Williams, Suzukovich,
Strangeman, & Novins, 2012). There is a lack of data on the health of urban and
reservation youth. More studies have collected data on reservations because of the
accessibility of a tribal community verses an urban area where many are geographically
dispersed.
The health status of AI adolescents is below that of the overall US adolescent
population (Baldwin, et al., 2011). AI youth experience exceedingly high rates of
depression, anxiety, trauma, substance abuse, suicide, and are at a high risk for a range of
poor outcomes, including teen pregnancy, school dropout, low academic achievement, out
of home placement, family and peer relationships, physical health concerns, accidental
death, and premature death (Fleming, Manson, & Bergeisen, 1996; Olson & Wahab, 2006;
Witko, 2006). They are at a heightened risk for chronic distress due to poverty, cultural
trauma, and violence (Grandbois, 2005; T. R. Rieckmann, Wadsworth, & Deyhle, 2004).
Many chronic and acute stressful life events occur consistently or infrequently among AI
youth and can lead to negative health behaviors and mental health outcomes.
The American Indian Population in United States
There are 566 federally-recognized American Indian (AI) tribes in the United States
and over 200 different languages spoken (Census, 2010). With federal recognition, AI
18

tribes can self-govern themselves as a sovereign nation while maintaining a government-
to-government relationship with the United States. Tribes are independent nations that
can form their own governments, establish membership, and provide health care,
education, and other social services to their tribal members. Non-federally recognized
tribes are tribes that never were recognized by the U.S government due to their small size;
this was part of the era to eradicate AI populations. Over 5.2 million people or 1.7%
identified as American Indian or Alaska Native, either alone or in combination with one or
more races, an increase of 27% from 2000 to 2010 (Census, 2010). Over three-fourths of
the AI population lives outside tribal areas with many in close proximity to reservations.
Many live in American cities (i.e. Los Angeles, Minneapolis, and Seattle) and are known as
“Urban Indians.” They are members or descendants of many AI tribes with most directly
linked to the forcible relocation efforts of the Termination and Relocation policies of the
1950’s (Dixon & Roubideaux, 2001). Urban Indians are geographically dispersed
throughout the metropolitan area where clusters of AI can be found throughout the region.
Many AIs possess a direct connection to their tribe and visit their reservation or homeland.
Approximately 28% of the AI populations speak another language other than
English at home compared to 21% for the rest of the nation (Census, 2010). Despite their
wealth in terms of tribal diversity and cultural traditions, AIs continue to be faced with
socioeconomic disadvantages (Huyser, Sakamoto, & Takei, 2010). Compared to the overall
US population, AIs are younger, poorer and more likely to be unemployed or to lack health
insurance (Census, 2010). Moreover, AI populations continue to suffer high rates of illness,
disability, and death from chronic and preventable conditions, injury, and suicide (Gary,
Baker, & Grandbois, 2005).
19

The American Indian Population in California
In California there are 107 federally recognized tribes and many urban American
Indians (Satter et al., 2012). Overall, there are approximately 350,000 American Indians
who identify as AI alone and approximately 600,000 who identify as AI and of another race
(Census, 2010). California is home to one of the largest AI populations in the country that
includes federally, non-federally recognized tribes, terminated tribes, and urban Indians.
In fact, nearly 80% of the American Indian population in California resides in urban areas
(Census, 2000). Among the federally recognized tribes in CA, there are 85 reservations or
Rancherias scattered throughout the state (Hodge, Fredericks, & Kipnis, 1996).
Economic, cultural, social, historical factors, as well as access to health care have led
to severe health disparities among the urban Indian population (Witko, 2006). The urban
AI population suffers from chronic health conditions and health disparities that are vastly
disproportionate to the health status of the general population, and other minority groups
(Castor et al., 2006). Despite reports documenting numerous health disparities, urban
Indians living California cities remain under-served.
Cultural Activities by CA American Indian Youth
Cultural activities in California can include but are not limited to Pow-wows, drum
groups, sweat lodges, roundhouse ceremonies, and funeral/wakes. These cultural
activities were selected for this study based on focus groups with AI youth in CA. Pow-
wows are community social gatherings that include traditional activities such as native
dance and song. It is also a celebration of tribal customs and cultural connectedness. Pow-
wows begin with a Grand Entry with all dancers participating to honor the event. A master
of ceremony is the voice of the Pow-wow to keep the singers, dancers, drum rotation, and
20

general public informed. Different styles of dancing with traditional regalia are
accompanied by drum and native songs. Traditional and contemporary foods are provided
or sold along with the event. Commercial vendors and information/outreach booths often
accompany Pow-wows, usually on the outskirts of the central dancing area (Wright et al.,
2011). Drum groups are accompanied by native singing or traditional songs and
intertwined with dancers at Powwows or other cultural based tribal events. Many youth
can participate in drumming and are taught by the elders. The sweat lodge ceremony is a
traditional purification ceremony that incorporates traditional singing, prayer, counseling,
and sharing similar to a talking circle. It takes place in an enclosed space (lodge) with
heated rocks, heat, and steam (Mails, 1978; Welch, 2002). Tribes may vary to integrate
their own customs, philosophies and traditional use of medicines during the facilitation of
the ceremony (Wright, et al., 2011). The sweat lodge is widely considered to be a
traditional medicine practice as well as a cultural activity. Traditional medicine use has
been shown to significantly improve health (Buchwald, Beals, & Manson, 2000). At a
funeral or wake, tobacco is sprinkled on the ground or smoked in honor of the deceased
person. Roundhouse is a large ceremonial house where AI community members gather
together for ceremonial dances, singing, and prayer where tobacco is used and respected.
This practice is mainly among the Central AIs of California and it is a very sacred practice
for their tribal members.
Socioeconomic Challenges Facing the AI Population
American Indian communities are disproportionately affected by numerous social
factors that increase their risk for physical, behavioral, and mental and health problems.
The 2010 Census reported that 28% of AI individuals live below the poverty level as
21

compared to 9.9% of non-Hispanic Whites who live below the poverty level (Census, 2010).
Among AIs who are aged 25 and over, 77% have at least a high school diploma compared to
90% of non-Hispanic White. The majority of AIs live in metropolitan areas (60%), with
22% living on reservations or other trust lands (Census, 2010). Twenty-eight percent of
the AI population is under the age of 18 years.
AIs living on reservations are especially impacted by socioeconomic disparities. For
instance, the poverty rate on reservations is 28.4% compared to 15.3% nationally among
the general population (Census, 2010). Socioeconomic conditions are seen as major factors
contributing to substance abuse among youth of Native American communities (May &
Moran, 1995). The economic reality of reservation and tribal community living is one in
which the annual family income is among the lowest in the nation and where the scarcity of
employment opportunities produces widespread job insecurity, high rates of
unemployment, and extensive need for state and federal welfare (Census, 2010; O'Nell &
Mitchell, 1996). Many AI youth are directly or indirectly faced with these negative social
factors and environments that can be deemed as stressful and contribute to negative
mental and behavioral health.
Commercial Tobacco Use among American Indian Adolescents
Commercial tobacco abuse is a serious public health issue among AI populations in
the United States. AI youth have a higher prevalence of commercial tobacco use than all
other racial and ethnic groups. According to the 2011 National Survey on Drug Use and
Health (SAMHSA, 2012), rates of past month cigarette use among youth aged 12 to 17 are
highest among American Indians/Alaska Natives (AI/AN) (12.3%), compared to Whites
(8.2%), Hispanics (6.1%), Blacks (4.9%), and Asians (3.3%). AI/AN youth also show the
22

most prevalent use of other tobacco products including cigarettes, smokeless tobacco,
cigars, or pipe tobacco (14.5%) (SAMHSA, 2012). In California, similar patterns have been
reported among 9th and 11
th
graders where AI youth (16%) had the highest rates
compared to Native Hawaiians/Pacific Islanders (13%), Whites (13%), African American
(12%), Hispanic/Latinos (12%), and Asians (7%) (California Healthy Kids Survey, 2009).
With gender differences, some studies have found a higher prevalence of cigarette smoking
among AI girls than among boys (Osilla, Lonczak, Mail, Larimer, & Marlatt, 2007), with boys
more likely than girls to use smokeless tobacco, alcohol, and marijuana (Schinke, Tepavac,
& Cole, 2000). In contrast, a study by LeMaster et al. (2002) reported no gender differences
in cigarette smoking among AI youth.
Smoking rates may vary by geographic region and tribe. For example, smoking
prevalence is higher among AI populations in the Northern Plains than in the Southwest,
where smoking prevalence among AIs is even lower than among the general population
(Nez Henderson, Jacobsen, & Beals, 2005). Explanations for these geographic differences
are uncertain but important to understand for tobacco education and prevention efforts,
particularly in California where a significant proportion of AIs live in urban areas.
Additionally, understanding gender differences and factors that explain the high smoking
prevalence rates is needed.
Depression among American Indian Adolescents
Depression is a major public and mental health problem among AI youth (Blum,
Harmon, Harris, Bergeisen, & Resnick, 1992; Dinges & Duong-Tran, 1992). Previous
research indicates that AIs are at a higher risk than any other ethnic group for mental
health problems (Costello, Messer, Bird, Cohen, & Reinherz, 1998; Moncher, Holden, &
23

Trimble, 1990). According to Saluja and colleagues (2004), a study using a school based
survey of a national representative sample of 9863 students to examine depressive
symptoms and found American Indian youth to have the highest prevalence of depressive
symptoms (29%) compared with Hispanic (22%), White (18%), Asian American (17%) and
African American (15%) youth . Another study among AI boarding school youth indicated
that 58% of the youth reported being depressed (S.M. Manson, Ackerson, Dick, Baron, &
Fleming, 1990). These concerns are even greater for AI youth who have the highest rates
of suicide in the U.S. of all racial and ethnic groups (CDC Prevention, 2009; Suicide
Prevention Research Center, 2011). Unfortunately, AI youth have the highest rates of
suicide, the second leading cause of death, with depression being a risk factor (Borowsky,
Resnick, Ireland, & Blum, 1999; T. R. Rieckmann, et al., 2004).
The first occurrence of depressive symptoms generally happens in childhood,
adolescence, or early adulthood years (Robins & Regier, 1991). Fortunately, validity
studies of subclinical depressive symptom measures have been examined among AI
populations, such as the CES-D measure. Research studies found the CES-D to be a highly
reliable measure, even though the factor structure slightly differed from non-AI
populations (Beals, Manson, Keane, & Dick, 1991b; Dick, Beals, Keane, & Manson, 1994;
Radloff, 1977). With the use of the CES-D measure, Beal and colleagues (1991) found 45%
of the sample of AI college students to be above the CES-D cut off score of 16. A study of AI
boarding school students reported an average CES-D score of 19.4 (S.M. Manson, et al.,
1990). When compared to the general population, AI youth CES-D average scores are
higher than among the general population where 26% high school students reported above
the cutoff on the CES-D (CDC, 2010) and an estimated 9% of adolescents aged 12 to 17 had
24

experienced at least one major depressive episode during the past year (SAMHSA, 2005).
These studies provide specific data for local region or tribes, but no current national data is
available among American Indian populations and depressive symptoms.
Theory
Historical Trauma Theory. Historical trauma (HT) theory is a relatively new concept
in public health. Sotero (2006) summarizes that HT theory builds upon three theoretical
frameworks in social epidemiology: 1) psychosocial theory associates disease to both
psychological and physical stress emerging from the social environment. In this
framework, psychosocial stressors not only create susceptibility to disease, but act as a
direct pathogenic mechanism affecting biological systems in the body, 2)
Political/economic theory, which addresses the political, economic and structural
determinants of health and disease such as class inequality, and 3) Social / ecological
systems theory recognizes the multilevel dynamics and interdependence of present/past,
proximate/distal, and life course factors in disease causation. Sotero further states that
four distinct assumptions are included in this theory: 1) mass traumatic events are
intentional and systematically forced upon a target population by a dominant population,
2) the events are not limited to a single catastrophic event, but occur over time, 3)
traumatic events do resonate throughout the population, creating a collective experience of
trauma by the community, and 4) the enormity of the events disrupts the population from
its natural, projected historical course resulting in a legacy of physical, psychological, social,
and economic disparities that persists across generations. Lastly, the three basic
constructs of HT theory are the historical trauma experience, the historical trauma
response, and the intergenerational transmission of HT (M.Y.H. Brave Heart, 2003; Danieli,
25

1998; Sotero, 2006). In this proposal, historical trauma experience will be further
examined as an antecedent to tobacco use and depressive symptoms.
Over generations, American Indians have experienced a series of traumatic events
that have included community massacres, genocidal policies, pandemics from the
introduction of deadly diseases, forced relocation, forced removal of children from their
families and into boarding schools, and government forbidding spiritual and traditional
ceremonies (Braveheart-Jordan, DeBruyn, Jeanne, & Gloria, 1995; BraveHeart, 1995; Duran
& Duran, 1995; T. R. Rieckmann, et al., 2004; Whitbeck, Walls, et al., 2009). Together, these
events are a history of ethnic genocide or “ethnic cleansing” (Evans-Campbell, 2008).
These events did not occur during a onetime event like the Holocaust, but over a period of
time. For more than 500 years AIs experienced these events and still live daily with the
economic conditions of reservation life, discrimination, and a sense of cultural loss
(Whitbeck, Chen, Hoyt, & Adams, 2004). Because of past and current historical events,
individual mental health and the healthy functioning of family and community are affected
by these experiences. It is unclear for how many generations will these historical traumatic
events affect the youth today and future generations.
It has been more than 500 years since the first contact between American Indian
tribes and European explorers. During that time, numerous historical traumatic events
have occurred that destroyed their culture, traditions, and resources which left devastating
circumstances that still exist today. The United States government went so far as to
systematically eradicate the AI people via military action (Duran & Duran, 1995). They
were forced to leave their lands to unfamiliar land territory or reservations, removing them
from their cultural way of life and connection with nature. Federal policies removed
26

children as young as 3 years old from their families and placed them in to boarding schools
(up to 100 miles away or more) (Duran & Duran, 1995). The boarding schools forbade
children from speaking their language, talking about their culture, wearing traditional
clothing, or practicing their spirituality. In the 1950’s, relocation of AI families to urban
areas was part of a federal subsidized program to reduce reliance on public assistance and
assimilate the AI people into mainstream society. The US government terminated many
tribes’ federally recognized status as sovereign nations which removed all rights of their
land and government policies that provided an infrastructure for the tribal community (i.e.
education, medical, and housing). Environmental assaults by the government occurred
such as radioactive extraction and dumping on tribal lands, flooding of homelands,
prohibition of whaling in the northwestern coast, and the introduction of diseases into
communities (Evans-Campbell, 2008). Because of these traumatic events, AIs had no safe
place to return to or immigrate to and their traditional means of survival were eradicated
(Whitbeck, Adams, et al., 2004). There was no specific end to the legal and systematic
“ethnic cleansing” of AIs. Rather it persisted for generations and now they face the daily
reminders of the loss: reservation living, encroachment of Europeans, loss of language, loss
of traditional beliefs and practices, loss of traditional family systems, and traditional
healing practices (Whitbeck, Adams, et al., 2004).
Ethnic Identity. Ethnic identity refers to the perception of the strength of a person’s
connection to an ethnic group (Moran, Fleming, Somervell, & Manson, 1999). There are
two main theoretical perspectives on ethnic identity, a social identity theory and a
development theory. The social identity theory asserts that identity is based on a sense of
belonging to a group and the feeling and attitudes that accompany a sense of a group
27

membership (Tajfel & Turner, 1986). Additionally, with social identity theory, there is an
underlying need to maintain self-esteem that is linked to group identity. A second
theoretical perspective is based on the work by Erik Erikson (1968), which posits that
identity formation occurs through the process of exploration leading to a successful
resolution of identity with the clarity of oneself and one’s place in society. Jean Phinney
(1990) has paralleled her work with these theories in the development of the measure for
ethnic identity, the Multigroup Ethnic Identity Measure (MEIM), which assesses ethnic
identity across diverse samples. Additionally, Phinney conceptualizes ethnic identity as a
process and acknowledges the differences among individuals as people explore and
evaluate the meaning of ethnic identity over time with their group membership (Phinney,
1996). With exploration, one may learn about one’s ethnic history, traditional cultural
values and activities, joining others that are members of one’s own ethnic group. There are
different stages one will experience early in one’s life with exploration into the meaning
and implications of one’s group membership and to achieve ethnic identity that reflects a
secure and confident individual to their group membership (Phinney, 1996). Another
dimension is commitment to identity where one has adopted or endorsed aspects of a
specific identity. This achieved identity can vary within an individual over time as
individuals are likely to re-examine their ethnic identity throughout their developmental
stages. With ethnic identity constantly changing and evolving in a youth’s growth years,
Phinney’s model is explicitly developmental and studies linking AI ethnic identity and
psychosocial outcomes have used the MEIM measure.
Newman (2005) examined ethnic identity (i.e. MEIM scale) exploration and
commitment to find it was related to developmental process and internalization of ethnic
28

identity among AI youth. This provided evidence that the constructs within MEIM did
relate to ethnic behaviors and practices among AI youth. Another study among Navajo
adolescents used the MEIM scale to examine ethnic identity and self-esteem and found
ethnic identity to increase self-esteem (M. Jones & R. Galliher, 2007).
Risk Factors for Tobacco Use and Depression among AI Youth
Prior research on the etiology of smoking behaviors among AI adolescents has been
examined in multiple domains (interpersonal, environmental, and cultural) to determine
the risk factors that influence commercial tobacco abuse. There is a paucity of research
examining the risk factors to depression among AI youth which include cultural risk
factors, social environment risks, and historical trauma.
Interpersonal Risk Factors for Tobacco Use. Interpersonal variables have been well
documented to show family members and peers who smoke can influence an AI youth’s
smoking behavior (M. Kegler, V. Cleaver, & M. Yazzie-Valencia, 2000; Kegler et al., 1999;
Kegler & Malcoe, 2002; LeMaster, Connell, Mitchell, & Manson, 2002; Okamoto, LeCroy,
Dustman, Hohmann-Marriott, & Kulis, 2004; Unger et al., 2003) with reasons that include
sense of belonging, fitting in, and being popular among their peers (Quintero & Davis,
2002). Peer influence has also been shown to be the strongest and most consistent
predictor of smoking behaviors among adolescents of diverse ethnic backgrounds (Conrad,
Flay, & Hill, 1992). Forster et al. (2008) found that among AI youth, the number of smoking
friends was highly predictive of past month smoking; those with three or four friends who
smoked were nine times more likely to have smoked compared to those with fewer
smoking friends. Family members may also contribute to youth smoking by direct and
indirect mechanisms. Examples of direct social influences include access to cigarettes by
29

siblings or cousins giving cigarettes to an AI youth, or older relatives buying cigarettes for
the younger teens. An example of an indirect influence is family members who leave
cigarettes around the house (M. Kegler, et al., 2000).
Secondhand Smoke and Smoking Policies. Environmental exposures such as
secondhand smoke (SHS) pose a serious risk to youth because of social modeling where
youth learn by example. According to the 2007 National Survey of Children’s Health, AI
children had 2.2 times higher odds of SHS exposure than non-AI children (Singh, Siahpush,
& Kogan, 2010). In a study by Kegler and Malcoe (2002), it was found that AIs were less
likely to report a complete car smoking ban than White nonsmokers. In regards to AI
household smoking restrictions, they can range from total smoking bans to unrestricted
smoking in the home (M. Kegler, et al., 2000). With limited or no smoking policies,
children may be more influenced by smoking behaviors by viewing family members smoke.
Exposure to SHS can also occur at outdoor AI cultural events like a Pow-Wow (J. B. Unger,
C. Soto, & L. Baezconde-Garbanati, 2006) where smoking is seen by the youth. This can
lead to emulating the behavior of someone smoking and wanting to try smoking. Although
Indian Pow-Wows are alcohol-free, cigarette smoking is common as well as at other social
American Indian functions (Hodge, 1995). Fortunately, there exist a number of smoking
policies at Indian Health clinics where no smoking is allowed within a 20 foot radius.
Additionally, no smoking is allowed on reservation school grounds and at other tribal
facilities. However, these policies are not always enforced and additional non-smoking
policies need to be implemented among cultural events and gatherings to reduce youth
being exposed to the behaviors of others.
30

Cultural Risk Factors for Depression. Research studies show that distress and
alienation from cultural traditions may lead to or be associated with depression, learning
problems, conduct disorders, substance use, running away, and suicide attempts (King,
Beals, Manson, & Trimble, 1992; Shaughnessy, Doshi, & Jones, 2004; K.L. Walters, Simoni, &
Evans-Campbell, 2002). Additionally, culture conflict and discrimination contribute to
depressive symptoms among AI populations (BraveHeart, 1995). The cultural conflict is
defined as the difference between the AI cultural values, beliefs, and practices and those of
the mainstream society and culture (BraveHeart, 1995). The American Indian culture
emphasizes values of affiliation, sharing, respect, reluctance to speak out, and the well-
being of the group before the individual, as opposed to the European American values that
highlight individual success and achievement (Whitbeck, McMorris, Hoyt, Stubben, &
LaFromboise, 2002). Opposing cultural values can be detrimental as AI cultural values
emphasize the community wellness before the individual. From this point of view, cultural
conflict has been associated with psychological symptoms, such as depressive symptoms
(Chapleski, Lamphere, Kaczynski, Lichtenberg, & Dwyer, 1997; Duran, Duran, Brave Heart,
& Yellow Horse-Davis, 1998).
Stressful Life Events on Depression and Tobacco Use. Among the AI community,
numerous stressors impact the individual, family and community. A recent study examined
the neighborhood safety among AI youth living on a reservation in the Southwest to find
that the presence of crime and drug sales was a strong predictor of depressive symptoms
and alcohol/marijuana use (Nails, Mullis, & Mullis, 2009). Depending on the tribe or
community where one grew up, life could include being exposed to alcoholic family
members, drug abuse, poverty, violence, and other events that occur daily (Costello,
31

Farmer, Angold, Burns, & Erkanli, 1997). Adolescents from more impoverished
communities experience more negative life events (Gore, Aseltine Jr, & Colten, 1992) and
with cultural and ethnic groups overrepresented in the lower socioeconomic status,
stressful life events for minority groups have more deleterious effects (Slavin, Rainer,
McCreary, & Gowda, 1991). These stressors can include cultural trauma (attack on fabric of
society affecting the community), historical trauma (cumulative exposure of traumatic
events that affect an individual and continue to affect subsequent generations), daily
stressful life events (family disruption, poverty, violent crime etc.), and perceived
discrimination (Dinges & Joos, 1988; Duran & Duran, 1995; Robin, Chester, Rasmussen,
Jaranson, & Goldman, 1997; K.L. Walters, et al., 2002). The experiences of the historical
and daily stressors have long-term effects among AIs and further investigation of the
mental and behavioral consequences are necessary.
Empirical studies among AI adolescents have examined the impact of stressful life
events and negative health outcomes. Research has shown that chronic psychosocial stress
is associated with physical, mental and behavioral health (Flier, Underhill, & McEwen,
1998; McEwen & Stellar, 1993). In a recent study by Baldwin and colleagues (2011),
among rural AI youth between the ages of 15-24 years residing in two boarding schools
located off-reservation in the southwestern US (Baldwin, et al., 2011), stressful life events
were directly associated with depressed mood, substance use, and risky behavior. Another
study examined the role of stressful life events in predicting severity and patterns of
comorbidity of depression, suicidality and substance abuse disorders among AI youth in a
multi-tribal boarding school (Dinges & Duong-Tran, 1992). Among the 124 youth (mean
age= 16, 52% female), 24% reported being depressed. Results showed increased levels of
32

substance abuse/dependence (alcohol, marijuana) in combination with depression
showing they co-occur. Females had higher rates of depression than males, and males had
higher rates of a combination of depression and substance abuse/dependence than
females. Loss of cultural supports was associated with depression with suicide ideation
and attempt. This alludes to the importance to maintain culture and cultural support.
Lastly, death of a family member or friend was associated with depression and substance
abuse which indicates stressful life events impact negative health outcomes.
Although some adolescent stress research has focused on the effects of specific life
events (e.g., divorce, death of a parent, and economic hardship), an alternative approach
involves studying the relationship between cumulative life changes and negative health
outcomes. Such studies are based on the assumption that increased numbers of stressful
events experienced within a relatively short period increase the risk for developing
problems in health and psychological adjustment. Consistent with Petersen, et al. (1991)
and Simmons et al (1987) who argued that youth are at greatest risk when they
simultaneously experience such multiple undesirable life events, this study used a measure
of cumulative stressful events within the year prior to the survey.
Historical Trauma and Loss. American Indians have experienced a different
historical context than the dominant culture (Whitbeck, Yu, et al., 2009). Few studies have
examined the prevalence of historical trauma among AI youth. The younger generation
may not have experienced the boarding school era or participated in the relocation
program, but they live with family members who first handedly endured the government’s
systematic ways to assimilate the AI community. Whitbeck et al. (2004) raised a good
point for thought in his study; Are AIs dealing with actual historical issues or more
33

proximate grief and contemporary trauma from the daily overt and institutionalized
discrimination, the many health issues, and high mortality rates? In his study, he
developed two scales to measure historical loss and emotional responses to losses and
found that the current generation of American Indian adults had frequent thoughts
pertaining to historical losses and that they associate these losses with negative feelings.
Another study by Whitbeck et al. (2009) reported the prevalence of perceived historical
loss among 459 AI youth aged 11-13 years and found that the prevalence of report thinking
of historical loss daily or several times a day was higher among youth than among adults.
For example, 20.5% of the AI youth reported daily or more than several times a day
thoughts about loss of land compared to 12.4% of their adult female caretakers (p<.05).
Additionally, 7.2% of youth reported thoughts about the loss of their language several
times a day compared to 4.7% among adults (p<.05), and 11.8% of youth reported
thoughts about loss of families from the reservation/reserve to government relocation
compared to 7.1% among adults (p<.05). This clearly indicates that the historical loss
perception is not confined to the elder generation but prominent among AI adults today
and the youth who had higher prevalence reports of historical loss. Further examination
will be conducted among AI youth who experience historical trauma as they grow up in a
cultural context of reminders of ethnic cleansing that may contribute to adolescent
depression or early outcomes of commercial tobacco use.
Protective Factors Against Tobacco Use and Depression among AI youth
Few studies exist on protective mechanisms to prevent smoking initiation among AI
youth. With AI youth using tobacco at earlier ages and in larger quantities compared to
non-AI peers (Osilla, et al., 2007), understanding protective factors is important when
34

developing intervention and prevention programs. Few research studies show protective
factors against depression among AI youth. These are imperative to know because youth
who have early onset of depressive symptoms are at increased risk of depression in
adulthood (R. C. Kessler & Magee, 1994).
Interpersonal protective factors. Protective factors against smoking include family
caring and support, strong cultural identification, school success, college aspirations,
involvement in team sports, and playing music (LeMaster, et al., 2002; Osilla, et al., 2007).
In a study by Gary et al. (2005), protective factors against depression included caring
family relationships, supportive tribal leaders, and positive school experiences. The
engagement and support of family and community is important for youth to have positive
and healthy lifestyles.
A study by Beebe et al. (2008) among inner-city AI youth found that the presence of
a non-parental adult role model was statistically significantly associated with tobacco non-
use in the past 30 days. This finding is consistent with the AI cultural value of collectivism
that includes the value of extended family, respect of elders, interdependence, cooperation,
and responsibility of a tribe or community. As a result, AI youth may be more likely to get
the advice of an adult other than a parent for support.
Environmental protective factors. Household smoking restrictions are protective
against smoking among AI youth (J. Forster, I. Brokenleg, K. Rhodes, G. Lamont, & J.
Poupart, 2008) and household smoking bans are important to reduce the harmful effects of
SHS exposure, reduce smoking, and increase cessation rates (Levy, Romano, & Mumford,
2004). Tribal policies can encourage smoking bans in the homes, cars, and in tribal
35

buildings, thus providing a positive safe and clean environment for the community, family,
and individuals.
Cultural protective factors. Culturally grounded protective factors are important for
study precisely because the history of colonization has disrupted the connections to
traditional values among American Indian cultures (Mohatt, Fok, Burket, Henry, & Allen,
2011). Adolescents who have higher levels of spirituality can utilize spiritual coping
resources and therefore may have fewer mental health problems and lower rates of high-
risk health behaviors than their less spiritual peers (Cotton, Zebracki, Rosenthal, Tsevat, &
Drotar, 2006). Many authors have identified cultural identity and enculturation, including
involvement in traditional cultural practices, as protective factors for native youth (T.D.
LaFromboise, Hoyt, Oliver, & Whitbeck, 2006; Oetting & Beauvais, 1990; Whitbeck, et al.,
2002). A study among the Hopi reservation found that high levels of traditionalism were
significantly associated with disease protective behaviors such as practicing traditional
Hopi activities to keep healthy and significantly inversely associated with smoking and
obesity (Coe et al., 2004). In contrast, a study by Hawkins et al. (2004) reported that
engagement in traditional cultural practices and cultural identity as protective against
substance use produced mixed results. Whitbeck and colleagues (2002) found AI adults
who engage in traditional practices of going to Powwows, speaking a traditional language,
and engaging in traditional activities reduced the likelihood of depressive symptoms.
Additionally, in the same study, traditional practice mitigated the relationship between
perceived discrimination and depressive symptoms.
Further research studies that examine youth who are involved in American Indian
cultural activities, ceremonies, and traditionalism can provide knowledge and practice of
36

spiritual ways to potentially serve as protective factors to negative health outcomes. These
values reflect both cultural practice and cultural identity. It is an important element when
examining protective factors to health outcomes as this dimension is often omitted in
cultural assessments of AI people. By measuring only one dimension (e.g., ethnic identity)
this has resulted in missing important information that may affect behaviors (Whitbeck,
Hoyt, Stubben, & LaFromboise, 2001).
Cultural practices will vary with the existence of numerous tribes and their beliefs,
values, and practices. With the TRDRP data proposed in this dissertation, a study was
published in the Journal of Psychoactive Drugs to examine California AI youth cultural
activities and its relationship to ethnic identity (Schweigman, Soto, Wright, & Unger, 2011).
The AI cultural activities included participation in a Pow-wow, sweat lodge, drum group
and roundhouse. Findings indicated that AI youth who participated in cultural activities
including Pow-wows reported significantly higher AI ethnic identity than their
counterparts who did not participate in cultural activities. Further findings indicated the
association between cultural activities and ethnic identity was only significant among
urban youth and not among reservation youth. It was noted that the cultural activities may
differ among urban and reservation youth because of the significant finding only among
urban youth. Also, urban youth may seek cultural activities to feel connected to their
culture. Overall, the results of this study show a strong association between involvement in
cultural activities and ethnic identity among AI youth in California. Next steps will
examine if participation in cultural activities and ethnic identity are protective against
depressive symptoms and if ethnic identity protects against smoking behaviors.
37

Ethnic Identity. The AI population is very diverse and although some similarities
exist among these tribal groups, there are significant differences based on specific tribal
values, beliefs, practices, languages spoken, and whether they live on a reservation. In the
United States the majority of AIs live in urban areas (Census, 2010) and many AI people
affiliate with more than one tribe and/or report being of mixed blood (Moran, et al., 1999).
With the complexities of ethnic identity among AI youth, it still important to measure AI
ethnic identity as it has shown to provide support for positive outcomes such as school
achievement and coping strategies (Moran, et al., 1999).
Studies conducted among AI youth have examined ethnic identity or cultural
identity and its positive relationship to well-being. Those with strong ethnic cultural
identity are more likely to have and maintain well-being, high self-esteem and resilience to
life changes (Martinez & Dukes, 1997; Yip & Fuligni, 2002). The sense of affiliation
provided by ethnic identity has been shown to help protect against negative stressful
experiences (Phinney, Madden, & Santos, 1998). Reickmann and colleagues (2004)
examined positive relationships among explanatory style, depression and Navajo cultural
identity to find high levels of Navajo cultural identity had a modest effect in terms of
reducing depression (T. R. Rieckmann, et al., 2004). A study among Alaska Natives (AN)
found ANs who identified more with their traditional way of life reported greater
happiness, more frequent use of religion and spirituality to cope with stress, and less
frequent use of drug to cope with stress (Wolsko, Lardon, Mohatt, & Orr, 2007). Ethnic
identity was positively associated with sense of community. These findings are in line with
traditional AI values of collectivism and community, such that adolescents who had a
stronger AI ethnic identity also had a stronger sense of community with their tribe. This
38

provides important implications in that it suggests that ethnic identity promotes a sense of
membership, which creates feelings of emotional safety, with a sense of belonging to and
identification with the larger collective (Kenyon & Carter, 2011). Many tribal substance
abuse prevention programs include ways to strengthen the AI culture and identity among
the youth and their families (Garrett & Carroll, 2000; May & Moran, 1995; Schinke, et al.,
2000; Thomas et al., 2009).
Evidence has shown ethnic identity to have higher levels of well-being, high self-
esteem, coping, sense of mastery, optimism, and resilience to life changes (M. Jones & R.
Galliher, 2007; Martinez & Dukes, 1997; Yip & Fuligni, 2002). Studies among AIs examining
ethnic identity and smoking outcomes are mixed. Among AI youth, two studies
investigated smoking and cultural identification where alienation from AI culture was
associated with lower levels of smoking in a boarding school (Weaver, 1999) and no
relationship between cultural factors and smoking among urban AI youth (Yu, Stiffman, &
Freedenthal, 2005). Intervention programs have worked under the assumption that strong
ethnic identity is protective against alcohol abuse and other risky behaviors (Trimble,
2007), therefore, with our large sample of AI adolescents from urban and reservation areas
of California, we hypothesize that AI adolescents with stronger ethnic identity will act as a
protective factor to smoking behaviors.
Is Traditional Tobacco a Risk or Protective Factor to Smoking Cigarettes?
It has been theorized that the sacred use of tobacco with increasing amounts of
commercial tobacco after the arrivals of the Europeans set the stage for high prevalence
rates among AIs today (C. Pego, et al., 1995). Today, tobacco plays a spiritual role among
many AI tribes and has for thousands of years. It is used as a medicine, for ceremonies,
39

prayers, offerings, invocations, and other traditional religious purposes (C. M. Pego, R. F.
Hill, G. W. Solomon, R. M. Chisholm, & S. E. Ivey, 1995; Winter, 2000c). When using sacred
tobacco, there are specific rules to be followed to promote well-being and good thoughts
(R. Struthers & F. S. Hodge, 2004). Modern-day AI youth understand and experience the
traditional uses of tobacco where they reported traditional tobacco being used in sweat
lodges to pray, at wakes to respect the deceased, and at Pow-Wows to respect the drum
before singing (J.B. Unger, C. Soto, & L. Baezconde-Garbanati, 2006). Often times, it is
difficult to obtain wild or homegrown tobacco, and commercial tobacco bought from the
store is used as a substitute. Tobacco may also contain other herbs (J. L. Forster, I.
Brokenleg, K. L. Rhodes, G. R. Lamont, & J. Poupart, 2008), bark, leaves, or oil to create a
milder substance called kinnikinnik (C. Pego, et al., 1995). It is important to note that
tobacco is only occasionally used and is not always inhaled (J. B. Unger, et al., 2006; Winter,
2000b). Therefore, when tobacco is respected and used for sacred purposes, it can limit
the adverse health effects.
Very few empirical studies have examined the influence of traditional tobacco use
on recreational use of commercial tobacco. A study by Henderson et al. (2010) reported
that smoking rates are generally higher among tribes who use tobacco ceremonially, in
contrast to tribes who do not use. This study included two tribes in the Northern Plains
and one tribe in the Southwest, and of the comparable groups (n=2,897 total), 14% of the
Southwest subjects and 50% of the Northern Plains subjects were current smokers. The
Northern Plains tribes traditionally use the “Sacred Pipe” more than the Southwest tribes
do. However, in contrast to the Henderson et al. (2010) findings, a study among the Alaska
and Southwest (Navajo tribe) groups found that reported cigarette use among the Alaska
40

groups was 32% compared to 8% among the Southwest group (Redwood et al., 2010). The
Navajo people (Southwest) have a strong tradition of using tobacco ceremonially unlike the
Alaskan groups who reported higher cigarette use than the Southwest group.
To my knowledge, no studies among AI adolescents exist to determine the role of
traditional tobacco and its impact on smoking. With the TRDRP data, preliminary analysis
was conducted to present at the TRDRP conference and Society of Behavioral Medicine in
April 2012. Results indicate that the use of traditional tobacco use is a risk factor for
smoking among AI youth in California. I examined the associations of knowledge and use
of natural tobacco (home-grown or wild) and/or commercial tobacco (store bought) for
ceremonial prayer/traditional reasons with smoking behavior (past-month or lifetime).
Additionally, I examined whether these associations differed across gender or between
urban and reservation youth. AI youth were more likely to report lifetime and past-month
smoking if they had used commercial tobacco for ceremonial/traditional reasons (lifetime
OR=6.65 (2.56-17.27), past-month OR=3.47 (1.61-7.49)), natural tobacco for
ceremonial/traditional reasons (past-month OR=2.42 (1.35-4.36)), or both (natural &
commercial tobacco) for ceremonial/traditional reasons (lifetime OR=3.33 (2.05-5.41),
past-month OR=3.32 (2.04-5.40)). There was a significant interaction with knowledge of
ceremonial use of tobacco x gender on lifetime smoking (OR=0.71 p=0.04) where the
association was stronger among boys than girls. Additionally, the interaction of
commercial tobacco use for ceremonial/traditional reasons x gender on lifetime smoking
was significant (OR=0.91 p=0.03) where the association was stronger among boys than
girls. Contrary to expectations, the use of any type of tobacco (natural, commercial, or
both) for ceremonial/traditional reasons was a risk factor for recreational smoking among
41

AI youth. Traditional tobacco messages to respect and preserve the use of sacred tobacco
must be carefully executed so that AI youth understand the distinction between traditional
and recreational use of tobacco, especially among boys who typically have a larger role in
the sacred use of tobacco.
Studies on the perceptions of AI youth and traditional tobacco use deserve attention.
One study used bivariate analysis with data of 336 AI youth aged 11-18 years from
Minnesota to find those who do not smoke cigarettes are least likely to use traditional
tobacco (J. L. Forster, et al., 2008). Additionally, among those who do smoke cigarettes,
they are more likely to use commercial tobacco for traditional purposes instead of Indian
tobacco. In another study by Unger et al. (2006), it was found that AI youth were
knowledgeable about the difference between ceremonial use of sacred tobacco and
recreational use of commercial tobacco. For example, youth reported commercial tobacco
being substituted for traditional purposes because it is more convenient to obtain.
However, these adolescents understood that commercial tobacco was more dangerous and
addictive than traditional homegrown or wild tobacco. Additionally, some youth believed
any tobacco is hazardous to one’s health. With the youth understanding this distinction
and the harmful effects of any tobacco, it can be difficult to separate and make the right
decision to not smoke. More empirical research is needed to understand AI youth’s use of
ceremonial tobacco and its association with smoking behavior.

42

CHAPTER 2: STUDY 1
RECREATIONAL AND CEREMONIAL USE OF TOBACCO AT CULTURAL EVENTS BY
AMERICAN INDIAN URBAN AND RESERVATION YOUTH IN CALIFORNIA
ABSTRACT
Background: American Indian (AI) adolescents have the highest prevalence of commercial
tobacco use of any ethnic group in the United States. However, tobacco used for
ceremonial purposes among AI youth is not well understood. This study documents AI
adolescents’ exposure to ceremonial and commercial tobacco use during five cultural
practices, including the type of tobacco used, who used tobacco, and how it was used, as
well as the prevalence of recreational cigarette use, other tobacco product use, and
preferred commercial tobacco brands. Associations of ceremonial tobacco use and
social/environmental exposure with cigarette smoking are examined.
Methods: AI youth in California (N= 940, ages 13-19, recruited from 49 different tribal
youth organizations and cultural events in urban and reservation areas of California)
completed a culturally-specific tobacco survey. Variation across gender, age, smoking
status, and region (urban vs. reservation) were examined. Multiple logistic regressions
were used to determine associations between predictor variables and smoking behavior
outcomes.
Results: Over half of the AI youth reported having ‘some’ or ‘a lot’ of knowledge about the
ceremonial uses of tobacco. At cultural events, youth observed tobacco being used in a
variety of ways (e.g., smoked in prayer, gift or offering); it was used primarily by elder men,
adult men, and teenage boys. Natural tobacco was used more often than store-bought
commercial tobacco for ceremonial purposes. Twenty-five percent were past-month
43

smokers and 30% were experimental smokers. Smoking tobacco in ceremonial ways and
using commercial tobacco at ceremonies were risk factors for recreational smoking.
Having grandparents who smoke served as a protective factor against smoking cigarettes.
Few significant differences by age, gender, region and smoking status were found.
Conclusions: Traditional tobacco messages to respect and preserve the use of sacred
tobacco must be carefully executed so that AI youth understand the distinction between
traditional and recreational use of tobacco, especially among those who smoke tobacco
ceremonially at cultural events. Health education messages are needed to communicate to
AI youth that the use of any commercial store-bought tobacco can be harmful and should
be avoided. Culturally appropriate prevention and cessation messages that acknowledge
and respect the ceremonial use of tobacco without condoning commercial tobacco use are
essential to curb the high rates of smoking. Further research is needed within specific
regions and tribes to understand the beliefs, attitudes and behaviors of traditional tobacco
for ceremonial purposes.

44

INTRODUCTION: STUDY 1
American Indians (AI) have a long history with tobacco, and it is still considered a
sacred and powerful substance used for ceremonial and medicinal purposes today (C. Pego,
et al., 1995). Unfortunately, many AIs misuse commercial tobacco for recreational
purposes and have the highest smoking prevalence of any ethnic group in the United States
(CDC, 2011). According to the 2011 National Survey on Drug Use and Health (SAMHSA,
2011), rates of past month cigarette use among youth aged 12 to 17 are highest among
American Indians/Alaska Natives (AI/AN) (12.3%), compared to Whites (8.2%), Hispanics
(6.1%), Blacks (4.9%), and Asians (3.3%). AI/AN youth also show the most prevalent use
of other tobacco products including cigarettes, smokeless tobacco, cigars, and pipe tobacco
(14.5%)(SAMHSA, 2012). Tobacco use behaviors vary by geographic region and tribe. For
example, smoking prevalence is higher among AI populations in the Northern Plains than in
the Southwest, where smoking prevalence among AIs is even lower than in the general
population (Henderson, Rhoades, Henderson, Welty, & Buchwald, 2004). Explanations for
these differences are unknown but important to understand for tobacco education and
prevention efforts. This is especially important in California, where large numbers of urban
and reservation youth live.
American Indians in California
According to the U.S. Bureau of Indian Affairs, there are 566 federally recognized
tribes in the United States, including 107 in California (Census, 2010; Satter, et al., 2012).
Among the federally recognized tribes in CA, there are approximately 85 reservations or
rancherias scattered throughout the state (Hodge, et al., 1996). California also has the
largest urban AI population in the United States (723,225 AI/AN alone or in combination
45

with another race) (Census, 2010). Urban Indians are individuals of AI ancestry who have
moved to cities and urban areas within state or from out-of-state either by choice to seek
employment, education or housing, or by force through Federal relocation policies that
started in the 1940s (Lobo, 2002).
Traditional Tobacco for Ceremonial Purposes
Today, tobacco plays a spiritual role among many AI tribes and has for thousands of
years. Numerous tribes in California use tobacco as a medicine, for ceremonies, prayers,
offerings, invocations, and other traditional religious purposes (C. Pego, et al., 1995;
Winter, 2000a). One form of tobacco is the natural tobacco plant that is naturally grown
and gathered in the wild or mountains and/or homegrown in a garden by community tribal
members. Often times it is difficult to obtain wild or homegrown natural tobacco for
ceremonial purposes (J. L. Forster, et al., 2008) and commercial store-bought tobacco is
used as a substitute. When tobacco is used for ceremonial or traditional purposes, it may
contain other herbs (J. L. Forster, et al., 2008), bark, leaves, or oil to create a milder
substance called kinnikinnik (C. Pego, et al., 1995). The use of tobacco is occasional and
does not always involve smoking. The loose form of tobacco can be sprinkled on the
ground as an offering to Mother Earth or be hand rolled into a cigarette (J. B. Unger, et al.,
2006; Winter, 2000b).
Tobacco Use at Cultural Activities
Modern-day California AIs use tobacco at some AI ceremonies, such as a sweat
lodge, roundhouse, funeral or wake, pow-wow, and drum group, where it is often given as a
gift to the host (Daley et al., 2010; C. Pego, et al., 1995; J. B. Unger, et al., 2006). Sweat
lodges, also known as a sweat or sweathouse, are lodges using hot rocks with water poured
46

over them to produce steam and are for spiritual and/or physical revival (Welch, 2002),
where tobacco may be offered as a gift to the sweat lodge leader or used in the sweat lodge
ceremony. A roundhouse is a large wood framed structure built with posts and rafters over
an excavated pit and then covered with earth (Simmons, 1997) where central California
Indians use tobacco in their ceremonies. At a funeral or wake, tobacco is sprinkled on the
ground or smoked in honor of the deceased person. Pow-wows are community social
gatherings that include AI traditional activities, such as dance, song, and drumming to
celebrate tribal customs and cultural connectedness (Schweigman, et al., 2011), where
tobacco is given as a gift of appreciation. Drum group members roll tobacco and pass it
around to pray before singing (J. B. Unger, et al., 2006). AI youth who attend these cultural
events may or may not participate in the use of ceremonial tobacco use, but they do
observe the tobacco used by community members and their peers.
Does ceremonial tobacco use influence the risk of recreational use of commercial
tobacco?
One might hypothesize that participation in ceremonial tobacco use would protect
AI youth from experimenting with commercial tobacco recreationally, because youth who
understand the sacred role of tobacco in AI cultures would be less likely to misuse tobacco
in a disrespectful way. Alternatively, one could also hypothesize that any exposure to
tobacco, even ceremonial tobacco use, would increase the risk of recreational use of
commercial tobacco by increasing access and perceived acceptability of tobacco. Few
empirical studies have examined the influence of traditional tobacco use on recreational
use of commercial tobacco. A study by Henderson et al. (2010) reported that smoking rates
are generally higher among tribes who use tobacco ceremonially, in contrast to tribes who
47

do not use. However, another study comparing a Southwest and Alaskan group found the
opposite with lower cigarette rates among the Southwest tribe who have a strong tradition
of using tobacco ceremonially (Redwood, et al., 2010).
It is not clear how youth comprehend the use of commercial tobacco for ceremonial
purposes, and whether this practice makes commercial tobacco seem more acceptable,
normative, or even beneficial to them. A study by Forster et al. (2008) among AI urban
youth found no association between Indian tobacco or commercial tobacco use and past-
month smoking. However, with numerous tribes in urban and reservation areas of CA who
use tobacco for ceremonial and traditional reasons, more careful attention to this
important public health concern is needed.
Risk Factors for Cigarette Smoking among AI youth
A number of risk factors play a significant role in tobacco use behavior, including
family and peer influences. Several studies among AI adolescents have shown family
influences as risk factors for smoking behaviors (M. Kegler, et al., 2000; Kegler & Malcoe,
2002; LeMaster, et al., 2002; Okamoto, et al., 2004). A study showed AI teens in Oklahoma
modeled the smoking behavior of other smokers in their families (M. Kegler, et al., 2000).
Extended family members such as grandparents, aunts, and uncles, as well as fictive kin
play a prominent role in AI family life (M. Kegler, et al., 2000) and may be viewed as
additional sources of social influence (Red Horse, Lewis, Feit, & Decker, 1978). Peer
influence is also a significant influence on smoking among AIs (J. Forster, et al., 2008;
Unger, et al., 2003), consistent with findings among other cultural groups (Conrad, et al.,
1992; Hoffman, Sussman, Unger, & Valente, 2006; M. Kegler, et al., 2000; LeMaster, et al.,
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2002; Unger, et al., 2003; Yu, et al., 2005). Motivations for smoking reported by AI youth
include a sense of belonging, fitting in, and being popular (Quintero & Davis, 2002).
Protective Factors to Cigarette Smoking
Few studies exist on protective mechanisms to prevent smoking initiation among AI
youth. Protective factors against smoking include family caring and support, strong
cultural identification, school success, having college aspirations, involvement in team
sports, and playing music (LeMaster, et al., 2002; Osilla, et al., 2007). A study by Beebe et
al. (2008) among inner-city AI youth found that the presence of a non-parental adult role
model was statistically significantly associated with tobacco non-use in the past 30 days.
As a result, AI youth may be more likely to get the advice of an adult other than a parent for
support showing the value of extended family, respect of elders, interdependence,
cooperation, and responsibility of tribe or community (Teresa D LaFromboise & Low,
1998).
Non-smoking policies in households, cars, and businesses also may serve as
deterrents against smoking and protect youth against secondhand smoke exposure.
According to the 2007 National Survey of Children’s Health, the prevalence (1.9%) of
children’s exposure to secondhand smoke (SHS) inside the home in California was low;
however, nationally, it was concluded that AI children had 2.2 times higher odds of SHS
exposure than non-AI children (Singh, et al., 2010). In private homes, SHS remains largely
unregulated (J. Jarvie & R. Malone, 2008). In 2008, CA legislation banned smoking in cars
with children present, making CA the third state in the US (Arkansas and Louisiana passed
similar laws) to adopt this law (J. A. Jarvie & R. E. Malone, 2008). However, this law does
not apply to tribal reservations unless they develop their own smoke-free policy as a
49

sovereign nation. A study compared rural American Indian (AI) and White families with
young children and found AIs were less likely to report a complete car smoking ban than
White nonsmokers (Kegler & Malcoe, 2002). Smoking a single cigarette for 5 minutes in a
car could prove harmful to children (Rees & Connolly, 2006). Household smoking
restrictions are protective against smoking among AI youth (J. Forster, et al., 2008) and
household smoking bans are important to reduce the harmful effects of SHS exposure,
reduce smoking, and increase cessation rates (Levy, et al., 2004).
Current Study
With the diversity of urban and reservation AI youth in California, there is much to
be learned about risk and protective factors, their knowledge, participation and observance
of tobacco use at AI cultural events, and especially whether ceremonial tobacco use
behaviors is associated with cigarette smoking. A culturally specific tobacco survey was
developed by AI tribal community members working with California AI populations in
tobacco control to learn about AI youth and their tobacco use behaviors. This article
examines (1) the type of tobacco (natural, commercial, or both) used for ceremonial
purposes by AI youth and its association to cigarette smoking (experimental and past-
month); (2) the perceptions of AI youth who attended the cultural events (i.e. pow-wow,
drum group, roundhouse, funeral/wake, and sweat lodge) to understand how tobacco was
used and by whom it was used (gender and age groups); (3) whether attendance at cultural
events is associated with cigarette smoking; (4) the prevalence of recreational cigarette
use, the use of other tobacco products, and the brands most preferred; and (5) the risks of
exposure to smoking in their social environments (i.e. family and friends who smoke,
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household smoking rules, and second-hand smoke exposures) and its association to
cigarette smoking.
Methods
Survey Procedure
In 2008, survey data were collected at 49 sites in urban and reservation areas of
northern, central, and southern California. To obtain a sample of at least 1000 AI
adolescents, data were collected in three primary settings: 1) high schools where at least
90% of the students were AI (n=6); 2) AI youth programs such as after-school cultural
enrichment and tutoring programs (n=22); 3) cultural events attended by AI families such
as Pow-Wows (n=21). These data collection sites were identified by a six-member
Advisory Committee that included AI tobacco control experts from northern, central, and
southern California.
Data collection was administered by the program manager (AI), project assistant
(non-AI) and trained data collectors (AI and non-AI). The staff attempted to recruit all AI
adolescents who were 13-19 years of age and were California residents at each data
collection site. Because the survey was anonymous, the IRB approved a waiver of written
consent. After verifying eligibility (self-identification as American Indian or Native
American, 13-19 years of age, and California resident), the data collectors explained the
purpose of the study, that it was an opportunity to share their opinions and feelings, and
that their responses were completely anonymous, before obtaining the adolescents’
written assent. If teachers, coordinators, directors, or parents were present, they were
instructed to give the adolescents privacy to maintain confidentiality. The paper and pencil
self-administered survey took approximately 30 to 40 minutes to complete. Upon
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completion of the survey, each student received an incentive worth $6. Additionally,
organizations that hosted a data collection received a $100 gift card to purchase supplies.
The University’s Institutional Review Board approved this research study.
Study Participants
There were 1265 completed surveys. Of those, 159 were excluded because they did
not self-identify as American Indian or Native American on the survey. Another 107 were
removed because they did not report living on a reservation or an urban area. Twenty
participants were excluded because they reported out-of-state zip codes. Birth date,
gender, and tribe(s) of all participants were compared to determine any replication. Based
on the comparisons, 10 participants were removed because they completed the survey
twice (e.g., the same student could have participated at school and then participated again
at a community event). An additional 29 participants were removed based on missing data.
The remaining 940 respondents were included in the analyses.
It is difficult to determine how many refused to participate in the study because of
the types of venues used to recruit. For example, if data were only collected at schools, the
number of potential students could be determined based on the number of eligible
students at each school. However, because youth were recruited at community events, it
was impossible to calculate how many additional eligible adolescents were at the event but
did not volunteer to participate.
Measures
Questions used in this analysis are shown in Table 1. The survey was pre-tested
with 100 AI youth in California to determine feasibility and comprehension. The survey
items included questions about recreational tobacco use, knowledge about ceremonial uses
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of tobacco, use of natural or commercial tobacco for ceremonial purposes, exposure to
secondhand smoke, family and friends who smoke, household smoking rules, participation
in five cultural events, kind of tobacco used at each cultural event, who used tobacco at the
cultural event, and how was it used at each cultural event. Three smoking status groups
were created: never-smoker (never tried smoking, even a few puffs), experimental smoker
(tried smoking but did not smoke in the past month), and past-month smoker (smoked at
least once in the past month). Other measures were recoded to nominal or ordinal
variables due to skewed distributions; ever used tobacco for ceremonial purposes was
recoded to 1=commercial store bought tobacco, 2=natural tobacco, 3=both, and 4=neither;
parental education questions for each parent were recoded to 1= less than high school,
2=high school graduate, 3=some college, 4=college graduate or advanced degree, and 5=I
don’t know; friends who smoke was recoded to 0=no friends, 1=1 friend, and 2=2 or more
friends; secondhand smoke exposure questions were recoded to 0=zero days and 1= 1 or
more days. For the multiple regression models, new variables were created to represent
the number of cultural events that each participant attended (sum of 5 dichotomous items)
and the number of events at which tobacco was smoked in a ceremonial way (sum of 5
dichotomous items). Log transformations of both new variables were conducted due to the
skewness in data.
Respondents self-reported their zip codes. Based on U.S. Census data, each zip code
was classified as urban (population density of 1000 or more people per square mile) or
rural (less than 1000 people per square mile). Participants were also asked whether they
live on a reservation most of the time. Because the vast majority of the rural respondents
lived on reservations and none of the urban respondents lived on reservations, we created
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a new “region” variable to classify each respondent’s residence as urban or reservation. A
small number of respondents (N=107) were deleted because they lived in rural zip codes
but not on a reservation. This number was too small to be retained as a separate group,
and we learned anecdotally that some respondents lived on very rural tribal lands without
zip codes and reported the zip code of the nearest town, making it difficult to code these
respondents as reservation or non-reservation.
Data Analysis
Means and frequencies were calculated to describe the sample and the distributions
of all variables. Chi-square tests examined the variables of interest by age, gender, smoking
status, and region (urban vs. reservation). All findings in Tables 2-4 were adjusted for
multiple tests with the Bonferroni correction test to reduce Type I error. P-values are
reported as statistically significant if they are less than .001 in Table 2, less than .004 in
Table 3, and less than .003 in Table 4. Multiple logistic regressions tested the associations
between the predictor and outcome variables in two separate models. One model used
past-month smoking as the outcome variable and the second model used experimental
smoking as the outcome variable. Odds ratios and 95% confidence intervals were
calculated. All analyses were conducted with the Statistical Analysis System software (9.2
version; SAS Institute Inc., 2009).
Results
Demographics
As shown in Table 2, the average age of the participants was 15.5 years and 57%
were female. The participants’ tribal affiliations included but were not limited to Yurok,
Luiseno, Chumash, Juaneno, Soboba, Navajo, Sioux, Pima, Pueblo, Kumeyaay, Aleut,
54

Chukchansi, Rincon, Cahuilla, and Choctaw. Some youth reported 2 or more tribes, and
others also self-identified as Mexican or Hispanic in addition to AI. Fifty-seven percent of
the sample was urban and 43% lived on a reservation.
Commercial Tobacco Products
Approximately 25% of the respondents were past-month smokers, 30% were
experimental smokers, and 45% never smoked (Table 2). Forty seven percent of the
respondents were between the ages of 10 and 13 years when they had their first puff on a
cigarette. Past 30-day smoking prevalence was almost double in the 17-19 year older age
group (38% past-month) than the 13-14 year younger age group (23% past-month)
(p<.0001). The top three types of cigarettes reported were Menthol, Regulars, and 100’s.
Menthols were more popular among the older and middle age group (12% and 9%
respectively) than the younger age group (2%) (p<.0001). Marlboro, Camel, and Newport
were the most preferred brands of cigarettes. Newport (16%) and Camel (14%) were
more popular with the older age group compared to the other age groups (p<.0001). There
were no other significant differences found by age or by gender.
The most frequently used ‘other tobacco products’ were blunts (i.e., a cigar that has
been hollowed out and refilled with marijuana) (14%), pipe (9%), cigars/little cigars (8%),
and chewing tobacco/snuff/smokeless tobacco/dip (8%). More males (12%) than females
(4%) reported use of chewing tobacco/snuff/smokeless tobacco/dip option (p<.0001).
The top 3 brands of chew tobacco were Grizzly, Copenhagen, and Skoal Classic. No other
significant differences were found by age or by gender.

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Knowledge and Use of Ceremonial Tobacco by AI youth
The majority (66%) of the AI youth had ‘some’ or ‘a lot’ of knowledge about the
ceremonial uses of tobacco (Table 3). The ‘never smokers’ were least likely to use both
natural and commercial tobacco for ceremonial reasons, compared with past-month and
experimental smokers. Among past-month smokers, the older age group (45%) reported
about three times the use of both natural and commercial tobacco for ceremonial use than
the younger age group (15%) (p<.0001).
Among AI youth who reported smoking tobacco at the cultural events, most
reported smoking it in a ceremonial way (35%-80%) (Table 3). Past-month smokers were
more likely than experimental and never smokers to smoke tobacco in a ceremonial way at
all cultural events. Significant differences by smoking status among those who smoked
tobacco in a ceremonial way at a pow-wow and sweat lodge (p<.0001) were found.
Additionally, significant age and gender differences were found among those who smoked
in a ceremonial way in a sweat lodge; the older age group (11%) had almost three times the
reports than among the younger age group (4%) (p<.004) and males reported twice more
than females (p<.0001).
Perceptions of Tobacco Use at Cultural Events
Table 4 illustrates the perceptions of youth who had gone to a cultural event; 85%
pow-wow, 60% funeral or wake, 43% sweat lodge, 27% drum group, and 24% roundhouse.
Most youth reported that they had seen tobacco being used at each cultural event (32%-
50%).

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What Kind of Tobacco Used at Cultural Practice?
The majority of AI youth said they did not know what kind of tobacco was used at
each cultural event. However, 47% did report traditional tobacco was used in a
roundhouse. No differences by age or gender were found.
Who used tobacco?
Typically, respondents perceived that elder men, adult men, and teenage boys used
tobacco at the cultural events (see Table 4). No differences by age or gender were found.
Was tobacco used in a ceremonial way?
The majority of respondents reported “yes” to tobacco being used in a ceremonial
way at each cultural event; 91% in a sweat lodge, 90% in a roundhouse, 90% in a drum
group, 82% in a funeral/wake, and 73% in a pow-wow. No differences by age or gender
were found.
How was it used?
At a powwow, 32% of the AI youth reported they saw people smoke tobacco in
prayer and 31% reported tobacco being given as a gift or offering. In a sweat lodge, 51% of
the AI youth stated people smoked tobacco in prayer. In a drum group, 51% of the AI youth
said tobacco was given as a gift or offering in a drum group. At a funeral or wake, 35% of
the youth described people to smoke tobacco in prayer and 38% reported it was given as a
gift or offering. Lastly, in a roundhouse, 44% of the AI youth reported tobacco was smoked
in prayer. No differences by age or gender were found.
Urban vs. Reservation Differences
Interestingly, there were no significant differences across region in the variables
reported in Tables 2 and 3. However, significant regional differences were found with the
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participation and observance at cultural events. Reservation (76%) youth were more likely
to attend a funeral/wake than urban (48%) youth (p<.0001). More urban youth (39%)
observed tobacco being given as a gift or offering at a pow-wow than reservation youth
(21%) (p<.003). More urban youth than reservation youth reported teenage boys to use
tobacco in a sweat lodge (p=.003).
Multiple Logistic Regression Model
Table 5 shows the multiple logistic regression analyses with the hypothesized risk
and protective factor variables predicting smoking behaviors. After controlling for
covariates, using store-bought commercial tobacco for ceremonial reasons was associated
with experimental smoking (OR=2.77 [1.23, 6.23]). AI youth who smoked tobacco
ceremonially at one or more cultural events have an increased risk of becoming a past-
month smoker (OR=7.47 [2.59, 10.55]) and experimental smoker (OR=2.14 [1.02, 4.49]). A
parent who smokes increases the risk for an AI youth to become a past-month smoker
(OR=1.72 [1.14, 2.60]) and a cousin who smokes increases the risk to become a past-month
smoker (OR=1.52 [1.01, 2.30]). Having one or more friends who smoke was associated
with experimental smoking (OR=2.98 [2.09, 4.26]) and past-month smoking (OR=6.86
[4.00, 1.76]). Interestingly, a grandparent who smokes was a protective factor against
experimental smoking (OR=0.69 [0.47, 1.00]) and past-month smoking (OR=0.53 [0.33,
085]). Exposure to second hand smoke in a car with someone who smokes was associated
with past-month smoking (OR=1.62 [1.03, 2.55]). The control variables, age and lower
socioeconomic status were associated with smoking behaviors.

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Discussion
This article examined how culture can potentially influence the secular use of
tobacco. Many AI youth in California participate in AI cultural events including powwows,
drum groups, sweat lodges, funeral/wake, and roundhouses. At each of these events,
different types of tobacco (i.e. natural, commercial, or both) are used in a ceremonial way
by AI youth, and youth have the opportunity to observe the use of tobacco by their peers
and other community members at these cultural events. One might predict that youth who
participate in cultural events and understand how tobacco is used ceremonially would be
reluctant to use tobacco in a secular manner. Contrary to expectations, the use of tobacco
for ceremonial reasons and smoking tobacco ceremonially at cultural events emerged as
risk factors for recreational smoking among AI youth.
The high smoking prevalence among AI youth suggests that more research is
needed to understand the social and environmental risk and protective factors for smoking.
Findings were fairly consistent with other studies; smoking friends and family members
and exposure to secondhand smoke were risk factors for adolescent smoking. The one
exception was that having a grandparent who smokes was a significant protective factor
against smoking.
Ceremonial Use of Tobacco
A major finding in this study is that AI youth who smoked tobacco in a ceremonial
way in one or more cultural events were at higher risk for recreational smoking. Nicotine
is a very potent and addictive substance and found in both commercial and natural tobacco
(D. A. Kessler, 1995; Seeman, Fournier, Paine, & Waymack, 1999). One study found that
traditional tobacco use was associated with greater smoking cessation success among AI
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adults, but only if the traditional tobacco was used in ways other than smoking (Daley, et
al., 2010). Fortunately, tobacco is not always inhaled when used for ceremonial or
traditional purposes and instead offered as a gift, sprinkled on a drum and/or Mother
earth, and burned in a fire. If smoking tobacco for ceremonial purposes increases the risk
of becoming a smoker, future health promotion efforts should be reexamined by tribal
leaders and those who teach the traditional way of tobacco use, especially when AI cultural
education programs typically include education about the sacred role of tobacco in AI
cultures. This study’s findings also illustrate the need for more culturally specific
prevention and cessation programs geared towards AI youth. Preservation of cultural
ways among AI populations is important and must be respected with careful attention
toward youth who are our future leaders.
Over half of the AI youth reported having ‘some’ or ‘a lot’ of knowledge about the
ceremonial uses of tobacco. This demonstrates that among our sample of AI youth who live
in a city or on the reservation, youth have cultural knowledge about tobacco that has been
used traditionally for thousands of years (C. Pego, et al., 1995). Interestingly, reports of
‘some’ or ‘a lot’ of knowledge were fairly similar among all smoking status groups (never,
experimental, and past-month smokers), where one might assume the more knowledge
one has about ceremonial tobacco, the less likely to smoke recreationally. Efforts should
continue to increase the knowledge about ceremonial tobacco use among AI youth so that it
is respected for its purposes to pray with, heal with, and be offered as a gift to an elder.
Often times, it is difficult to obtain wild or homegrown tobacco (natural tobacco)
and it is substituted with commercial tobacco bought from the store. In our study, the
youth reported use of natural tobacco more often than store bought commercial tobacco
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for ceremonial purposes. In contrast, Forster et al. (2008) found that more AI youth from
Minnesota used commercial tobacco than native tobacco for their ceremonies. Tobacco is
known to grow wild in certain areas of California, potentially making it more available than
in other states. Additionally, some tribes in California are growing their own tobacco and
harvesting it for their community members (i.e. United Indian Health Services in Eureka,
CA). Efforts to gather tobacco in the mountains or to grow tobacco at home or in a
community garden are necessary to make natural tobacco more accessible. This is
especially important in the context of our finding that the use of commercial store bought
tobacco for ceremonial reasons is a risk factor for experimental smoking. If youth observe
how wild tobacco is gathered in the mountains or how tobacco is gathered and stored from
the garden for ceremonial use, this can promote respect for the tobacco plant. AI youth see
many marketing advertisements by tobacco companies that use AI traditional beliefs and
values such as “Natural American Spirit,” with AI depictions such as feathered headdresses
on the packaging. Youth are vulnerable to these tobacco industry promotions and if they
see commercial store bought tobacco used for ceremonial reasons, they may think smoking
recreationally is acceptable or even beneficial. Health education prevention messages are
needed to counter the belief that smoking cigarettes is sacred when used out of context.
Perceptions of Traditional Tobacco use at Cultural Events
Participation in cultural events varied with the majority of AI youth participating in
a pow-wow, and the least participation in a roundhouse. The roundhouse is the center of
the traditional, ceremonial and social life of mostly central California Indians, hence the low
participation rate. Boys were more likely than girls to participate in the sweat lodge and
drum group. Typically drum groups are comprised of approximately four to ten male
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singers who sit around the drum, beat on the drum with a drumstick and sing (Mattern,
1996). Women do sometimes join or form drum groups of their own. For example, drum
groups usually perform at pow-wows where mostly males sit around the drum and women
will join during a song to sing in a higher octave voice adding to the melody. Although
tribes vary in customs regarding male and female roles, sweat lodges are practiced by both
genders and sometimes they can be same gender ceremonies. Funerals and wakes
typically occur on a reservation and urban Indians travel back to their reservations to
participate in ceremonies.
The majority of youth did not know the kind of tobacco used at each cultural event.
When youth are not actually using tobacco at cultural event, it can be difficult to determine
the difference between natural and commercial tobacco. However, the majority did report
tobacco was used in a ceremonial way at each cultural event with an understanding of how
it was most often used. In a qualitative study by Unger et al. (2006), AI youth were
knowledgeable about the difference between ceremonial use of sacred tobacco and
recreational use of commercial tobacco. In our study, most AI youth reported that people
smoked the tobacco in prayer at cultural events.
According to Forster et al. (2008), youth are usually offered tobacco for ceremonial
purposes when they become older and the males typically use tobacco more often than
females. Our study also found that the oldest age group (17-19 years) and males had the
highest frequency of both natural tobacco and commercial tobacco used for ceremonies.
Among California tribes, Wintu men smoke and pray with tobacco every morning and
evening (Bean, 1992). The Shasta tribal men will use tobacco when they receive a vision
from their quests to be successful with hunting and other activities (Winter, 2000c). The
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Yokuts are known to use tobacco to initiate boys into manhood, to obtain supernatural
powers, to stimulate visions, and for shamans to communicate with their helpers by
smoking a little tobacco (Winter, 2000c). These examples show primarily men using
tobacco and children less likely to do so.
Recreational Use of Commercial Tobacco
Consistent with previous findings that recreational smoking is more prevalent
among AI youth than among other ethnic or racial groups (SAMSHA, 2010); approximately
30% of our sample reported lifetime smoking and 25% reported past-month smoking. A
novel finding in this study is that menthol cigarettes were especially popular, where similar
findings have been reported among other minority groups. Ethnic variations exist in brand
preference as ethnic communities are targeted by clever marketing tactics and promotional
activities by the tobacco industry to encourage smoking (Gittelsohn et al., 1999) (Pierce,
Choi, Gilpin, Farkas, & Berry, 1998). No regional differences were found; however, future
research is needed to understand how the tobacco companies market toward AI youth who
live on the reservation and among the urban AI youth.
Recreational past-month use of other tobacco products confirmed blunts, pipes,
cigars/little cigarillos and chewing tobacco/snuff/smokeless tobacco/dip to be the top four
most reported. Our survey did not specify if “blunt” implied a type of cigar or a cigar
stripped of tobacco and replaced with marijuana. Marijuana was not specifically addressed
in the survey, but the high response rate to “blunt”, “pipe”, and “cigars/little cigarillos” may
allude to possible marijuana use by AI youth. Therefore, further attention to understand
marijuana use among AI youth is encouraged and should be addressed in prevention
efforts along with other tobacco products usage.
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Social Exposures to Smoking
Peer influence has been shown to be the strongest and most consistent predictor of
smoking behaviors across diverse ethnic groups (Conrad, et al., 1992; Wang, Fitzhugh,
Westerfield, & Eddy, 1995). Over half of our sample reported one or more friends smoke
and it was associated with smoking behaviors. Additionally, respondents with cousins who
smoke were more likely to report past-month smoking. With family having a strong role in
the AI culture, attention to reduce the number of smokers in the family is essential.
An interesting finding was that youth with grandparents who smoke were actually
less likely to smoke. One reason for this finding could be that in the AI culture, elders are
respected and often teach about cultural traditions (Garrett, 1996; Whitbeck, Adams, et al.,
2004). They may teach youth about the medicinal and ceremonial purposes of tobacco and
reinforce respect for traditional tobacco (Davis, Lambert, Cunninghamsabo, & Skipper,
1995; R. Struthers & F.S. Hodge, 2004). This is particularly important for youth in urban
areas that are away from their homeland and cultural traditions that exist on the
reservations and yearn for cultural knowledge. Other reasons may be that youth are
dissuaded from smoking because they see the harmful, long-term effects from smoking
cigarettes on their grandparent(s), like a severe cough or deadly illness or grandparents
may discuss the negative consequences, harmful effects, and addictive nature of smoking
with their grandchildren (M. C. Kegler, V. L. Cleaver, & M. Yazzie-Valencia, 2000).
Numerous studies indicate that American Indian youth are exposed to secondhand
smoke (SHS) at high rates (J. Forster, et al., 2008; Singh, et al., 2010; J. B. Unger, et al.,
2006). In our study, 40%-66% of the total sample reported secondhand smoke exposure
while riding in a car with a smoker, being in the same room with a smoker, and being in an
64

outdoor area with a smoker. Given these high rates of SHS exposure, it is encouraging that
60% of the sample did report ‘smoking is not allowed’ in the home. However, one may
question the enforcement of household no smoking rules because it is unclear whether
being in the same room with a smoker was at a friend’s or other family member’s house
that allows smoking or a tribal building, or in their own home. There is no safe level of SHS
exposure, therefore smoking bans and restrictions are key components to any tribal
tobacco control policy that will protect infants, children, and the entire community (Satter,
et al., 2012). Even though tribal smoking policies exist on the reservation, enforcement of
these smoke-free policies is unclear and can differ in each tribal community. Enforcing and
implementing multiple smoke-free policies in tribal buildings, schools, casinos, and
outdoor areas can potentially reduce SHS exposure and smoking opportunities for tribal
community members and provide a safe and clean environment.
Limitations
There are several limitations to the results of this study. First, the data are cross-
sectional, therefore no causality can be assumed with the associations. Second, AI youth
provided self-report information. Third, the youth in this study live in urban and
reservation areas of California and the findings cannot be generalizable to other tribes in
the United States. However, this study does include traditionally underrepresented groups
in research, such as American Indian youth living in different regions. There are over 560
distinct tribes with different cultural histories and practices; therefore, future research
should provide empirical evidence that contribute to the development of culturally specific
tobacco control programs that benefit AI youth in urban, rural, and reservation areas.
65

Finally, the five specific cultural practices in this study are unique but are not a
representation of all CA Indian traditional ceremonies.
Implications
It is well known that recreational smoking is more prevalent among AI youth than
among other ethnic or racial groups. The results from this study show that culturally
specific tobacco prevention, education and cessation programs should be a top priority to
reduce serious health illnesses and early death. When one person becomes ill or dies from
a smoking-related disease, a family is also affected and the community suffers due to the
loss of cultural or traditional knowledge that person had to contribute (Satter, et al., 2012).
With current smoking rates highest for California AI adults ages 25-39 years (Satter et al.,
2012), there is a need to prioritize prevention and cessation efforts in urban and
reservation communities to target AI youth to curb these high rates. Otherwise, the high
smoking rates will persist as the youth get older and morbidity and mortality rates will
continue to rise.
A sacred relationship exists between tobacco and American Indian cultural beliefs
(R. Struthers & F. S. Hodge, 2004), and preservation of this existence must continue with
the use of only traditional homegrown tobacco, tobacco gathered in the mountains, or the
mixed herbs of sage, cedar, and sweet grass. Eliminating the use of commercial tobacco
products for ceremonies will provide a healthier community by reducing exposure of
cigarettes and other tobacco products, and encouraging the harvesting of natural tobacco
or collecting tobacco in the community (e.g. mountains). The AI youth are the future
generations and increasing their knowledge about the difference of traditional and secular
use of tobacco is important to reduce the rates of smoking in AI communities.
66

Table 1. Study 1 Survey Items
Category Question Response Categories
Demographic Information
Parental education What is the highest grade completed by your
mother/father? (2 separate questions)
8
th
grade or less; some high school; high school graduate;
some college; college graduate; advanced degree; I don’t
know
Family members who
smoke
Do any of these people smoke cigarettes? Parent; step-parent; sibling (brother or sister);
grandparent; cousin; none of these people smoke
cigarettes
Friends who smoke How many of your five closest friends smoke cigarettes? None of them; 1 friend; 2 friends; 3 friends; 4 friends; all
5 friends
Household smoking rules What are the smoking rules or restrictions in your house,
if any?
Smoking is not allowed inside the house; smoking is
allowed in some areas of the house; smoking is allowed
anywhere in the house; there are no smoking rules; I
don’t know
Secondhand smoke
exposure
During the past 7 days, on how many days were you in the
same room with someone who was smoking cigarettes?
0 days; 1 or 2 days; 3 or 4 days; 5 or 6 days; all 7 days
During the past 7 days, on how many days did you ride in
a car with someone who was smoking cigarettes?
0 days; 1 or 2 days; 3 or 4 days; 5 or 6 days; all 7 days
During the past 7 days, on how many days were you in an
outdoor area where someone was smoking cigarettes
near you?
0 days; 1 or 2 days; 3 or 4 days; 5 or 6 days; all 7 days
Recreational Smoking
Experimental smoking Have you ever tried or experimented with cigarette
smoking, even a few puffs?
0 days; 1 or 2 days; 3-5 days; 6 to 9 days; 10 to 19 days;
20 to 29 days; all 30 days
Past-month smoking Think about the last 30 days. On how many of these days
did you smoke cigarettes?
0 days; 1 or 2 days; 3-5 days; 6 to 9 days; 10 to 19 days;
20 to 29 days; all 30 days
Type of Cigarette What type of cigarettes do you prefer or usually smoke? I do not smoke cigarettes, light, menthol, flavored,
cloves/kreteks, filtered, unfiltered, regulars, and 100's
Brand of Cigarette During the past 30 days what brand of cigarettes did you
usually smoke?
I do not smoke cigarettes; no usual brand; Natural
American Spirit; Basic; Benson & Hedges; Camel; Capri;
Carlton; Generic; Geronimo; GP; Kent; Kool; Lucky Strike;
Marlboro; Merit; More; Native Brand; Newport; Omaha
Brand; Noble; Pall Mall; Parliament; Salem; Santa Fe;
Seneca Brand; USA Gold; Virginia Slims; Winston; I don’t
know
67

Other tobacco products Which of these tobacco products have you used in the last
30 days?
Chewing tobacco/snuff/smokeless tobacco/dip; Bidis;
Clove cigarettes/Kreteks; Commercial tobacco in a pipe;
Flavored cigarettes; Menthols; Cigars/little cigars;
Blunts; Cigarillos; Pipe, Hookah; I haven’t used any of
these tobacco products in the past 30 days
Brands of chewing tobacco If you use chewing tobacco or snuff, what brands do you
usually use?
I do not use chewing tobacco or snuff; Beechnut;
Copenhagen; Grizzly; Hawkins; Husky; Kodiak; Levi
Garrett; Longhorn; Redman; Red Seal; Rooster; Skoal
Classic; Skoal Bandits; Timberwolf
Ceremonial tobacco use
Natural tobacco for
ceremonies
Have you ever used natural tobacco (not store bought) for
ceremonial prayer or traditional reasons?
No; yes; not sure
Commercial tobacco for
ceremonies
Knowledge about
ceremonial uses of tobacco

Have you ever used commercial tobacco (store bought)
for ceremonial prayer or traditional reasons?
How much do you know about ceremonial uses of
tobacco?

No; yes; not sure

Some; A lot; Not Sure; Nothing

Tobacco use at Cultural Practices
Participation in cultural
practices
Have you ever gone to a Pow Wow? No; Yes
Have you ever gone to a sweat lodge? No; Yes
Have you ever participated in an American Indian drum
group?
No; Yes
Have you ever gone to an American Indian funeral or
wake?
No; Yes
Have you ever gone to a Roundhouse? No; Yes
Tobacco use at Cultural
Practices
Was tobacco used at the Pow Wow/Sweat Lodge/ Drum
Group/ Funeral/ and Roundhouse?
No; yes; not sure
Kind of tobacco used What kind of tobacco was it?” Traditionally grown or wild tobacco; commercial loose
tobacco (like tobacco in a pouch or can, bought from a
store); cigarettes; I don’t know.
Who used tobacco Who used the tobacco at the Pow Wow/Sweat Lodge/
Drum Group/ Funeral/ and Roundhouse?
Elder men; elder women; adult men; adult women;
teenage boys (13-19 years old); teenage girls (13-19
years old); young boys (0-12 years old); young girls (0-12
years old); I don’t know
68

Used in a ceremonial way? Was tobacco at the Pow Wow/Sweat Lodge/ Drum
Group/ Funeral/ and Roundhouse used in a ceremonial
way?
No; yes; I don’t know
How was it used?

Smoked tobacco at any
cultural practice?

If yes, smoked in
ceremonial way?
If tobacco was used in a ceremonial way, how was it used?

Did you smoke tobacco at the Pow Wow/Sweat Lodge/
Drum Group/ Funeral/ and Roundhouse?

If you smoked tobacco at the Pow Wow/Sweat Lodge/
Drum Group/ Funeral/ and Roundhouse, did you smoke it
in a ceremonial way?
People smoke it in prayer; people smoked it in another
ceremonial way; it was burned but not inhaled; it was
given as a gift or offering; I don’t know

No; Yes

No; Yes
69

Table 2. Demographics of American Indian California Youth
Total Sample n=952
Recreational Cigarette Smoking
a

Experimental smoker 281 (30%)
Past-month smoker
Never smoker
233 (25%)
426 (45%)
Age ƚ
13-14 years 318 (33%)
15-16 years 338 (36%)
17-19 years
Mean ±SD
296 (31%)
15.5 (±1.75)
Gender
Female 542 (57%)
Males
Region
Urban
Live on the reservation
410 (43%)

543 (57%)
409 (43%)
Parental Education
Less than high school 181 (19%)
High School graduate 209 (22%)
Some college 190 (20%)
College graduate or advanced degree 203 (21%)
I don't know 169 (18%)
Family Members Who Smoke ƚ
Parent 415 (44%)
Step-parent 117 (12%)
Sibling (brother or sister) 230 (24%)
Grandparent 249 (26%)
Cousin 416 (44%)
None smoke 141 (15%)
Friends Who Smoke
0 friends 434 (46%)
1 friend 136 (14%)
2 or more friends 382 (40%)
Household Smoking Rules
Smoking not allowed in house 571 (60%)
Smoking allowed in some areas 56 (6%)
Smoking allowed anywhere 56 (6%)
There are no smoking rules 95 (10%)
I don't know 174 (18%)
SHS Exposure in past 7 days
In the same room (>1 day) 468 (49%)
Ride in a car w/ smoker (>1 day) 384 (40%)
Outdoor area (>1 day) 628 (66%)
Top 3 Type of Cigarette Usually Smoke
b

Menthol * 71 (30%)
Regulars 45 (19%)
100's 42 (18%)

70

Top 3 Brands of Cigarettes
b

Camel * 93 (39%)
Marlboro 175 (74%)
Newport * 92 (39%)
Other Tobacco Products
c

Chewing Tobacco/Snuff/smokeless
tobacco/dip ^ 72 (14%)
Bidis 12 (2%)
Clove cigarettes/Kreteks 23 (4%)
Commercial tobacco in pipe 17 (3%)
Flavored cigarettes 45 (9%)
Cigars/ little cigars 73 (14%)
Blunts 130 (25%)
Cigarillos 17 (3%)
Pipe 84 (16%)
Hookah * 66 (13%)
Top 3 Brands of Chew Tobacco
d

Grizzly 38 (53%)
Copenhagen 31 (43%)
Skoal classic 16 (22%)
Notes:
a
12 missing subjects

b
Among past-month smokers only (n=233)

c
Check all that apply (denominator is with smoker n=514)
d
Among past-month chew/snuff/smokeless tobacco users (n=72)
* age p<.001
^ gender p<.001
ƚ smoking status p<.001 (experimenter, past-month, never)

71

Table 3. Knowledge and Use of Ceremonial Tobacco by Smoking Status (n=940)
Questions Never smokers
N=426 (45%)
Experimenta
l smokers
a
N=281
(30%)
Past-month
smokers
N=233 (25%)
Total Sample
N=940
(100%)
Knowledge about the
ceremonial uses of tobacco?
Some
A lot
Not sure
Nothing
Missing

196 (46%)
56 (13%)
56 (13%)
111 (26%)
7 (2%)

151 (54%)
43 (15%)
27 (10%)
58 (20%)
2 (1%)

117 (50%)
47 (20%)
24 (10%)
40 (17%)
5 (2%)

464 (49%)
146 (16%)
107 (11%)
209 (22%)
14 (2%)
Used natural tobacco or
commercial tobacco (store
bought) for ceremonial prayer
or traditional reasons? *^
Natural tobacco
Commercial tobacco
Both
Neither
Missing

46 (11%)
15 (4%)
36 (8%)
319 (75%)
10 (2%)

33 (12%)
23 (8%)
48 (17%)
173 (62%)
4 (1%)

42 (18%)
22 (9%)
57 (24%)
106 (45%)
6 (3%)

121 (13%)
60 (6%)
141 (15%)
598 (64%)
20 (2%)
Attended Cultural Event
Powwow
Sweat Lodge* ƚ
Drum Group
Funeral/Wake
Roundhouse
Missing

332 (78%)
151 (35%)
99 (23%)
225 (53%)
94 (22%)
19 (4%)

234 (83%)
119 (42%)
72 (26%)
172 (61%)
62 (22%)
9 (3%)

197 (85%)
123 (53%)
73 (31%)
148 (64%)
63 (27%)
10 (4%)

763 (81%)
393 (42%)
244 (26%)
545 (58%)
219 (23%)
38 (4%)
If smoked at cultural event,
smoked tobacco in a
ceremonial way
Smoked at Powwow (n=69)*
Smoked at Sweat Lodge (n=79)* ^ ƚ
Smoked at Drum Group (n=26)
Smoked at Funeral/Wake (n=51)*
Smoked at Roundhouse (n=31)

2 (1%)
11 (3%)
3 (1%)
5 (1%)
5 (1%)

7 (3%)
23 (8%)
2 (1%)
10 (4%)
7 (3%)

15 (7%)
29 (13%)
8 (4%)
16 (7%)
10 (5%)

24 (35%)
63 (80%)
13 (50%)
31 (61%)
22 (71%)
Smoking *p<.004 (Criterion for statistical significance after Bonferroni correction)
Age ^p<.004
Gender ƚ p<.004
a
Experimental smokers include no past-month smokers
Natural tobacco is gathered in the wild or mountains and/or homegrown
Commercial tobacco is store bought

72

Table 4. Cultural Activities and Prevalence of Tobacco Use

Pow-Wow
n=763 (81%)
Sweat Lodge
n=393 (42%)
Drum Group
n=244 (26%)
Funeral
n=545 (58%)
Roundhouse

n=219 (23%)
Was Tobacco Used at event?

No 131 (17%) 104 (26%) 96 (39%) 165 (30%) 47 (21%)
Yes 248 (33%) 195 (50%) 103 (42%) 223 (41%) 89 (41%)
I don’t know 395 (51%) 95 (24%) 47 (19%) 160 (29%) 86 (39%)
What kind of tobacco was used?
a

Traditional tobacco 60 (24%) 64 (33%) 28 (25%) 66 (30%) 42 (47%)
Commercial loose tobacco 32 (13%) 38 (19%) 33 (29%) 31 (14%) 8 (9%)
Cigarettes 18 (7%) 4 (2%) 6 (5%) 41 (18%) 6 (7%)
I don't know 138 (56%) 90 (46%) 36 (41%) 85 (38%) 33 (37%)
Who used tobacco?
a b

Elder men 171 (69%) 131 (67%) 60 (58%) 165 (74%) 69 (78%)
Elder women 75 (30%) 68 (35%) 22 (21%) 102 (46%) 36 (40%)
Adult men 105 (42%) 100 (51%) 60 (58%) 118 (53%) 49 (55%)
Adult women 70 (28%) 63 (32%) 19 (18%) 96 (43%) 33 (37%)
Teenage boys (13-19 yrs) 43 (17%) 47 (24%) 33 (32%) 53 (24%) 27 (30%)
Teenage girls (13-19 yrs) 28 (11%) 32 (16%) 15 (15%) 46 (21%) 19 (2 1%)
Boys (0-12 yrs) 13 (5%) 20 (10%) 9 (9%) 16 (7%) 7 (8%)
Girls (0-12 yrs) 7 (3%) 10 (5%) 7 (7%) 15 (7%) 4 (5%)
I don't know 46 (19%) 18 (9%) 11 (11%) 31 (14%) 13 (15%)
Was Tobacco used in ceremonial way?
a

No 31 (13%) 6 (3%) 4 (4%) 23 (10%) 3 (3%)
Yes 182 (73%) 181 (92%) 93 (90%) 184 (83%) 80 (90%)
I don't know 35 (14%) 9 (5%) 6 (6%) 16 (7%) 6 (7%)
How was it used?
a b

People smoked it in prayer 79 (32%) 100 (51%) 29 (28%) 79 (35%) 39 (44%)
Used in another ceremonial
way 25 (10%) 23 (12%) 8 (8%) 28 (13%) 16 (18%)
Burned but not inhaled 67 (27%) 52 (27%) 22 (21%) 60 (27%) 26 (29%)
Given as gift or offering 78 (31%) 52 (27%) 52 (51%) 85 (38%) 35 (39%)
I don’t know 56 (23%) 33 (17%) 18 (18%) 40 (18%) 16 (18%)

a
Calculations based on respondents who marked ‘yes’ to the question, ‘Was tobacco used at event?’
b
Check all that apply

73

Table 5. Multiple Logistic Regression Models of Past-Month and Experimental Smoking
Odds Ratio Estimates
Ceremonial Tobacco Use
Experimental Smoking
OR and 95% CI
N=799
Past month Smoking
OR and 95% CI
N=856
Knowledge about ceremonial
uses of tobacco
0.97 (0.81, 1.17) 0.96 (0.76, 1.20)
Used store bought tobacco for
ceremonial prayer
2.77 (1.23, 6.23)* 1.65 (0.79, 3.45)
Used natural tobacco for
ceremonial prayer
1.17 (0.69, 1.99) 1.74 (0.97, 3.15)
Used both for ceremonial prayer 1.06 (0.59, 1.92) 1.37 (0.76, 2.46)
Smoked tobacco in a ceremonial way
at 1 or more cultural events
7.47 (2.59, 1.55)*** 2.14 (1.02, 4.49)*
Attended 1 or more cultural events 1.03 (0.89, 1.19) 1.03 (0.87, 1.22)
Social and Environmental Exposures
Parent smokes 1.18 (0.82, 1.68) 1.72 (1.14, 2.60)**
Sibling smokes 1.23 (0.81, 1.84) 0.77 (0.49, 1.20)
Grandparent smokes 0.69 (0.47, 1.00)* 0.53 (0.33, 0.85)**
Cousin smokes 1.31 (0.91, 1.88) 1.52 (1.01, 2.30)*
Friends smokes (1 or more) 2.98 (2.09, 4.26)† 6.86 (4.00, 1.76)†
Household smoking rules 0.89 (0.65, 1.21) 0.77 (0.54, 1.10)
Exposure to secondhand smoke in same
room
1.24 (0.81, 1.90) 1.51 (0.92, 2.48)
Exposure to secondhand smoke in car 1.41 (0.93, 2.12) 1.62 (1.03, 2.55)*
Exposure to secondhand smoke in
outdoor area
0.96 (0.63, 1.46) 1.33 (0.76, 2.37)
Covariates
Age 1.48 (1.34, 1.65)† 1.32 (1.17, 1.49)†
Gender 0.82 (0.58, 1.16) 0.99 (0.66, 1.49)
Parental Education 1.11 (0.98, 1.26) 1.07 (0.92, 1.24)
Socioeconomic Status 0.62 (0.39, 0.97)* 1.00 (0.60, 1.66)
Urban vs. Reservation area 0.75 (0.53, 1.06) 0.88 (0.58, 1.32)
†p<.0001, ***p<.001, **p<.01, *p<.05

74

CHAPTER 3: STUDY 2
STRESSFUL LIFE EVENTS, ETHNIC IDENTITY, HISTORICAL TRAUMA, AND
PARTICIPATION IN CULTURAL EVENTS: ASSOCIATIONS WITH SMOKING BEHAVIORS
AMONG AMERICAN INDIAN ADOLESCENTS IN CALIFORNIA
ABSTRACT
Background: American Indian (AI) adolescents have the highest prevalence of commercial
tobacco use of any ethnic group in the United States. Few studies among AI youth exist that
examine the impacts of historical trauma thoughts on smoking behaviors. Therefore, this
study documents AI adolescents’ thoughts of historical loss and how that it impacts
experimental and past-month smoking. Additionally historical trauma will be examined as
a mediator between three predictor (ethnic identity, participation in cultural activities, and
stressful life events) variables and smoking behaviors.
Methods: AI youth in California (N= 818, ages 13-19, recruited from 49 different tribal
youth organizations and cultural events in urban and reservation areas of California)
completed a culturally-specific tobacco survey. Structural Equation Modeling analysis was
used to assess the observed and latent variables.
Results: Historical trauma was found to mediate the participation in cultural activities and
stressful life events to past-month smoking. However, an inconsistent mediated effect
occurred where a negative direct effect from ethnic identity to past-month and a positive
indirect effect from ethnic identity to historical trauma to past-month smoking. As
hypothesized, all exogenous variables predicted historical trauma. A significant positive
path emerged from historical trauma to the outcome. Lastly, a significant positive path
emerged from stressful life events to depressive symptoms.
75

Conclusions: Our findings provide evidence that historical losses are on the minds of AI
youth. Clearly, AI youth have a conceptual understanding of the detrimental impact of
historical trauma events on AI populations and have learned about them interpersonally or
with experiences that trigger thoughts of historical loss. More emphasis is needed toward
AI youth to help them process these thoughts and empower themselves to contribute to
their family, community, and most importantly themselves.

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INTRODUCTION: STUDY 2
American Indians (AI) have the highest smoking prevalence of any ethnic group in
the United States (CDC, 2011). According to the 2011 National Survey on Drug Use and
Health (SAMHSA, 2011), rates of past-month cigarette use among youth aged 12 to 17 are
highest among American Indians/Alaska Natives (AI/AN) (12.3%), compared to Whites
(8.2%), Hispanics (6.1%), Blacks (4.9%), and Asians (3.3%). Many reasons for the
increased risk for tobacco use among AI youth have been hypothesized including peer
influences, parental influences, easier access to tobacco, and second hand smoke exposures
(J. Forster, et al., 2008; LeMaster, et al., 2002; Satter, et al., 2012; Unger, et al., 2003). Less
attention has examined the trauma and suffering that has resulted from historical trauma
and its relationship to behavioral health. With a large population of AI youth living in
urban and reservation areas of California, this information is important for future
prevention, intervention and cessation programs that are culturally specific for AI
adolescents.
A possible cause of the higher prevalence of tobacco use among AI youth is their
experience of historical trauma (M.Y.H. Brave Heart, 2000; Whitbeck, Yu, et al., 2009).
Historical trauma has been defined as the “cumulative emotional and psychological
wounding over the lifespan and across generations emanating from massive group
experience” (Brave Heart, 2003; p. 5). According to Walters and colleagues (2011), the
impact of historical trauma on American Indian communities has been viewed in at least
four different ways. They include 1) historical trauma as an etiologic agent, 2) historical
trauma as an outcome, 3) historical trauma as a mechanism for intergenerational
transmission of problem behaviors and, 4) historical trauma related stressors (Karina L
77

Walters et al., 2011). This study examines historical trauma as a mediating mechanism
linking ethnic identity, cultural activities, and stressful life events to smoking behaviors.
Therefore, this paper examines 3 of the 4 impacts of historical trauma, 1) historical trauma
as a precursor to smoking behaviors, 2) historical trauma as an outcome, 3) and how daily
life stressors impact historical trauma thoughts. With the diversity and history of
American Indian tribes, there is much to learn about what may influence historical trauma
and its effect on the behavioral health of AI adolescents.
American Indian Youth in California
According to the U.S. Bureau of Indian Affairs, there are 566 federally recognized
tribes in the United States, including 107 in California (Census, 2010; Satter, et al., 2012).
Among the federally recognized tribes in CA, there are approximately 85 reservations or
Rancherias scattered throughout the state (Hodge, et al., 1996). California also has the
largest urban AI population in the United States (689,320 AI/AN alone or in combination
with another race) (Census, 2010). Urban Indians are individuals of AI ancestry who have
moved to cities and urban areas within state or from out-of-state either by choice to seek
employment, education or housing, or by force through the federal government’s relocation
policies that started in the 1940s (Lobo, 2002). Overall, there are approximately 350,000
American Indians who identify as AI alone and approximately 600,000 who identify as AI
and of another race (Census, 2010).
Historical Trauma
Over generations, American Indians have experienced a series of traumatic events
by the United States government that have included community massacres, genocidal
policies, pandemics from the introduction of mortal diseases, forced relocation, removal of
78

children from families, boarding schools to assimilate AIs into mainstream society, and
bans against the practice of spiritual and traditional ceremonies (Duran & Duran, 1995).
The descriptions of these multiple traumatic events and the concept of historical trauma
has been developed by a Lakota researcher, Maria Yellow Horse Brave Heart, who defines
historical trauma as cumulative emotional and psychological wounding across generations
and over the lifespan (Brave Heart-Jordan, DeBruyn, Jeanne, & Gloria, 1995; M.Y.H. Brave
Heart, 1995, 1999, 2003; M.Y.H. Brave Heart & DeBruyn, 1998). Brave Heart relates the
broad array of historical events that include American Indian genocide, ethnic cleansing,
policies of forced relocation, and assimilation to the Holocaust experience and symptoms of
the Holocaust survivors and their families. These historical traumatic events have left
devastating daily reminders that still exist today: bleak living conditions of the reservation
system, encroachment of Europeans, loss of language, loss and confusion regarding
traditional beliefs and practices, loss of traditional family systems (Evans-Campbell, 2008;
Whitbeck, Chen, et al., 2004). Although AI youth are generations removed from many
historically traumatic events like the boarding school experience, the trauma associated
with such events can still be present in their emotional life. Research has shown that
children and grandchildren of survivors of traumatic events have high levels of interest in
ancestral trauma (Danieli, 1998; Whitbeck, et al., 2002).
Most of today’s youth have not directly experienced the numerous historical
traumatic events that their parents, grandparents, and great grandparents endured, but
they do live with daily reminders in their living environments and they hear about family
members’ experiences secondhand. It has been suggested that the effects of historical
trauma are transmitted intergenerationally as descendants identify emotionally with the
79

ancestral suffering (M.Y.H. Brave Heart, 1999). A measure of historical trauma among
American Indian populations has been developed by Whitbeck and colleagues (2004) to
examine the transmission of historical trauma over generations among AI/ANs with the
development of the Historical Loss Scale. AI adults reported frequent thoughts pertaining
to historical losses and associated these losses with negative feelings, alcohol abuse and
distress (Whitbeck, Adams, et al., 2004). AI youth aged 11-13 years actually reported
thinking about these historical losses more frequently than their adult caretakers did
(Whitbeck, Walls, et al., 2009). This showed that historical trauma may have originated
long ago but still persisted with reminders of economic disadvantage, discrimination, and
loss of cultural ways (Whitbeck, Walls, et al., 2009). In this respect, we must keep in mind
that the concept of historical trauma is collective and multilayered where it not only affects
the individual but the family and community (Evans-Campbell, 2008).
Research on historical trauma and American Indian populations is limited,
especially among AI youth. At the individual level, the impact of historical trauma on health
includes impairment on family communication (Evans-Campbell, 2008), mental health
systems of PTSD, survivor guilt, anxiety, depression and substance use (Whitbeck, Chen, et
al., 2004). No studies have examined the impact of historical trauma on smoking behaviors.
Historical Trauma as a Mediator
Because recent descriptions of historical trauma (Karina L Walters, et al., 2011)
have conceptualized it as both a potential etiologic agent and a potential outcome, this
study examines historical trauma as a mediator between three predictor variables (ethnic
identity, participation in cultural activities, and stressful life events) and smoking behaviors
among AI youth in California. Positive ethnic identity has shown less substance use and
80

stronger antidrug norms in various ethnic groups (Marsiglia, Kulis, Hecht, & Sills, 2004) but
little is known about its protective effect on smoking behaviors among American Indian
adolescents. In a population that has experienced historical trauma, the same protective
factor (i.e. ethnic identity) can also have negative effects because they cause adolescents to
experience the historical trauma more deeply which may lead to smoking as a possible
coping mechanism. As for stressful life events, adolescents are at greatest risk when they
experience multiple stressors simultaneously, potentially triggering historical trauma
thoughts and impacting smoking behaviors. Participation in cultural activities may also
provide an opportunity to learn and think about historical trauma thoughts. Further
explanation is provided for each construct considered in the theoretical model.
Ethnic Identity
Ethnic identity refers to the strength of a person’s connection to an ethnic group
(Moran, et al., 1999). It is based on two theoretical perspectives. Erik Erikson (1968)
posited that identity formation occurs through the process of exploration leading to a
successful resolution of identity and clear understanding of oneself and one’s place in
society. Social identity theory asserts that identity is based on a sense of belonging to a
group and the feeling and attitudes that accompany a sense of a group membership (Tajfel
and Turner, 2000). Social identity theory also emphasizes the underlying need to maintain
self-esteem that is linked to group identity. Phinney (1990; 1996) integrated these two
theories to conceptualize ethnic identity as a process and to acknowledge individual
differences in the ways in which people explore and evaluate the meaning of their ethnic
identity over time.
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Studies have shown that those with strong ethnic identity have higher levels of well-
being, self-esteem, coping, sense of mastery, optimism, and resilience to life changes (M.
Jones & R. Galliher, 2007; Martinez & Dukes, 1997; Yip & Fuligni, 2002). Studies among AIs
examining ethnic identity and smoking outcomes are mixed. Among AI youth, two studies
investigated smoking and cultural identification where alienation from AI culture was
associated with lower levels of smoking in a boarding school (Weaver, 1999) and no
relationship between cultural factors and smoking among urban AI youth (Yu, et al., 2005).
Intervention programs have worked under the assumption that strong ethnic identity is
protective against alcohol abuse and other risky behaviors (Trimble, 2007), therefore, with
our large sample of AI adolescents from urban and reservation areas of California, we
hypothesize that AI adolescents with stronger ethnic identity will act as a protective factor
to smoking behaviors.
However, it is also possible that ethnic identity may have adverse effects when
minority youth become more aware of the injustices suffered by their ancestors. According
to Erickson, during adolescence one goes through a period of exploration and
experimentation during adolescence to achieve ethnic identity. During this period an AI
youth may be immersed in one’s culture through activities such as talking with elders or
other community members to learn about language, dance, songs, and history of ethnic
cleansing specific to their tribe or other tribes. During this time they learn the importance
of maintaining their cultural heritage and traditional ways where much of their spiritual
traditions were forbidden. Therefore, we hypothesize that AI youth who have higher levels
of ethnic identity will report more historical trauma thoughts than those with lower levels
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of ethnic identity. To further our understanding, we also hypothesize historical trauma to
act as a mediator between ethnic identity and smoking outcomes.
According to Social Identity Theory (Tajfel & Turner, 1986), being a member of a
group provides individuals with a sense of belonging that contributes to self-concept.
Individuals seek to achieve positive self-esteem by positively differentiating their in-group
from a comparison out-group on some valued dimension (Tajfel & Turner, 1986). AI youth
who identify with their ethnic group may differentiate themselves from other ethnic
groups who have not experienced the historical trauma their families and ancestors have
endured. Therefore, even when ethnic identity increases historical trauma thoughts, ethnic
identity will also have a protective effect on smoking behaviors because one will have
higher levels of self-esteem and confidence being part of an in-group who share the same
values and experiences.
The Role of Culture
Modern-day California AI youth participate in AI ceremonies and cultural activities,
such as a sweat lodge and drum group (J. B. Unger, et al., 2006). A sweat lodge, also known
as a sweat or sweathouse, is a purification ceremony inside a dome lodge built by
community members with tree limbs covered with several layers of tarps. The rituals and
traditions vary from region to region and from tribe to tribe, but they often include prayer,
singing, and offerings to the spirit world with the use of tobacco. In the sweat lodge water
is poured over hot rocks to produce steam for spiritual and/or physical revival (Welch,
2002). Drum groups are comprised of approximately four to ten singers who sit around
the drum, beat on the drum with a drumstick and sing (Mattern, 1996). Tobacco may be
sprinkled on a drum or used to pray with before singing (J. B. Unger, et al., 2006).
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Participation in a drum group is typically at a pow-wow, a community social gatherings
that include AI traditional activities, such as dance, song, and drumming to celebrate tribal
customs and cultural connectedness (Schweigman, et al., 2011). Both activities include the
opportunity for an AI youth to interact with elders and AI community members to learn
about the cultural beliefs of tobacco, traditional values, history, and language.
Few studies have examined associations between youth involvement in AI cultural
activities and positive health outcomes. One study found AI youth involvement in
traditional culture increased academic performance (Whitbeck, et al., 2001). Enculturation
(i.e. spiritual involvement and participation in AI cultural activities) influenced greater
resilience among AI youth than those without enculturation (T.D. LaFromboise, et al.,
2006). A study among AI youth and adults showed commitment to cultural spirituality
decreased suicide attempts (Garroutte, Goldberg, Beals, Herrell, & Manson, 2003), and with
adults engaged in traditional practices of going to Pow wows, speaking a traditional
language, and engaging in traditional activities were associated better health, personal
strength, and hope (Herman-Stahl, Spencer, & Duncan, 2003). Based on these studies, one
might theorize participation in cultural activities to provide personal strength and
resilience among AI youth against smoking behaviors. However, with previous empirical
research, AI youth who used natural or commercial tobacco for ceremonial prayer
/traditional purposes was found to pose as a risk factor to recreational smoking. With the
cultural activities (i.e. drum group and sweat lodge) in this study, tobacco is used
traditionally. Therefore, we hypothesize AI youth who participate in cultural activities will
be a risk for smoking cigarettes. We are unclear how tobacco may be used (i.e. smoked,
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sprinkled on drum, and offered in prayer); however, youth who are exposed to any type of
tobacco may increase their likelihood to smoke.
Youth who participate in cultural activities are deeply engaged spiritually,
physically, and emotionally and are more likely to perceive higher levels of historical
trauma (Whitbeck, Walls, et al., 2009). Historical trauma can be transmitted from one
person to another through storytelling and participation in shared activities (Evans-
Campbell, 2008), especially in a drum group sitting in a circle with elders. Therefore,
participation in cultural activities is hypothesized to influence thoughts of historical
trauma, and in turn, historical trauma reports will increase the likelihood of an AI youth to
smoke.
Stressful Life Events
American Indian communities are disproportionately affected by numerous social
factors that increase their risk for adverse behavioral health outcomes. They are at a
heightened risk for chronic distress due to poverty, cultural trauma, and violence (T. R.
Rieckmann, et al., 2004). The 2010 Census reported that 28% of AI individuals live below
the poverty level as compared to 9.9% of non-Hispanic Whites (Census, 2010). Among AIs
age 25 and over, only 77% have at least a high school diploma compared to 90% of non-
Hispanic White. The economic reality of reservation and tribal community living is one in
which the annual family income is among the lowest in the nation and where the scarcity of
employment opportunities produces widespread job insecurity, high rates of
unemployment, and extensive need for state and federal welfare (Barnes, Adams, & Powell-
Griner, 2010). Among the urban Indian population, economic, cultural, social, historical,
and access to health care factors have led to severe health disparities (Gone & Trimble,
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2012; T. Rieckmann et al., 2012; Rutman, Park, Castor, Taualii, & Forquera, 2008; Sarche &
Spicer, 2008).
The impact of stressful life events on AI adolescent behavioral health is cumulative
and they are at greatest risk when experiencing multiple stressors (Baldwin, et al., 2011;
Dinges & Duong-Tran, 1992; Whitbeck, et al., 2002). Studies among AI youth have shown
stressful life events to be positively associated with depressed mood, substance use, and
risky behavior (Baldwin, et al., 2011). A study in California of urban AI youth being treated
for mental health services found that those who experienced more than 3 traumatic events
had an increased risk for alcohol use disorders compared with those who experienced no
traumatic events (Dickerson & Johnson, 2012). Stressful life events are the more
contemporary proximal stressors that AI youth experience such as facing repeated losses of
relatives and others from alcohol related accidents, homicides, and suicide (M.Y.H. Brave
Heart & DeBruyn, 1998) to violence, economic hardship, and discrimination (Gonzales,
Gunnoe, Jackson, & Samaniego, 1995). Unfortunately, AI youth who experience stressful
life events are at risk for unhealthy behaviors. With smoking outcomes, one study among
AI youth found those who experienced stressful life events were at greater risk to smoke
cigarettes and smokeless tobacco (LeMaster, et al., 2002). To further our knowledge with
our CA AI youth sample, we hypothesize those who experience more stressful life events
will be more likely to smoke in the past-month or have experimented with smoking.
With many of the stressful life events being shaped from the past history of ethnic
cleansing by the government to eradicate and assimilate AIs into mainstream society, those
who experience current contemporary stressful life events may function as a trigger to
historical trauma thoughts among AI youth. Therefore, we hypothesize that AI youth who
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report more stressful life events will have higher reports of historical trauma and in turn,
be positively associated with smoking behaviors than among those who experience less
stressful life events.
Current Study
This article examines historical trauma as a potential mediator of the effects of
ethnic identity, participation in cultural activities, and stressful life events on smoking
behaviors among California AI adolescents. A key feature of the historical trauma concept
is the emotional consequences of the trauma experience are transmitted to subsequent
generations through physiological, environmental and social pathways resulting in a
intergenerational cycle of historical trauma thoughts (M.Y.H. Brave Heart, 2003; Danieli,
1998; Duran & Duran, 1995; Sotero, 2006). We want to further our understanding of the
exogenous variables to historical trauma and in turn, the impact to smoking behaviors.
Figure 1 shows the theoretical model underlying our research study. Specific hypotheses
are as follows; (1) All predictors will be positively associated with historical trauma (path
a), (2) historical trauma will be positively associated with past-month and experimental
smoking (path c), (3) higher levels of ethnic identity will be negatively associated with
past-month and experimental smoking (path b), and (4) experiencing more stressful life
events and participation in cultural activities will have a positive direct impact on past-
month and experimental smoking (path b).
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Cultural
Events
Stressful Life
Events
Experimental
Smoking
Covariates – Age, Gender, Urban, SES
Past-month
Smoking
Figure 1. Theoretical Model (Study 2)
a
c
c
b
b
b (-)
b (-)
b
a
a
b
Ethnic
Identity
Historical
Trauma

Methods
Survey Procedure
In 2008, survey data were collected at 49 sites in urban and reservation areas of
northern, central, and southern California. To obtain a sample of at least 1000 AI
adolescents, data were collected in three primary settings: 1) high schools where at least
90% of the students were AI (n=6); 2) AI youth programs such as after school cultural
enrichment and tutoring programs (n=22); 3) cultural events attended by AI families such
as Pow-Wows (n=21). These data collection sites were identified by a six-member
Advisory Committee that included AI tobacco control experts from northern, central, and
southern California.
Data collection was administered by the program manager (AI), project assistant
(non-AI) and trained data collectors (AI and non-AI). The staff attempted to recruit all AI
adolescents who were 13-19 years of age and were California residents at each data
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collection site. Because the survey was anonymous, the IRB approved a waiver of written
consent. After verifying eligibility (self-identification as American Indian or Native
American, 13-19 years of age, and California resident), the data collectors explained the
purpose of the study, that it was an opportunity to share their opinions and feelings, and
that their responses were completely anonymous, before obtaining the adolescents’
written assent. If teachers, coordinators, directors, or parents were present, they were
instructed to give the adolescents privacy to maintain confidentiality. The paper and pencil
self-administered survey took approximately 30 to 40 minutes to complete. Upon
completion of the survey, each student received an incentive worth $6. Additionally,
organizations that hosted a data collection received a $100 gift card to purchase supplies.
The University’s Institutional Review Board approved this research study.
Study Participants
There were 1265 completed surveys. Of those, 159 were excluded because they did
not self-identify as American Indian or Native American on the survey. Another 107 were
removed because they did not report living on a reservation or an urban area. Twenty
participants were excluded because they reported out-of-state zip codes. Birth date,
gender, and tribe(s) of all participants were compared to determine any replication. Based
on the comparisons, 10 participants were removed because they completed the survey
twice (e.g., the same student could have participated at school and then participated again
at a community event). An additional 151 participants were removed based on missing
data. The remaining 818 respondents were included in the analyses.
It is difficult to determine how many refused to participate in the study because of
the types of venues used to recruit. For example, if data were only collected at schools, the
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number of potential students could be determined based on the number of eligible
students at each school. However, because youth were recruited at community events, it
was impossible to calculate how many additional eligible adolescents were at the event but
did not volunteer to participate.
Measures
Ethnic identity
Ethnic Identity was assessed using the 12-item Multi-group Ethnic Identity Measure
(MEIM) (Phinney, 1992). The MEIM measures (a) positive feelings and a sense of
belonging to one’s ethnic group, (b) ethnic identity achievement including exploration and
resolution of identity issues, and (c) ethnic behaviors and cultural practices. Items were
rated on a four-point scale ranging from 1=strongly disagree through 4=strongly agree, so
that high scores indicate strong ethnic identity. The Cronbach’s alpha was 0.93.
Stressful Life Events
Stressful Life Events was measured with the Multicultural Events Schedule for
Adolescents (MESA) scale generated to be used with adolescents living in multiethnic,
urban environments (Gonzales, et al., 1995). MESA consists of 83 items that assess family
trouble, family conflict, peer hassles/conflicts, school hassles, economic stress, perceived
discrimination, and violence. For each item on the scale, students were asked to report
whether the event happened within the past 3 months (checked all that applied). For the
purpose of this study, responses to this group of variables were summed and a new
variable named SLE was created.

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Cultural Activities
Cultural activities was assessed with two questions, “Have you ever participated in
an American Indian drum group?” and “Have you ever gone to a sweat lodge?” Response
options were no or yes. The two questions were recoded to create a new variable ‘Activity’
where 0=no participation in any cultural activity and 1= participation in 1 or both cultural
activities. 35% of the participants participated in one of the cultural activities and 19%
participated in both cultural events.
Historical Trauma
Historical Trauma was assessed with the Historical Loss Scale that measures the
degree to which respondents report a sense of loss as a result of historical trauma
(Whitbeck, Adams, et al., 2004). The scale consist of 12-items; loss of land, language,
culture, traditional spiritual ways, loss of family and family ties, loss of self-respect, loss of
trust, loss of people through early death, and loss of respect by children for elders and for
traditional ways. Respondents rate how frequently they think about each loss on the
following scale: 1=several times a day, 2=daily, 3=weekly, 4=monthly, 5=yearly or at
special times, and 6=never. Cronbach’s alpha was 0.95.
Smoking Behaviors
Cigarette smoking was assessed with two questions from the Youth Risk Behavior
Surveillance Survey (CDC, 2000). To assess experimental smoking, respondents were
asked, “Have you ever tried or experimented with cigarette smoking, even a few puffs?”
Response options were no or yes. To assess past-month smoking, respondents were asked,
“Think about the last 30 days. On how many of these days did you smoke cigarettes?”
Seven response options were available: 0 days, 1 or 2 days, 3 or 5 days, 6 to 9 days, 10 to 19
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days, 20 to 29 days, or all 30 days. Due to the skewness in data for this variable, past-
month smoking was recoded to 0=never and 1= 1 or more times. Fifty-four percent of
participants have experimented with smoking and 25% reported past-month smoking.
Covariates
Covariates included age, gender, socioeconomic status (SES), and region (urban/
reservation). Age was coded in years. Gender was recoded to 0=females and 1=males. SES
was created from two questions, “How many people live in the home where you spent most
of your time (including you)?” and “How many rooms does your house or apartment have
(excluding kitchen and bathroom)?” SES was calculated by dividing the number of rooms
in the home by the number of people living in the home. This “overcrowding index” is
strongly correlated with SES (Myers, Baer, & Choi, 1996); thus, higher scores indicate
higher SES. Respondents self-reported their zip codes. Based on U.S. Census data, each zip
code was classified as urban (population density of 1000 or more people per square mile)
or rural (less than 1000 people per square mile). Participants were also asked whether
they live on a reservation most of the time. Because the vast majority of the rural
respondents lived on reservations and none of the urban respondents lived on
reservations, we created a new “region” variable to classify each respondent’s residence as
urban or reservation. A small number of respondents (N=107) were deleted because they
lived in rural zip codes but not on a reservation. This number was too small to be retained
as a separate group, and we learned anecdotally that some respondents lived on very rural
tribal lands without zip codes and reported the zip code of the nearest town, making it
difficult to code these respondents as reservation or non-reservation.

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Statistical Analysis
First, preliminary analyses included descriptive statistics and intercorrelations
between variables. Next, the hypothesized Structural Equation Model shown in Figure 1
was tested with 2 latent variables and 4 manifest variables. Latent variables for ethnic
identity and historical trauma were created using parceled indicators (Little, Cunningham,
Shahar, & Widaman, 2002) so that no more than four indicators were attached to either
latent variable. This model was estimated using the MPLUS 7.1 statistical package
(Muthén & Muthén, 2012). The 818 respondents with complete data on all variables in the
model were included in the analysis. The covariates, age, gender, SES, and region were
adjusted for in the model. Before estimating the model, the assumptions of multivariate
normality and linearity and absence of outliers were evaluated for each variable (p<.001).
No outliers were identified. Maximum likelihood estimation was used. The goodness of fit
indicators was referenced to assess the model. Common fit indexes for acceptable fit of
data are Non-Normed Fit Index (NNFI) to be 0.95, Comparative Fit Index (CFI) to be 0.95,
the Root Mean Square Error of Approximation (RMSEA) to be smaller where 0 indicates
perfect fit, Weighted Root Mean Square Residual (WRMSR) to be less than 0.90, and the
Chi-square where the ratio of chi-square to degrees is close to 1 (Schreiber, Nora, Stage,
Barlow, & King, 2006).
Results
Analysis of Missing Data
Analyses were conducted to examine the differences between the respondents with
complete data and those who had missing data and were therefore excluded from the
analysis. Respondents with missing data were younger in age (chi-square=9.38, p<.001),
male (chi-square=7.11, p<.01), had lower levels of ethnic Identity (t-test=-3.49, p<.001),
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less historical trauma thoughts (t-test=-2.46, p<.01), and experienced less stressful life
events (t-test=-4.57, p<.0001).
Preliminary Analyses
In the overall sample, 59% of participants were female, the mean age was 15.5
years, and 60% were urban youth (i.e. lived in cities rather than on reservations). Over half
participated in 1 or both cultural activities. Table 6 presents the means, standard
deviations, and correlations of the variables. As expected, ethnic identity, cultural
activities, and stressful life events were positively correlated with historical trauma.
Historical Trauma was positively correlated to both smoking outcomes. Stressful life
events and historical trauma were positively correlated with smoking outcomes.
Interestingly, ethnic identity was not correlated with either smoking outcome.
Table 7 shows the distribution of responses for Historical Trauma. Fifteen percent
of the AI adolescents think of Historical Trauma losses monthly and 9% daily. Table 8
shows Ethnic Identity where 77% of the overall sample agreed or strongly agreed to all
response items. Table 9 shows the percentage of responses for each Stressful Life Event
question.
Mediation Analyses
Figure 2 presents the final mediated model that examined the links of the predictors
(ethnic identity, cultural activities, and stressful life events) to the mediator (historical
trauma) and the outcomes (experimental and past-month smoking). The overall fit of the
model was adequate based on the following fit indices: Chi-square=203.10 (76 degrees of
freedom, p-value<.0001), Comparative Fit Index (CFI) = .935, the Non-Normed Fit Index
(NNFI) = .902, the RMSEA=.04, and the WRMR=1.054. Post-hoc modifications were
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indicated but theoretically did not make sense, and the residual analysis did not indicate
any problems. Standardized parameter estimates are provided in Figure 4. As
hypothesized, ethnic identity, cultural events, and stressful life events variables had a
significant positive path to historical trauma. Positive paths from historical trauma to both
smoking outcomes were significant. Stressful life events had a positive significant
association to experimental and past-month smoking. There was a significant negative
direct path from ethnic identity to past-month smoking. No significant direct paths
emerged between cultural activities and smoking outcomes. A mediation effect emerged
from stressful life events to historical trauma to past-month smoking with a significant
positive indirect effect (standardized coefficient= 0.03, p<.05). There was a positive
indirect effect (mediation) with cultural activities to historical trauma to past-month
smoking (standardized coefficient=.02, p<05). A positive indirect effect (standardized
coefficient=.05, p<.05) emerged from ethnic identity to past-month smoking (historical
trauma as a mediator). Because the direct effect was negative from ethnic identity to past-
month smoking, this indirect effect can be interpreted as suppression (MacKinnon, Krull, &
Lockwood, 2000; Tzelgov & Henik, 1991), resulting in an inconsistent mediation effect. No
mediation effects were found with any predictors and experimental smoking outcomes.
Discussion
Major findings of this study showed historical trauma to mediate the relationships
between cultural activities and stressful life events with past-month smoking among urban
and reservation youth in California. The results provide evidence that historical trauma
thoughts are on the minds of AI youth and impact smoking behaviors. Contrary to our
hypothesis, a suppressed effect occurred when the direct and mediated effects of ethnic
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identity on past-month smoking had opposite signs (MacKinnon, et al., 2000). This
occurrence is rare and with both the direct and mediated effects not having the same sign,
there is no mediation effect.
An inconsistent mediation effect was found with the effect of ethnic identity on
smoking behaviors mediated by historical trauma. However, there was a direct significant
negative path from ethnic identity to past-month smoking, and a direct significant positive
path from ethnic identity to historical trauma. To our knowledge, this study is the first to
examine these constructs and find ethnic identity as a protective factor to smoking and
have an impact on historical trauma thoughts. A study found the opposite effect; urban AIs
with high cultural identification were more likely to smoke cigarettes (Angstman, Harris,
Golbeck, & Swaney, 2009). Studies among AI adolescents have found cultural identification
to be related to higher self-esteem (Whitesell, Mitchell, & Spicer, 2009) social functioning,
and feelings of belonging at school (M. Jones & R. Galliher, 2007). With these positive
outcomes, maybe they are functioning in a similar way to protect the AI youth from
smoking. As hypothesized, ethnic identity also impacted feelings of historical trauma. It is
possible that as ethnic identity gains salience over time with one’s sense of self as a group
member, along the way they are learning the historical perspective of the colonial injustices
on AI populations. Ethnic identity is a complex process that involves perceptions,
cognitions, and emotions that relate to how individuals understand and relate it to their
ethnic awareness (Cuellar, Nyberg, Maldonado, & Roberts, 1997) where historical trauma
thoughts are part of the awareness when learning about language, culture, and history.
Further attention is needed among youth who think about historical trauma to cope with
their emotions so smoking is not used as a coping mechanism. It would have been
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interesting if other substance use outcomes were included to compare and determine
which substances are used more often. Youth experiences differ as do their emotional
reactions. Therefore, future research needs the inclusion of the Historical Loss Associated
Symptoms Scale immediately following the Historical loss measure. Once the emotions are
better understood future interventions can target these with healing treatments.
Although these respondents are generations removed from historical traumatic
events, AI youth who had higher levels of ethnic identity, participated in cultural activities,
and experienced numerous stressful life events had higher levels of historical trauma.
These associations with historical trauma provide evidence that reminders of historical
loss remain ever present, represented by economic disadvantages on reservations and city
life, national disrespect (use of AI imagery to advertise consumer products and sports
teams), discrimination and a sense of traditional cultural loss that affect the children,
family members, and the entire community (Whitbeck, Adams, et al., 2004).
Participation in cultural activities (i.e. sweat lodge and drum group) positively
impacted historical trauma. The sweat lodge ceremony is central to many AI cultures and
spiritual life to heal the mind, body and soul through the ritual process of singing and
praying (Schweigman, et al., 2011; J. B. Unger, et al., 2006). In a drum group, drummers are
singing songs from different tribal regions during pow-wows. During cultural activities,
youth are learning and practicing what was once attempted to be taken away and not
allowed. The history of colonization attempted to disrupt the connections to traditional
values among AI cultures. Fortunately, youth are engaged in cultural practices and with
their involvement they may become further aware about how much more there is to learn
about their own tribal cultural ways. Additionally, they may also think about other AI
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youth who are less involved who should be engaged to preserve their traditions. Whitbeck
and colleagues (2009) perceived historical loss to affect only those adolescents who are
deeply engaged in their culture. Interestingly, in our study, cultural activity involvement
was associated with more thoughts about loss of land, loss of language, loss of self-respect
from poor government treatment among AI youth. Contrary to our hypothesis,
involvement in cultural activities did not positively impact past-month smoking. In fact,
full mediation occurred with the inclusion of the historical trauma mediator between
cultural activities and past-month smoking. It makes sense that AI youth who are more
involved in cultural activities would be more acutely aware of what has been lost in terms
of their Native languages, culture, and traditions. This exemplifies that these historical
losses are on their mind more frequently than those who do not participate in cultural
activities, and in turn, smoke cigarettes in the past-month. This implies a need for youth to
engage in healing around these losses that they are aware of where youth are encourage to
practice their cultural ways to preserve the traditions. One study among AI families found
when parents participated in a family program that emphasized traditional activities, their
scores on the Historical Loss Scale initially increased, but then when they had the
opportunity to do some healing, the scores returned to even lower levels (Goodkind, et al.,
2010). Maybe a similar approach with AI youth who are connected and engaged in cultural
activities can also focus on the healing around the losses they often think about and learn
that smoking is not a healthy way to deal with their emotions.
AI youth who experienced more stressful life events (i.e. proximal causes) reported
more thoughts about historical trauma and increased smoking behaviors. Living in an
urban area or on a reservation, conditions of poverty and neighborhood disadvantages
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predispose AI youth to smoking behaviors because they are exposed to more proximal
negative life events (Yu, et al., 2005). Although this study did not provide evidence for a
specific effect of family trouble or conflict, peer hassle or conflict, school hassle, economic
stress, personal violence, or perceived discrimination on smoking behaviors, this study
showed the cumulative effect of these numerous stressful life events that directly impact
thoughts of historical trauma losses and smoking. Additionally, historical trauma partially
mediated the association between stressful life events and past-month smoking. A similar
finding occurred in a study among AI adults where historical trauma mediated the
association between perceived discrimination and alcohol abuse (Whitbeck, Chen, et al.,
2004). It was speculated that “Alcohol may serve to reduce intrusive thoughts or feelings
related to historical loss and to numb reminders of that loss” (p.416). Perceived
discrimination questions are included in the Multicultural Events Schedule for Adolescents
measure used in our study and smoking cigarettes may be a way to relieve thoughts of
historical trauma losses and stressful life events. Further research is needed to understand
the effects of these stressors on emotional well-being so that youth do not resort to
smoking cigarettes or other unhealthy behaviors.
American Indian scholars and researchers have partnered to create culturally
specific interventions designed to resolve historical loss grief and to empower AI adults. In
1992, the Return to the Sacred Path intervention was the first Historical Trauma and
Unresolved Grief (HTUG) Intervention, designed by an AI non-profit organization Takini
(means ‘Survivor’ in Lakota language) for the Lakota community to heal from historical
trauma and unresolved grief (Maria Yellow Horse Brave Heart, Chase, Elkins, & Altschul,
2011; M.Y.H. Brave Heart & DeBruyn, 1998). HTUG was selected as a Tribal Best Practice in
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2009 by the First Nations Behavioral Health Association and the Substance Abuse and
Mental Health Services Administration. The intervention group process allowed
participants to confront historical trauma, understand historical trauma, release the pain,
and transcend the trauma with traditional culture and ceremonies that facilitated cathartic
release of emotions while mastering feelings of trauma. With most of the evaluation done
with the Lakota, the HTUG has been delivered to other tribes in the United States. Efforts
should be considered with the AI community in California to combine the HTUG
intervention components with culturally adapted practices to meet the needs of
reservation and urban AI youth. A youth program called RezRIDERS (Reducing Risk
through Interpersonal Development, Empowerment, Resiliency, & Self Determination)
aims to reduce substance abuse and depression among high risk AI youth (NCAI, 2012). A
program initiated by the Pueblo of Jemez and the University of New Mexico, developed a
multilevel extreme-sport experiential education youth intervention that incorporates
extreme sports (snowboarding, white-water rafting, rock climbing) to directly link youth to
the sacred cycle of water (mountain snow, rivers, rains, and clouds). With the cultural
mentorship component, youth negotiate contradictions between Western and traditional
ways with discussion of topics that include past history, present history, and future role
expectations. To support any research efforts with AI populations, a community based
participatory approach is necessary and relationships between tribes and researchers
should be fostered.

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Limitations
With the cross-sectional nature of our study we cannot assume causality. With our
structural equation model, we tested direct and indirect correlations rather than causation.
Therefore, future research should focus on longitudinal data. Second, only participation in
2 cultural activities (i.e. sweat lodge and drum group) was included and is not a
representation of all CA Indian traditions. Third, the measure of stressful life events did
not specify the intensity, duration and frequency of events. Longitudinal data on stressful
life events could provide more comprehensive information. Fourth, the items in the
historical trauma measure are negatively worded, which may induce concurrent negative
thinking in subsequent items. Additionally, this measure was designed to assess historical
trauma among those who live on or near rural reservations (Whitbeck, Walls, et al., 2009).
Although the measure has not been validated among urban AIs, the consistency of the
Cronbach’s alpha across our reservation and urban subsamples suggests that the measure
would be reliable and valid among urban AIs as well. Fifth, youth in this study live in urban
and reservation areas of California and the findings cannot be generalizable to other tribes
in the United States. However, this study does include traditionally underrepresented
groups in research, such as American Indian youth living in different regions. There are
over 560 distinct tribes with different cultural histories and practices; therefore, future
research should provide empirical evidence that contribute and inform future prevention
and intervention programs geared toward AI youth in urban, rural, and reservation areas.
Future Directions
Future research is needed to understand AI youth responses to the thoughts of
historical trauma with use of the Historical Loss Associated Symptoms Scale immediately
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following the Historical Trauma Loss Scale (Whitbeck, Adams, et al., 2004). Symptomology
can differ, therefore, understanding the emotional responses can inform treatment geared
toward AI youth to reduce smoking behaviors and increase coping mechanisms. Further
investigation of AI youth resilience and healing around the continuum of trauma can help
us better understand the strengths and pliability that result from survival. Building on
these strengths can help search for pathways to heal the legacy of intergenerational trauma
and daily stressful life events. Knowing the potential transmission of historical trauma
through ethnic identity, cultural activities and stressful life events, family and community
are part of this too; therefore, interventions should not only include youth, but their family,
and the community with a focus to heal and deal with daily trauma that persists from past
colonization.
Few studies have examined AI and historical trauma and this paper provides further
insight that historical trauma is on the minds of AI youth. What is not clear is how these
thoughts are based on proximal or distal events and current living conditions that are a
result of historical traumatic events. There are different events that have occurred in the
past that have impacted communities, families and individuals which has manifested to the
children. We do not know which events have influenced smoking behaviors and whether it
was a cumulative effect of events that lead them to smoke in the past 30 days. Future
research can examine specific events to determine any differences between tribes.
However, this work would be challenging among urban Indians who represent numerous
tribes throughout the U.S.

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Conclusions
Our findings provide evidence that historical losses are on the minds of AI youth.
Clearly, AI youth have a conceptual understanding of the detrimental impact of historical
trauma events on AI populations and have learned about them interpersonally or with
experiences that trigger thoughts of historical loss. This study contributes to literature by
exploring the contribution of ethnic identity, participation in cultural events, and stressful
life events on historical trauma. More emphasis is needed toward AI youth to help them
process these thoughts and empower themselves to contribute to their family, community,
and most importantly themselves.

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Table 6. Study 2 -Correlations, Mean, and Standardized Deviation.

Pearson Correlation Coefficients
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
1. MEIM 1.0
2. Cultural Activities 0.136*** 1.0
3. Stressful Life Events 0.134*** 0.045 1.0
4. Historical Trauma 0.337*** 0.168*** 0.257*** 1.0
5. Experimental Smoking 0.051 0.132** 0.185** 0.173** 1.0
6. Past-month Smoking 0.006 0.149** 0.150*** 0.163*** 0.518*** 1.0
7. Age 0.146*** 0.046 0.156*** 0.195*** 0.355*8* 0.275*** 1.0
8. Gender -0.108** 0.170*** -0.162*** -0.057 -0.006 0.034 -0.038 1.0
9. Region -0.055 -0.027 0.127** -0.078* -0.026 0.016 0.1165** -0.052 1.0
10. SES 0.025 -0.017 -0.089* 0.017 -0.056 -0.010 -0.021 0.066 -.094** 1.0
Mean 3.04 0.52 14.26 2.77 0.53 0.25 0.43 15.57 0.57 0.81
SD 0.61 0.49 11.75 1.35 0.49 0.43 0.49 1.75 0.49 0.37
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Cultural
Events
Stressful Life
Events
Experimental
Smoking
.21*
.18*
Covariates – Age, Gender, Urban , SES
Past-month
Smoking
Non-Normed Fit Index=.902
Comparative Fit Index=.935
RMSEA=.04 (90% CI 0.04,0.05)
WRMR = 1.054
Chi-square=203.10 (p<.0001)
76 df
Figure 3. SEM Final Model
.82 .92 .84 .87
Ethnic
Identity
Historical
Trauma
.90 .85
..86
.78
.39
.28
.19
.26
.15 .33 .24 .15
.11*
.30*
-.13*
.11*
.16*
.16
.07
.12
.15*
*p<.05

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Table 7. Historical Trauma Measure and Distribution among AI adolescents
Historical Trauma Never Yearly Monthly Weekly Daily
Several
Times a
Day
Loss of our land 34% 26% 13% 12% 9% 5%
Loss of our language 30% 22% 14% 11% 14% 8%
Losing our traditional spiritual ways 31% 21% 17% 11% 12% 9%
The loss of our family ties because of boarding schools 48% 18% 13% 8% 8% 5%
The loss of families from the reservation to government
relocation 40% 23% 14% 9% 9% 6%
The loss of self-respect from poor treatment by
government officials 38% 21% 14% 9% 11% 8%
The loss of trust in whites from broken treaties 35% 21% 13% 9% 12% 9%
Losing our culture 28% 19% 15% 12% 14% 11%
The losses from the effects of alcoholism on our people 32% 17% 15% 10% 15% 11%
The losses from the effects of methamphetamine use on
our people 40% 15% 14% 12% 10% 9%
Loss of respect for elders 33% 15% 15% 10% 15% 13%
Loss of our people through early death 27% 17% 18% 11% 14% 13%
Loss of respect for traditional ways 30% 18% 15% 10% 14% 13%
Total 34% 20% 15% 10% 12% 9%
Cronbach alpha=0.95

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Table 8. Ethnic Identity Measure and Distribution among AI adolescents
ETHNIC IDENTITY
MEIM
Strongly
Disagree Disagree Agree
Strongly
Agree
Spent time trying to find more 7% 17% 53% 23%
Active in organizations 10% 27% 47% 16%
Clear sense of identity 6% 19% 52% 22%
Life being affected by membership 9% 24% 47% 20%
Happy with my group membership 4% 8% 39% 49%
Strong sense of belonging 6% 15% 43% 35%
Understand pretty well 6% 15% 48% 31%
Talked to other people about my
group 7% 22% 47% 24%
Lot of pride in my ethnic group 5% 8% 36% 51%
Participate in cultural practices 8% 19% 43% 29%
Feel strong attachment 6% 15% 44% 35%
Feel good about my ethnic
background 5% 7% 40% 48%
Total 7% 16% 45% 32%

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Table 9. Stressful Life Events Questions
Stressful Life Events in the Past 3 Months %
1. Family members, relatives, or step-parents moved in or out of your house. 32
2. Someone you live with got pregnant. 14
3. Someone you live with had a baby. 12
4. Your family moved to a new home. 18
5. You moved far away from family or friends. 13
6. You broke up with your boyfriend / girlfriend. 27
7. If female: You got pregnant. 3
8. If female: You had a baby. 1
9. If male: You got someone pregnant. 2
10. If male: Someone you got pregnant had a baby 1
11. Your parent lost a job. 9
12. You changed schools. 18
13. You lost your pet or your pet died. 20
14. You were seriously ill or injured. 16
15. A close family member was seriously ill or injured. 25
16. A close family member died. 28
17. A close friend died. 14
18. Your parents separated or divorced. 9
19. You got a new guardian or step-parent. 7
20. Your home was damaged by fire, accident, or natural disaster (i.e., bad
storm). 3
21. People from the government (Immigration, Welfare, Police, etc.)
investigated someone in your family. 13
22. You were pressured to do drugs, smoke or drink alcohol. 27
23. You were pressured against your will to join a gang. 4
24. Someone stole something valuable from you. 23
25. Your parent(s) got upset at you for not participating in the family’s cultural
or religious traditions. 9
26. You heard gun shots fired at your school or in your neighborhood. 22
27. You did poorly on an exam or school assignment. 45
28. You were unfairly accused of doing something bad because of your race or
ethnicity. 16
29. A close family member or someone you live with got drunk or high. 46
30. You saw someone carrying a weapon. 29
31. Your parent was upset because he or she could not find work. 12
32. You had to wear clothes that were dirty, worn out, or don’t fit. 15
33. Your close friend(s) got drunk or high. 52
34. People put you down for practicing the customs or traditions of your own
race or ethnicity or country of origin. 13
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Stressful Life Events in the Past 3 Months %
35. A close family member or someone you live with had serious emotional
problems. 31
36. You saw someone being threatened with a knife or gun. 12
37. A close family member or someone you live with participated in gang
activity. 12
38. Someone close to you was threatened with a knife or gun. 11
39. You were excluded from a group because of your culture or race. 8
40. Your parent(s) talked about having serious money problems. 32
41. Your family had to stay in a homeless shelter or public place. 3
42. Your friends criticized you for hanging out with other ethnic or racial
groups. 12
43. Someone close to you was shot or attacked. 14
44. Other kids made fun of the way you look. 16
45. A friend that you trusted did not keep a secret. 29
46. You had a major failure in sports or an extracurricular activity. 12
47. You were not chosen for a team or activity that you wanted to join. 8
48. Your parent(s) criticized you for hanging out with people of a different race
or culture. 10
49. Your boyfriend / girlfriend dumped you or cheated on you. 18
50. You heard people say bad things or make jokes about your culture or race. 29
51. You were physically attacked by someone not in your family. 10
52. Things in your home did not work the way they should (no water, no
electricity, things falling apart, etc.) 16
53. You liked someone who didn’t like you. 29
54. You had a serious disagreement with your mom’s boyfriend/partner or
dad’s girlfriend/partner. 20
55. Other members of your family (or people you live with) had a serious
disagreement or fight. 24
56. People in your family accused you of not being proud of your culture or
race. 7
57. You had a disagreement or fight with a close friend. 33
58. You had a disagreement or fight with a teacher or principal. 22
59. You had to spend time away from your family because of family problems. 23
60. Other kids wanted to fight with you or tried to fight with you. 35
61. You were called a racial name that was a put down. 17
62. Members of your family hit or hurt each other. 15
63. A close friend had a serious emotional problem. 30
64. A teacher or principal criticized you or tried to embarrass you in front of
other students. 12
65. Members of your family refused to speak to each other. 26
66. Your parent did not do something he or she promised. 32
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Stressful Life Events in the Past 3 Months %
67. Someone broke into your home or damaged it. 6
68. You had to work to support other family members. 8
69. You could not buy yourself something important because your family did
not have enough money. 24
70. You were pressured about having sex. 11
71. You saw another student treated badly or discriminated against because of
his/her race/ethnicity. 20
72. Your parents had a serious disagreement or fight with each other. 18
73. Your mom/dad had a serious disagreement or fight with a partner. 13
74. Family members could not go someplace they needed to go (work, school,
doctor, etc.) because they had no transportation. 17
75. You were threatened with a knife or gun. 7
76. Your parent(s) acted badly in front of your friends (yelled at them, criticized
them, or was drunk in front of them). 12
77. A close family member or someone you live with committed a crime, got in
trouble with the law, or was sent to jail. 22
78. You had to go without a meal because your family did not have enough
money. 8
79. You saw someone get shot or attacked. 11
80. You had to do almost all the cooking, cleaning, or childcare in your home
because your parent(s) had to work. 18
81. You had to do almost all the cooking, cleaning, or childcare in your home
because your parent(s) were using drugs or alcohol. 7
82. You saw someone commit a crime (e.g., stealing, selling drugs, etc.) in your
neighborhood. 26
83. You didn’t feel confident in your schoolwork. 45

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CHAPTER 4: STUDY 3
STRESSFUL LIFE EVENTS, ETHNIC IDENTITY, HISTORICAL TRAUMA, AND
PARTICIPATION IN CULTURAL EVENTS: ASSOCIATIONS WITH DEPRESSIVE
SYMPTOMS AMONG AMERICAN INDIAN ADOLESCENTS IN CALIFORNIA
ABSTRACT
Background: Depression is a major public and mental health problem among American
Indian (AI) youth. Few studies among AI youth exist that examine the impacts of historical
trauma thoughts on mental health. Therefore, this study examines AI adolescents’ thoughts
of historical loss as a mediator between three predictor (ethnic identity, participation in
cultural activities, and stressful life events) variables and depressive symptoms.
Methods: AI youth in California (N= 818, ages 13-19, recruited from 49 different tribal
youth organizations and cultural events in urban and reservation areas of California)
completed a culturally-specific tobacco survey. Structural Equation Modeling analysis was
used to assess the observed variables.
Results: Historical trauma was found to mediate the participation in cultural activities and
stressful life events to depressive symptoms. However, an inconsistent mediated effect
occurred with a negative direct effect from ethnic identity to depressive symptoms and a
positive indirect effect from ethnic identity to historical trauma to depressive symptoms.
As hypothesized, all exogenous variables predicted historical trauma. A significant positive
path emerged from historical trauma to the outcome. Lastly, a significant positive path
emerged from stressful life events to depressive symptoms.
Conclusions: Our findings provide evidence that historical losses are on the minds of AI
youth. Clearly, AI youth have a conceptual understanding of the detrimental impact of
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historical trauma events on AI populations and have learned about them interpersonally or
with experiences that trigger thoughts of historical loss. More emphasis is needed toward
AI youth to help them process these thoughts and empower themselves to contribute to
their family, community, and most importantly themselves.

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INTRODUCTION: STUDY 3
Depression is a major public and mental health problem among American Indian
(AI) youth. According to SAMHSA (2007), among adolescents ages 12 to 17, American
Indian/Alaska Natives had the highest lifetime (13.3%) and past-year (9.3%) prevalence of
major depressive episode (MDE). A school- based study with 9,863 students found
American Indian youth to have the highest prevalence of depressive symptoms (29%)
compared with Hispanic (22%), White (18%), Asian American (17%) and African American
(15%) youth (Saluja, et al., 2004). Depressive symptoms generally appear in childhood,
adolescence, or early adulthood (Thrane, et al., 2004).
A possible cause of the higher prevalence of depression among AI youth is their
experience of historical trauma (M.Y.H. Brave Heart, 2000; Whitbeck, Yu, et al., 2009).
Historical trauma has been defined as the “cumulative emotional and psychological
wounding over the lifespan and across generations emanating from massive group
experience” (Brave Heart, 2003; p. 5). According to Walters and colleagues (2011), the
impact of historical trauma on American Indian communities has been viewed in at least
four different ways. They include 1) historical trauma as an etiologic agent, 2) historical
trauma as an outcome, 3) historical trauma as a mechanism for intergenerational
transmission of problem behaviors and, 4) historical trauma related stressors. This study
examines historical trauma as a mediating mechanism linking ethnic identity, cultural
activities, and stressful life events to depressive symptoms. Therefore, this paper examines
3 of the 4 impacts of historical trauma, 1) historical trauma as a precursor to smoking
behaviors, 2) historical trauma as an outcome, 3) and how daily life stressors impact
historical trauma thoughts. With the diversity and history of American Indian tribes, there
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is much to learn about what may influence historical trauma and its effect on the mental
health of AI adolescents.
American Indian Youth in California
According to the U.S. Bureau of Indian Affairs, there are 566 federally recognized
tribes in the United States, including 107 in California (Census, 2010; Satter, et al., 2012).
Among the federally recognized tribes in CA, there are approximately 85 reservations or
Rancherias scattered throughout the state (Hodge, et al., 1996). California also has the
largest urban AI population in the United States (689,320 AI/AN alone or in combination
with another race) (Census, 2010). Urban Indians are individuals of AI ancestry who have
moved to cities and urban areas within state or from out-of-state either by choice to seek
employment, education or housing, or by force through the federal government’s relocation
policies that started in the 1940s (Lobo, 2002). Overall, there are approximately 350,000
American Indians who identify as AI alone and approximately 600,000 who identify as AI
and of another race (Census, 2010).
Historical Trauma
Over generations, American Indians have experienced a series of traumatic events
by the United States government that have included community massacres, genocidal
policies, pandemics from the introduction of mortal diseases, forced relocation, removal of
children from families, boarding schools to assimilate AIs into mainstream society, and
bans against the practice of spiritual and traditional ceremonies (Duran & Duran, 1995).
The descriptions of these multiple traumatic events and the concept of historical trauma
has been developed by a Lakota researcher, Maria Yellow Horse Brave Heart, who defines
historical trauma as cumulative emotional and psychological wounding across generations
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and over the lifespan (Brave Heart-Jordan, et al., 1995; M.Y.H. Brave Heart, 1995, 1999,
2003; M.Y.H. Brave Heart & DeBruyn, 1998). Brave Heart relates the broad array of
historical events that include American Indian genocide, ethnic cleansing, policies of forced
relocation, and assimilation to the Holocaust experience and symptoms of the Holocaust
survivors and their families. These historical traumatic events have left devastating daily
reminders that still exist today: bleak living conditions of the reservation system,
encroachment of Europeans, loss of language, loss and confusion regarding traditional
beliefs and healing practices, and loss of traditional family systems (Evans-Campbell, 2008;
Whitbeck, Chen, et al., 2004). Although AI youth are generations removed from many
historically traumatic events like the boarding school experience, the trauma associated
with such events can still be present in their emotional life. Research has shown that
children and grandchildren of survivors of traumatic events have high levels of interest in
ancestral trauma (Danieli, 1998; Whitbeck, et al., 2002).
Most of today’s youth have not directly experienced the numerous historical
traumatic events that their parents, grandparents, and great grandparents endured, but
they do live with daily reminders in their living environments and they hear about family
members’ experiences secondhand. It has been suggested that the effects of historical
trauma are transmitted intergenerationally as descendants identify emotionally with the
ancestral suffering (M.Y.H. Brave Heart, 1999). A measure of historical trauma among
American Indian populations has been developed by Whitbeck and colleagues (2004) to
examine the transmission of historical trauma over generations among AI/ANs with the
development of the Historical Loss Scale. AI adults reported frequent thoughts pertaining
to historical losses and associated these losses with negative feelings, alcohol abuse and
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distress (Whitbeck, Adams, et al., 2004). AI youth aged 11-13 years actually reported
thinking about these historical losses more frequently than their adult caretakers did with
a significant correlation to depressive symptoms (Whitbeck, Walls, et al., 2009). This
showed that historical trauma may have originated long ago but still persisted with
reminders of economic disadvantage, discrimination, and loss of cultural ways (Whitbeck,
Walls, et al., 2009). In this respect, we must keep in mind that the concept of historical
trauma is collective and multilayered where it not only affects the individual but the family
and community (Evans-Campbell, 2008).
Historical Trauma as a Mediator
Because recent descriptions of historical trauma (K. L. Walters, Beltran, Evans-
Campbell, & Simoni, 2011; Karina L Walters, et al., 2011) have conceptualized it as both a
potential etiologic agent and a potential outcome, this study examines historical trauma as
a mediator between three predictor variables (ethnic identity, participation in cultural
activities, and stressful life events) and depressive symptoms among AI youth in California.
Positive ethnic identity and participation in cultural activities have shown a protective
effect to depression (M. D. Jones & R. V. Galliher, 2007; Torres & Ong, 2010; Whitbeck,
Chen, et al., 2004; Williams, Chapman, Wong, & Turkheimer, 2012). However, in a
population that has experienced historical trauma, these same protective factors can also
have negative effects because they may cause adolescents to experience the historical
trauma more deeply which can increase depressive symptoms. As for stressful life events,
adolescents are at greatest risk when they experience multiple stressors simultaneously,
potentially triggering historical trauma thoughts and increasing depressive symptoms
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(Dinges & Duong-Tran, 1992). Further explanation is provided for each construct
considered in the theoretical model.
Ethnic Identity
Ethnic identity refers to the strength of a person’s connection to an ethnic group
(Moran et al, 1999). It is based on two theoretical perspectives. Erik Erikson (1968)
posited that identity formation occurs through the process of exploration leading to a
successful resolution of identity and clear understanding of oneself and one’s place in
society. Social identity theory asserts that identity is based on a sense of belonging to a
group and the feeling and attitudes that accompany a sense of a group membership (Tajfel
and Turner, 2000). Social identity theory also emphasizes the underlying need to maintain
self-esteem that is linked to group identity. Phinney (1990; 1996) integrated these two
theories to conceptualize ethnic identity as a process and to acknowledge individual
differences in the ways in which people explore and evaluate the meaning of their ethnic
identity over time.
Studies have shown that those with strong ethnic identity have higher levels of
well-being, self-esteem, coping, sense of mastery, optimism, and resilience to life changes
(Martinez & Dukes, 1997; Yip & Fuligni, 2002). However, few studies have examined the
association between ethnic identity and positive outcomes among American Indian youth.
One study found Navajo adolescents’ ethnic identity to be positively associated with self-
esteem, social functioning, and feelings of belonging at school (M. Jones & R. Galliher,
2007). Another study found AI youth bicultural identification to predict psychological well-
being (Moran, et al., 1999). Therefore, we hypothesize that AI adolescents with stronger
ethnic identity will show lower levels of depressive symptomatology. However, it is also
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possible that ethnic identity may have adverse effects when minority youth become more
aware of the injustices suffered by their ancestors. According to Erickson, during
adolescence one goes through a period of exploration and experimentation during
adolescence to achieve ethnic identity. During this period an AI youth may be immersed in
one’s culture through activities such as talking with elders or other community members to
learn about language, dance, songs, and history of ethnic cleansing specific to their tribe or
other tribes. During this time they learn the importance of maintaining their cultural
heritage and traditional ways where much of their spiritual traditions were forbidden.
Therefore, we hypothesize that AI youth who have higher levels of ethnic identity will
report more historical trauma thoughts than those with lower levels of ethnic identity. To
further our understanding, we also hypothesize historical trauma to act as a mediator
between ethnic identity and depressive symptoms.
According to Social Identity Theory (Tajfel & Turner, 1986), being a member of a
group provides individuals with a sense of belonging that contributes to self-concept.
Individuals seek to achieve positive self-esteem by positively differentiating their in-group
from a comparison out-group on some valued dimension (Tajfel & Turner, 1986). AI youth
who identify with their ethnic group may differentiate themselves from other ethnic
groups who have not experienced the historical trauma their families and ancestors have
endured. Therefore, even when ethnic identity increases historical trauma thoughts, ethnic
identity will also have a protective effect on depressive symptoms because one will have
higher levels of self-esteem and confidence being part of an in-group who share the same
values and experiences.

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The Role of Culture
Modern-day California AI youth participate in AI ceremonies and cultural activities,
such as a sweat lodge and drum group (J. B. Unger, et al., 2006). A sweat lodge, also known
as a sweat or sweathouse, is a purification ceremony inside a dome lodge built by
community members with tree limbs covered with several layers of tarps. The rituals and
traditions vary from region to region and from tribe to tribe, but they often include prayer,
singing, and offerings to the spirit world. In the sweat lodge water is poured over hot rocks
to produce steam for spiritual and/or physical revival (Welch, 2002). Drum groups are
comprised of approximately four to ten singers who sit around the drum, beat on the drum
with a drumstick and sing (Mattern, 1996). Participation in a drum group is typically at a
pow-wow, a community social gathering that includes AI traditional activities, such as
dance, song, and drumming to celebrate tribal customs and cultural connectedness
(Schweigman, et al., 2011). Both activities include the opportunity for an AI youth to
interact with elders and AI community members to learn about the cultural beliefs, values,
history, and language.
Few studies have examined associations between youth involvement in AI cultural
activities and mental health outcomes. One study found AI youth involvement in
traditional culture increased academic performance (Whitbeck, et al., 2001). Enculturation
(i.e. spiritual involvement and participation in AI cultural activities) was associated with
greater resilience among AI youth (T.D. LaFromboise, et al., 2006). A study among AI youth
and adults showed commitment to cultural spirituality decreased suicide attempts
(Garroutte, et al., 2003). Adults engaged in traditional practices of going to Pow wows,
speaking a traditional language, and engaging in traditional activities were associated with
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lower levels of depressive symptoms (Whitbeck, et al., 2002), better health, personal
strength, and hope (Herman-Stahl, et al., 2003). With few studies among AI adolescents
and mental health protective effects, we hypothesize that AI youth who participate in
cultural activities will report less depressive symptoms.
Youth who participate in cultural activities are deeply engaged spiritually,
physically, and emotionally and are more likely to perceive higher levels of historical
trauma (Whitbeck, Walls, et al., 2009). Historical trauma can be transmitted from one
person to another through storytelling and participation in shared activities (Evans-
Campbell, 2008), such as a drum group. Therefore, participation in cultural activities is
hypothesized to influence thoughts of historical trauma, and in turn, historical trauma
reports will increase depressive symptoms. However, with the involvement in AI cultural
activities it can also act as a protective factor against depressive symptoms with spiritual
involvement and participation in AI activities being linked to greater resilience (T.D.
LaFromboise, et al., 2006).
Stressful Life Events
American Indian communities are disproportionately affected by numerous social
factors that increase their risk for adverse mental health outcomes. They are at a
heightened risk for chronic distress due to poverty, cultural trauma, and violence (T. R.
Rieckmann, et al., 2004). The 2010 Census reported that 28% of AI individuals live below
the poverty level as compared to 9.9% of non-Hispanic Whites who live below the poverty
level (Census, 2010). Among AIs age 25 and over, only 77% have at least a high school
diploma compared to 90% of non-Hispanic White. The economic reality of reservation and
tribal community living is one in which the annual family income is among the lowest in the
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nation and where the scarcity of employment opportunities produces widespread job
insecurity, high rates of unemployment, and extensive need for state and federal welfare
(Barnes, et al., 2010). Among the urban Indian population, economic, cultural, social,
historical, and access to health care factors have led to severe health disparities (Gone &
Trimble, 2012; T. Rieckmann, et al., 2012; Rutman, et al., 2008; Sarche & Spicer, 2008).
The impact of stressful life events on AI adolescent mental and behavioral health is
cumulative and they are at greatest risk when experiencing multiple stressors. Studies
among AIs have shown that chronic and acute stressful life events can increase depressive
symptoms (Baldwin, et al., 2011; Dinges & Duong-Tran, 1992; Whitbeck, et al., 2002). In a
study among AI youth, stressful life events were positively associated with depressed
mood, substance use, and risky behavior (Baldwin, et al., 2011). AIs who experience
discrimination are more likely to report depressive symptoms (Whitbeck, et al., 2002). A
study in California of urban AI youth being treated for mental health services found that
those who experienced more than 3 traumatic events had an increased risk for alcohol use
disorders compared with those who experienced no traumatic events (Dickerson &
Johnson, 2012). These contemporary traumas include experiencing a threat of injury,
witnessing an injury, intentional injury, or experiencing sexual abuse (Deters, Novins,
Fickenscher, & Beals, 2006). Another study found that AI youth and adults who experience
3 or more traumatic events had about 4 times the risk of having an alcohol use disorder
(Boyd‐Ball, Manson, Noonan, & Beals, 2006). To further our knowledge with our CA AI
youth sample, we hypothesize those who experience more stressful life events will be more
likely to smoke in the past-month or have experimented with smoking.
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With many of the stressful life events being shaped from the past history of ethnic
cleansing by the government to eradicate and assimilate AIs into mainstream society, those
who experience current contemporary stressful life events may function as a trigger to
historical trauma thoughts among AI youth. Therefore, we hypothesize that AI youth who
report more stressful life events will have higher reports of historical trauma and in turn,
have higher depressive symptoms than those who experience less stressful life events.
Also the more stressful life events one experiences will have a direct positive impact to
depressive symptoms. Stressful life events are the more contemporary proximal stressors
that AI youth experience such as facing repeated losses of relatives and others from alcohol
related accidents, homicides, and suicide (M.Y.H. Brave Heart & DeBruyn, 1998) to
violence, economic hardship, and discrimination (Gonzales, et al., 1995).
Current Study
This article examines historical trauma as a potential mediator of the effects of
ethnic identity, participation in cultural activities, and stressful life events on depressive
symptoms among California AI adolescents. A key feature of the historical trauma concept
is that the emotional consequences of the trauma experience are transmitted to subsequent
generations through physiological, environmental and social pathways resulting in a
intergenerational cycle of historical trauma thoughts (M.Y.H. Brave Heart, 2003; Danieli,
1998; Duran & Duran, 1995; Sotero, 2006). We want to further our understanding of the
exogenous variables to historical trauma and in turn, its association with depressive
symptoms. Figure 1 shows the theoretical model underlying this study. Specific
hypotheses are as follows; (1) All predictors will be positively associated with historical
trauma (path a), (2) historical trauma will be positively associated with depressive
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symptoms (path c), (3) higher levels of ethnic identity and participation in cultural
activities will be negatively associated with depressive symptoms (path b), and (4)
experiencing more stressful life events will have a positive direct impact on depressive
symptoms (path b).
Ethnic
Identity
Cultural
Activities
Stressful Life
Events
Historical
Trauma
Depressive
Symptoms
Figure 2. Theoretical Model (Study 3)
(-)
(+)
(+)
(+)
(-)
(+)
a
a
a
b
b
c
(+)
b
Covariates – Age, Gender, Urban, SES

Methods
Survey Procedure
In 2008, survey data were collected at 49 sites in urban and reservation areas of
northern, central, and southern California. To obtain a sample of at least 1000 AI
adolescents, data were collected in three primary settings: 1) high schools where at least
90% of the students were AI (n=6); 2) AI youth programs such as after school cultural
enrichment and tutoring programs (n=22); 3) cultural events attended by AI families such
as Pow-Wows (n=21). These data collection sites were identified by a six-member
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Advisory Committee that included AI tobacco control experts from northern, central, and
southern California.
Data collection was administered by the program manager (AI), project assistant
(non-AI) and trained data collectors (AI and non-AI). The staff attempted to recruit all AI
adolescents who were 13-19 years of age and were California residents at each data
collection site. Because the survey was anonymous, the IRB approved a waiver of written
consent. After verifying eligibility (self-identification as American Indian or Native
American, 13-19 years of age, and California resident), the data collectors explained the
purpose of the study, that it was an opportunity to share their opinions and feelings, and
that their responses were completely anonymous, before obtaining the adolescents’
written assent. If teachers, coordinators, directors, or parents were present, they were
instructed to give the adolescents privacy to maintain confidentiality. The paper and pencil
self-administered survey took approximately 30 to 40 minutes to complete. Upon
completion of the survey, each student received an incentive worth $6. Additionally,
organizations that hosted a data collection received a $100 gift card to purchase supplies.
The University’s Institutional Review Board approved this research study.
Study Participants
There were 1265 completed surveys. Of those, 159 were excluded because they did
not self-identify as American Indian or Native American on the survey. Another 107 were
removed because they did not report living on a reservation or an urban area. Twenty
participants were excluded because they reported out-of-state zip codes. Birth date,
gender, and tribe(s) of all participants were compared to determine any replication. Based
on the comparisons, 10 participants were removed because they completed the survey
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twice (e.g., the same student could have participated at school and then participated again
at a community event). An additional 151 participants were removed based on missing
data. The remaining 818 respondents were included in the analyses.
It is difficult to determine how many refused to participate in the study because of
the types of venues used to recruit. For example, if data were only collected at schools, the
number of potential students could be determined based on the number of eligible
students at each school. However, because youth were recruited at community events, it
was impossible to calculate how many additional eligible adolescents were at the event but
did not volunteer to participate.
Measures
Ethnic identity
Ethnic Identity was assessed using the 12-item Multi-group Ethnic Identity Measure
(MEIM) (Phinney, 1992). The MEIM measures (a) positive feelings and a sense of
belonging to one’s ethnic group, (b) ethnic identity achievement including exploration and
resolution of identity issues, and (c) ethnic behaviors and cultural practices. Items were
rated on a four-point scale ranging from 1=strongly disagree through 4=strongly agree, so
that high scores indicate strong ethnic identity. The Cronbach’s alpha was 0.93.
Stressful Life Events
Stressful Life Events was measured with the Multicultural Events Schedule for
Adolescents (MESA) scale generated to be used with adolescents living in multiethnic,
urban environments (Gonzales, et al., 1995). MESA consists of 71 items that assess family
trouble, family conflict, peer hassles/conflicts, school hassles, economic stress, perceived
discrimination, and violence. For each item on the scale, students were asked to report
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whether the event happened within the past 3 months (checked all that applied). For the
purpose of this study, responses to this group of variables were summed and a new
variable named SLE was created.
Cultural Activities
Cultural activities was assessed with two questions, “Have you ever participated in
an American Indian drum group?” and “Have you ever gone to a sweat lodge?” Response
options were no or yes. Responses to these two questions were recoded to create a new
variable ‘Activity’ where 0=no participation in any cultural activity and 1= participation in
1 or both cultural activities. 35% of the participants participated in one of the cultural
activities and 19% participated in both cultural events.
Historical Trauma
Historical Trauma was assessed with the Historical Loss Scale that measures the
degree to which respondents report a sense of loss as a result of historical trauma
(Whitbeck, Adams, et al., 2004). The scale consist of 12 items: loss of land, language,
culture, traditional spiritual ways, loss of family and family ties, loss of self-respect, loss of
trust, loss of people through early death, and loss of respect by children for elders and for
traditional ways. Respondents rate how frequently they think about each loss on the
following scale: 1=several times a day, 2=daily, 3=weekly, 4=monthly, 5=yearly or at
special times, and 6=never. Cronbach’s alpha was 0.95.
Depressive symptoms
Depressive Symptoms was assessed with the Center for Epidemiologic Studies
Depression (CES-D) scale (Radloff, 1977), a 20-item self-report scale used to evaluate past
week levels of depressive symptoms. It has been used extensively among Indigenous
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adolescents (Beals, Manson, Keane, & Dick, 1991a; S.M. Manson, et al., 1990; Thrane, et al.,
2004). Response categories are a four-point scale; 0 days, 1-2 days, 3-4 days, 5-7 days. The
scoring of positive items was reversed. The possible ranges of scores are 0 to 60, with the
higher score indicating more depressive symptomology. Cronbach’s alpha coefficient was
0. 88.
Covariates
Covariates included age, gender, socioeconomic status (SES), and region (urban/
reservation). Age was coded in years. Gender was coded as 0=female and 1=male. SES
was created from two questions, “How many people live in the home where you spent most
of your time (including you)?” and “How many rooms does your house or apartment have
(excluding kitchen and bathroom)?” SES was calculated by dividing the number of rooms
in the home by the number of people living in the home. This “overcrowding index” is
strongly correlated with SES (Myers, et al., 1996); thus, higher scores indicate higher SES.
Respondents self-reported their zip codes. Based on U.S. Census data, each zip code was
classified as urban (population density of 1000 or more people per square mile) or rural
(less than 1000 people per square mile). Participants were also asked whether they live on
a reservation most of the time. Because the vast majority of the rural respondents lived on
reservations and none of the urban respondents lived on reservations, we created a new
“region” variable to classify each respondent’s residence as urban or reservation. A small
number of respondents (N=107) were deleted because they lived in rural zip codes but not
on a reservation. This number was too small to be retained as a separate group, and we
learned anecdotally that some respondents lived on very rural tribal lands without zip
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codes and reported the zip code of the nearest town, making it difficult to code these
respondents as reservation or non-reservation.
Statistical analysis
First, preliminary analyses included descriptive statistics and intercorrelations
between variables. Next, the hypothesized Structural Equation Model shown in Figure 1
was tested with only manifest variables. This model was estimated using the EQS 6.1
statistical package (Bentler & Wu, 2003). The 818 respondents with complete data on all
variables in the model were included in the analysis. The covariates, age, gender, SES, and
region were adjusted for in the model. Before estimating the model, the assumptions of
multivariate normality and linearity and outliers were evaluated for each variable
(p<.001). No outliers were identified. Maximum likelihood parameter estimation was used
to estimate the free parameters in the model. Fit was assessed with the Comparative Fit
Index (CFI) , Non-Normed Fit Index (NNFI), Root Mean Square Error of Approximation
(RMSEA), Weighted Root Mean Square Residual (WRMSR), and Chi-square. The goodness
of fit indicators was referenced to assess the model. Common fit indexes for acceptable fit
of data are Non-Normed Fit Index (NNFI) to be 0.95, Comparative Fit Index (CFI) to be 0.95,
the Root Mean Square Error of Approximation (RMSEA) to be smaller where 0 indicates
perfect fit, and the Chi-square where the ratio of chi-square to degrees is close to 1
(Schreiber, et al., 2006).
Results
Analysis of Missing Data
Analyses were conducted to examine the differences between the respondents with
complete data and those who had missing data and were therefore excluded from the
analysis. Respondents with missing data were younger in age (chi-square=9.38, p<.001),
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more likely to be male (chi-square=7.11, p<.01), had lower levels of ethnic identity (t-
test=3.49, p<.001), less historical trauma thoughts (t-test=-2.46, p<.01), lower SES, and
experienced less stressful life events (t-test=4.57, p<.0001).
Preliminary Analyses
In the overall sample, 59% participants were female, the mean age was 15.5 years,
and 60% were urban youth (i.e. lived in cities rather than on reservations). Over half
participated in 1 or both cultural activities. Table 1 presents the means, standard
deviations, and correlations of the variables. As expected, ethnic identity, cultural
activities, stressful life events were positively correlated with historical trauma. Stressful
life events and historical trauma were positively correlated with depressive symptoms.
Interestingly, ethnic identity was not correlated with depressive symptoms.
Table 2 shows the distribution of responses for Historical Trauma. Fifteen percent
of the AI adolescents think of Historical Trauma losses monthly and 9% daily. Table 3
shows Ethnic Identity where 77% of the overall sample agreed or strongly agreed to all
response items. Table 4 shows Depressive Symptoms questions where more than 50% of
the participants responded to depressive feelings in the past week.
Mediation Analyses
Figure 2 presents the mediated model that examined the links of the predictors
(ethnic identity, cultural activities, and stressful life events) to the mediator (historical
trauma) and the outcome (depressive symptoms). The overall fit of the model was
adequate based on the following fit indices: Chi-square=5.41 (4 degrees of freedom, p-
value=0.24), Comparative Fit Index (CFI) = .99, the Non-Normed Fit Index (NNFI) = .97, and
the RMSEA=.02. No post-hoc modifications were indicated, and the residual analysis did
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not indicate any problems. Standardized parameter estimates are provided in Figure 2. As
hypothesized, ethnic identity, cultural events, and stressful life events variables had a
significant positive path to historical trauma. A positive path from historical trauma to
depressive symptoms was significant. Stressful life events had a positive significant
association to depressive symptoms. There was a significant negative direct path from
ethnic identity to depressive symptoms. No significant direct path emerged between
cultural activities and depressive symptoms. A mediation effect emerged from stressful life
events to historical trauma to depressive symptoms with a significant positive indirect
effect (standardized coefficient= 0.02, p<.05). There was a positive indirect effect
(mediation) with cultural activities to historical trauma to depressive symptoms
(standardized coefficient=.012, p<05). A positive indirect effect (standardized
coefficient=.03, p<.05) emerged from ethnic identity to depressive symptoms (historical
trauma as a mediator). Because the direct effect was negative from ethnic identity to
depressive symptoms, and the indirect mediated effect estimate was positive, this can be
interpreted as a suppression (MacKinnon, et al., 2000; Tzelgov & Henik, 1991), resulting in
an inconsistent mediation effect. The model revealed that 17% of the variance (r
2
=0.17) in
depressive symptoms was predicted by all independent variables, mediator, and
covariates.
Discussion
This study found that historical trauma mediated the relationships between cultural
activities and stressful life events with depressive symptoms among urban and reservation
youth in California. The results provide evidence that historical trauma thoughts are on the
minds of AI youth and predict depressive symptoms. Contrary to our hypothesis, a
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suppressed effect occurred when the direct and mediated effects of ethnic identity on
depressive symptoms had opposite signs (MacKinnon, et al., 2000). This occurrence is rare
and with both the direct and mediated effects not having the same sign, there is no
mediation effect.
An inconsistent mediation effect was found with the effect of ethnic identity on
depressive symptoms mediated by historical trauma. However, there was a direct
significant negative path from ethnic identity to depressive symptoms, and a direct
significant positive path from ethnic identity to historical trauma. Studies among AI
adolescents have found cultural identification to be related to higher self-esteem
(Whitesell, et al., 2009) social functioning, and feelings of belonging at school (M. Jones & R.
Galliher, 2007). With these positive outcomes, maybe they are functioning in a similar way
to reduce depressive symptoms. As hypothesized, ethnic identity also impacted feelings of
historical trauma. It’s possible as ethnic identity gains salience over time with one’s sense
of self as a group member, along the way they are learning the historical perspective of the
colonial injustices on AI populations. Ethnic identity is a complex process that involves
perceptions, cognitions, and emotions that relate to how individuals understand and relate
it to their ethnic awareness (Cuellar, et al., 1997) where historical trauma thoughts are part
of the awareness when learning about language, culture, and history. Further attention is
needed among youth who think about historical trauma to cope with their emotions. Youth
experiences differ as do their emotional reactions. Therefore, future research needs the
inclusion of the Historical Loss Associated Symptoms Scale immediately following the
Historical loss measure. Once the emotions are better understood, future interventions can
target these with healing treatments.
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Although these respondents are generations removed from historical traumatic
events, AI youth who had higher levels of ethnic identity, participated in cultural activities,
and experienced numerous stressful life events had higher levels of historical trauma.
These associations with historical trauma provide evidence that reminders of historical
loss remain ever present, represented by economic disadvantages on reservations and city
life, national disrespect (use of AI imagery to advertise consumer products and sports
teams), discrimination and a sense of traditional cultural loss that affect the children,
family members, and the entire community (Whitbeck, Adams, et al., 2004).
Participation in cultural activities (i.e. sweat lodge and drum group) positively
impacted historical trauma. The sweat lodge ceremony is central to many AI cultures and
spiritual life to heal the mind, body and soul through the ritual process of singing and
praying (Schweigman, et al., 2011; J. B. Unger, et al., 2006). In a drum group, drummers are
singing songs from different tribal regions during pow-wows. During cultural activities,
youth are learning and practicing what was once attempted to be taken away and not
allowed. The history of colonization attempted to disrupt the connections to traditional
values among AI cultures. Fortunately youth are engaged in cultural practices and with
their involvement they may become further aware about how much more there is to learn
about their own tribal cultural ways. Additionally, they may also think about other AI
youth who are less involved who should be engaged to preserve their traditions. Whitbeck
and colleagues (2009) perceived historical loss affects only those adolescents who are
deeply engaged in their culture. Interestingly, in our study, cultural activity involvement
was associated with more thoughts about loss of land, loss of language, loss of self-respect
from poor government treatment among AI youth. Contrary to our hypothesis,
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involvement in cultural activities did not have a direct significant negative impact to
depressive symptoms. In fact, full mediation occurred with the inclusion of the historical
trauma mediator between cultural activities and depressive symptoms. It makes sense that
AI youth who are more involved in cultural activities would be more acutely aware of what
has been lost in terms of their Native languages, culture, and traditions. This exemplifies
that these historical losses are on their mind more frequently than those who do not
participate in cultural activities, and in turn, have higher levels of depressive symptoms.
Our findings indicate a need for youth to engage in healing around these losses that they
are aware of. One study among AI families found when parents participated in a family
program that emphasized traditional activities, their scores on the Historical Loss Scale
initially increased, but then when they had the opportunity to do some healing, the scores
returned to even lower levels (Goodkind, et al., 2010). The AI youth in our study are
connected and engaged in cultural activities and may need support in healing around the
losses they often think about and learn to deal with their emotions in a healthy way.
AI youth who experienced more stressful life events (i.e. proximal causes) reported
more thoughts about historical trauma and increased depressive symptoms. Living in an
urban area or on a reservation, conditions of poverty and neighborhood disadvantages
predispose AI youth to depressive symptoms because they are exposed to more proximal
negative life events. Although this study did not provide evidence for a specific effect of
family trouble or conflict, peer hassle or conflict, school hassle, economic stress, personal
violence, or perceived discrimination on depressive symptoms, this study showed the
cumulative effect of numerous stressful life events that directly impact thoughts of
historical trauma losses and depressive symptoms. Additionally, historical trauma
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partially mediated the association between stressful life events and past-month smoking. A
similar finding occurred in a study among AI adults where historical trauma mediated the
association between perceived discrimination and alcohol abuse (Whitbeck, Chen, et al.,
2004). It was speculated that “Alcohol may serve to reduce intrusive thoughts or feelings
related to historical loss and to numb reminders of that loss” (p.416). Perceived
discrimination questions are included in the Multicultural Events Schedule for Adolescents
measure used in our study and with depressive feelings, one may resort to alcohol as a way
to relieve thoughts of historical trauma losses and stressful life events. Further research is
needed to understand the effects of these stressors on emotional well-being so that youth
do not resort to unhealthy behaviors.
American Indian scholars and researchers have partnered to create culturally
specific interventions designed to resolve historical loss grief and to empower AI adults. In
1992, the Return to the Sacred Path intervention was the first Historical Trauma and
Unresolved Grief (HTUG) Intervention, designed by an AI non-profit organization Takini
(means ‘Survivor’ in Lakota language) for the Lakota community to heal from historical
trauma and unresolved grief (Maria Yellow Horse Brave Heart, et al., 2011; M.Y.H. Brave
Heart & DeBruyn, 1998). HTUG was selected as a Tribal Best Practice in 2009 by the First
Nations Behavioral Health Association and the Substance Abuse and Mental Health Services
Administration (SAMHSA). The intervention group process allowed participants to
confront historical trauma, understand historical trauma, release the pain, and transcend
the trauma with traditional culture and ceremonies that facilitated cathartic release of
emotions while mastering feelings of trauma. With most of the evaluation done with the
Lakota, the HTUG has been delivered to other tribes in the United States. Efforts should be
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considered with the AI community in California to combine the HTUG intervention
components with culturally adapted practices to meet the needs of reservation and urban
AI youth. A youth program called RezRIDERS (Reducing Risk through Interpersonal
Development, Empowerment, Resiliency, & Self Determination) aims to reduce substance
abuse and depression among high risk AI youth (NCAI, 2012). A program initiated by the
Pueblo of Jemez and the University of New Mexico, developed a multilevel extreme-sport
experiential education youth intervention that incorporates extreme sports
(snowboarding, white-water rafting, rock climbing) to directly link youth to the sacred
cycle of water (mountain snow, rivers, rains, and clouds). With the cultural mentorship
component, youth negotiate contradictions between Western and traditional ways with
discussion of topics that include past history, present history, and future role expectations.
To support any research efforts with AI populations, a community based participatory
approach is necessary and relationships between tribes and researchers should be
fostered.
Limitations and Future Directions
With new findings that are novel concepts with specific cultural interpretations and
new measures to further understand AI youth, this study must note several important
limitations. First, with the cross-sectional nature of our study we cannot assume causality.
With our structural equation model, we tested direct and indirect correlations rather than
causation. Therefore, future research should focus on longitudinal data. Second, only
participation in 2 cultural activities (i.e. sweat lodge and drum group) was included and is
not a representation of all CA Indian traditions. Third, the measure of stressful life events
did not specify the intensity, duration and frequency of events. Longitudinal data on
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stressful life events could provide more comprehensive information. Fourth, the items in
the historical trauma measure are negatively worded, which may induce concurrent
negative thinking in subsequent items. Additionally, this measure was designed to assess
historical trauma among those who live on or near rural reservations (Whitbeck, Walls, et
al., 2009). Although the measure has not been validated among urban AIs, the consistency
of the Cronbach’s alpha across our reservation and urban subsamples suggests that the
measure would be reliable and valid among urban AIs as well. Fifth, youth in this study live
in urban and reservation areas of California and the findings cannot be generalizable to
other tribes in the United States. However, this study does include traditionally
underrepresented groups in research, such as American Indian youth living in different
regions. There are over 560 distinct tribes with different cultural histories and practices;
therefore, future research should provide empirical evidence that contribute and inform
future prevention and intervention programs geared toward AI youth in urban, rural, and
reservation areas.
Future Directions
Future research is needed to understand AI youth responses to the thoughts of
historical trauma with use of the Historical Loss Associated Symptoms Scale immediately
following the Historical Trauma Loss Scale (Whitbeck, Adams, et al., 2004) used in our
study. Symptomology can differ, therefore, understanding the emotional responses can
inform treatment geared toward AI youth to reduce depressive symptoms and increase
coping mechanisms. Further investigation of AI youth resilience and healing around the
continuum of trauma can help us better understand the strengths and pliability that result
from survival. Building on these strengths can help search for pathways to heal the legacy
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of intergenerational trauma and daily stressful life events. Knowing the potential
transmission of historical trauma through ethnic identity, cultural activities and stressful
life events, family and community are part of this too; therefore, interventions should not
only include youth, but their family, and the community with a focus to heal and deal with
daily trauma that persists from past colonization.
Few studies have examined historical trauma among AI youth and this paper
provides further insight that historical trauma is on the minds of AI adolescents. What is
not clear is how these thoughts are based on proximal or distal events and current living
conditions that are a result of historical traumatic events. There are different events that
have occurred in the past that have impacted communities, families and individuals which
has manifested to the children. We do not know which events influence depressive
symptoms and whether it was a cumulative effect of events. Future research can examine
specific events to determine any differences between tribes. However, this work would be
challenging among urban Indians who represent numerous tribes throughout the U.S.
Conclusions
Our findings provide evidence that historical losses are on the minds of AI youth.
Clearly, AI youth have a conceptual understanding of the detrimental impact of historical
trauma events on AI populations and have learned about them interpersonally or with
experiences that trigger thoughts of historical loss. More emphasis is needed toward AI
youth to help them process these thoughts and empower themselves to contribute to their
family, community, and most importantly themselves.

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Table 10. Study 3 - Correlations, Means, and Standard Deviations
Pearson Correlation Coefficients
1. 2. 3. 4. 5. 6. 7. 8. 9.
1. MEIM 1.0
2. Cultural Activities 0.136*** 1.0
3. Stressful Life Events 0.134*** 0.045 1.0
4. Historical Trauma 0.337*** 0.168*** 0.257*** 1.0
5. Depressive Symptoms -0.024 -0.020 0.369*** 0.155*** 1.0
6. Age 0.146*** 0.046 0.156*** 0.195*** 0.072* 1.0
7. Gender -0.108** 0.170*** -0.162*** -0.057 -0.162*** -0.044 1.0
8. Region -0.055 -0.027 0.127** -0.078* 0.020 0.092** -0.028 1.0
9. SES 0.025 -0.017 -0.089* 0.017 -0.099** -0.026 0.060 -0.079* 1.0
Mean 3.04 0.52 14.26 2.77 1.88 15.57 0.43 0.57 0.81
Standard Deviation 0.61 0.49 11.75 1.35 0.58 1.75 0.49 0.49 0.37

138

Ethnic
Identity
Cultural
Events
Stressful Life
Events
Historical
Trauma
Depressive
Symptoms
-.12*
.27*
.21*
.12*
.34*
.10*
.07
.15
.11
Covariates – Age, Gender, Urban, SES
Non-Normed Fit Index=.97
Comparative Fit Index=.99
RMSEA=.02 (90% CI 0.00,0.06)
Chi-square=5.41 (p=0.24)
4 df
Figure 4. Structural Equation Model with Historical Trauma mediating the relationship between ethnic identity,
participation in cultural events, stressful life events, and depressive symptoms.
*P<.05
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Table 11. Depressive Symptoms Measure and Distribution
Depressive Symptoms Never
1-2
days
3-4
days
5-7
days
In the past week…
I was bothered by things that usually don't bother me 48% 32% 11% 9%
I did not feel like eating; my appetite was poor 57% 24% 11% 7%
I felt like I could not shake off the blues even with help
from my family or friends 54% 25% 13% 8%
I felt I was jus as good as other people 28% 20% 20% 32%
I had trouble keeping my mind on what I was doing 34% 30% 18% 18%
I felt depressed 53% 24% 11% 12%
I felt that everything I did was an effort 29% 25% 24% 23%
I felt hopeful about the future 19% 24% 23% 34%
I thought my life had been a failure 67% 16% 9% 9%
I felt fearful 60% 22% 10% 8%
My sleep was restless 44% 25% 15% 16%
I was happy 11% 19% 22% 47%
I talked less than usual 47% 26% 15% 12%
I felt lonely 52% 23% 13% 12%
People were unfriendly 61% 23% 10% 6%
I enjoyed life 13% 16% 20% 51%
I had crying spells 70% 14% 8% 8%
I felt sad 49% 27% 13% 11%
I felt that people disliked me 60% 21% 9% 11%
I could not get "going" 55% 24% 12% 9%
Total 46% 23% 14% 17%
Cronbach alpha=0.88

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CHAPTER 5: CONCLUSION
With the numerous health disparities American Indian populations’ face, this
dissertation provides new insight on behavioral and mental health disparities among a
unique sample of urban and reservation California AI youth. In the overall sample, AI youth
indicated high depressive symptomology (average CES-D score of 17) and double the past-
month smoking rates when compared to national smoking rates. Specifically, Study 1
furthered our understanding of how their use of ceremonial tobacco was associated to
recreational smoking, and other risk and protective factors to cigarette smoking. With
depression being a major public health problem among AI youth, Study 2 and 3 examined
historical trauma thoughts as a mediation mechanism linking ethnic identity, participation
in cultural activities, and stressful life events to depressive symptoms and smoking
behaviors. Given the diversity and history of AI tribes that exist in California, the findings
from Study 1 to 3 have implications for prevention interventions to enhance the well-being
among AI populations. With the limitations and implications for prevention interventions,
many opportunities exist for future research with Study 1-3 findings. Future research
must investigate protective factors to these health disparities to increase parity with AI
populations.
New evidence in Study 1 showed AI youth who smoke tobacco ceremonially at AI
cultural events were at greater risk for recreational smoking than among AI youth who did
not smoke ceremonially. Additionally, youth who use commercial (store-bought) tobacco
for ceremonial purposes were at a greater risk for past-month smoking than among youth
who used natural tobacco for ceremonial purposes. An interesting finding showed AI youth
whose grandparent smoked, acted as a protective factor against smoking. Dissemination of
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these findings back to the tribes and AI urban organizations are imperative to further
develop new prevention messages to clearly delineate the difference between ceremonial
use of tobacco and recreational smoking. The challenge is how to best address ceremonial
tobacco use in these cultural activities so it serves as a protective factor rather than a risk
factor. Tribes must take a leadership role to address these prevention efforts with policies
that mandate use of natural tobacco for ceremonial purposes and that tobacco is only to be
respected for traditional purposes.
In study 2 and 3, major findings showed historical trauma to mediate the
relationships between participation in cultural activities and stressful life events to past-
month smoking and depressive symptoms. Study 2 showed ethnic identity to have a
positive direct impact to historical trauma and a direct negative association to past-
smoking. Study 3 had the same predictor variables and historical trauma as a mediator to
depressive symptoms. Similar findings showed historical trauma to mediate the
relationships between cultural activities, stressful life events and depressive symptoms.
Ethnic Identity had a positive significant association to historical trauma and a significant
inverse relationship to depressive symptoms. The results provide evidence that historical
trauma thoughts are on the minds of AI youth and impact behavioral and mental health.
Although these respondents are generations removed from historical traumatic events, AI
youth who had higher levels of ethnic identity, participated in cultural activities, and when
experienced numerous stressful life events had higher levels of historical trauma. These
associations with historical trauma provide evidence that reminders of historical loss
remain ever present, represented by economic disadvantages on reservations and city life,
national disrespect (use of AI imagery to advertise consumer products and sports teams),
142

discrimination and a sense of traditional cultural loss that affect the children, family
members, and the entire community (Whitbeck, Adams, et al., 2004). It is dangerous for
the young AI generation to have depressive symptoms as this can lead to other disruptive
behaviors and into adult depression. Additionally, with AI youth-suicide rates being 2 to 3
times the national average (Strickland & Cooper, 2011), further insight to reduce
depressive symptoms is necessary for the well-being of AI youth.
Implications for Prevention
Study 1-3 findings demonstrate the need for health parity among AI populations. At
the individual level, we have found how cultural and historical loss thoughts impact mental
and behavioral health (i.e. recreational smoking). Prevention for AI youth is needed at
multiple levels; individual, family, community, service systems, and national contexts.
Engaging higher levels may be more of a challenge; however, these larger systems should
not be overlooked.
Study 1 provides evidence that culturally specific commercial tobacco prevention,
education, and cessation programs are needed to reduce serious smoking related health
illnesses and early death. When one person becomes ill or dies from a smoking-related
disease, a family is also affected and the community suffers due to the loss of cultural or
traditional knowledge that person had to contribute (Satter, et al., 2012). Tribal policies
regarding commercial tobacco control can help reduce tobacco use initiation, increase
tobacco cessation, and reduce exposure to secondhand smoke. As sovereign nations, AI
tribes can develop commercial tobacco smoke –free policies in tribal health facilities, tribal
casinos, schools, indoor working environments, and the home environment. Urban
organizations can adopt similar smoke-free policies in their buildings, and encourage
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smoke-free policy adoptions by the youth and their family members to not smoke in their
home, car, or outdoor areas with people nearby. Cessation programs for AI youth and their
family members can be effective to reduce tobacco initiation and exposure to secondhand
smoke. However, with the finding of ceremonial tobacco use being a risk factor to
recreational smoking, clever educational messages are needed to delineate the differences
between ceremonial and recreational smoking. With AI youth participating in cultural
activities, youth must understand that tobacco is only for ceremonial use. When used out
of context, youth should understand that they are putting themselves at risk for addiction
and harmful health effects from smoking. Tribal communities are encouraged to continue
harvesting their own homegrown tobacco or gathering from the wild (i.e. mountains) to
reduce the alternative of store-bought tobacco for ceremonial use. This way youth don’t
think of store-bought commercial products as acceptable when smoking for recreational
purposes. With elders being respected in the AI community, grandparents can be
influential for youth to not smoke with their teachings of the harmful effects of recreational
smoking and that tobacco should only be used for ceremonial purposes where it does not
require inhalation.
In understanding depressive symptoms, it is important to recognize the unique
social historical contexts that many youth experience. Study 3 results indicated depressive
symptoms exists due in part to historical trauma loss thoughts. With depression identified
as a crucial individual risk factor related to suicide among AI youth (Strickland & Cooper,
2011) this finding has important implications for mental health services.
It is imperative that AI populations, particularly youth, receive mental health
services that are culturally-based and rooted in the community instead of Western
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institutions that focus only on the individual. As AIs cope in both the Western and AI
worlds on a daily basis, more recognition and acceptance for community defined evidence
by the federal, state, county, and city level is needed to have a larger impact with tribal and
urban communities. The “gold standard” of the Western evidence based practices (EBP)
does not reflect the diversity of tribes that exist in California with regard to cultural,
linguistic, and geographical differences. The current mental health system of care delivers
individual interventions and more cultural collective interventions need to be favored to
reach AI youth and their families. The future of effective preventive interventions depend
on cultural relevance and acceptance by the community that may include elder wisdom,
positive youth development, and address co-occurring disorders, such as alcohol and other
drug dependence. Some tribes have embarked on community level healing with inclusion
of cultural and traditional practices such as the canoe journey and traditional hunting
practices (e.g. whale) (Evans-Campbell, 2008). Tribal specific ways to restore the social
unit of the community and foster youth development is a promising strategy to promote
healthy living among the individual, family, and community.
In regards to positive youth development, one mental health therapy example is
“talking circles” that have been successful for treatment and prevention (Nebelkopf & King,
2003). Talking circles are a safe support group to provide space for one to self-express
oneself, provide conflict resolution, and for the development of community cohesion that
can include family. Including components like “talking circles” of treatment and healing
within prevention programs makes sense given the high rates of mental health challenges,
trauma exposure, and other disproportionate stressors faced by AI youth and the
recognition that past oppression and current institutional racism affect all AI communities.
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Promising practices and effective models in mental and behavioral health for AI
populations have been identified by the Native American Health Center in Oakland, CA who
serves the AI population in California. Acknowledging the challenge that EBPs are rarely
developed specifically for AI populations or tested among the AI populations, many of the
prevention and early intervention mental and behavioral health programs have reach a
certain level of community acceptance as best practices. This community-defined evidence
(CDE) is important for future programs to identify cultural adaptations for EBPs that have
been successful with AI populations. Networking and sharing of CDEs are necessary for
other tribes to adopt and evaluate to determine the level of effectiveness with their
respective community. Therefore, more scientific validation and community validation is
needed with these existing prevention and early intervention programs to improve the
well-being of the AI population. Another important piece to the development and validity
of existing programs is to incorporate community-based participatory research (CBPR)
approaches to build on the strength of participant communities, and empower
communities to generate knowledge and solutions that are culturally meaningful and
healthful. It’s important to build on the strengths and the resources available and
sustainable in tribal communities with AI communities to identify their own specific
prevention needs. It’s essential in moving toward healthier minds and bodies as well as the
preservation of AI cultures and youth.
Historical traumatic events have occurred in the past that have impacted
communities, families and individuals which has manifested to the children. Interventions
are critical to strengthen family, community, and health care systems to help and reduce
risk. It has been suggested that interventions be directed at the actual cause of the problem
146

and not just to “fix” individuals but to change social and economic policies and the current
distribution of power (Goodkind, Hess, Gorman, & Parker, 2012). Tribes share a history of
colonization, genocide, oppression and racism that continues to impact lives today. Healing
by the individual and community level should be within an ecological framework that
recognizes the impact on multiple levels (e.g. individual, family, community, tribal, state,
and federal) for the individual development and health (Bronfenbrenner, 1979).
Many Native and non-Native scholars have begun to develop intervention programs
that integrate theories of historical trauma, community capacity, and community
empowerment. These programs are designed in a holistic, culturally relevant, and mindful
of AI understanding of HT and its impact on community health. Evidence has shown that
symptoms like diabetes, suicide, and domestic violence are from historical trauma and have
been addressed from a different perspective. In Study 2 and 3, the Historical Trauma and
Unresolved Grief (HTUG) intervention was mentioned where it was selected as a Tribal
Best Practice in 2009. HTUG is a culturally congruent intervention for grief intervention
and trauma mastery for AI adults. It has proven to improve relationships and
communication with parents, grandparents, and children. Such interventions and
approaches to healing might need to be tailored according to age with the focus to
strengthen communication and awareness across generations.
Engaging youth in social change efforts to achieve social justice may change their
cognitions about themselves (Goodkind, et al., 2012). Youth are being educated about the
past history and facilitation of communication and interaction between elders, parents and
youth are needed to have an intergenerational approach. It’s possible that a community
building, social change component might be considered for interventions where the
147

community together tackles a project that creates social change. Despite the need for
effective and early interventions for preventing and reducing depression, anxiety, and
related problems in AI youth, very few intervention outcome studies have been conducted.
Gone and Alcántara (2007) reported that only two interventions to date have been
sufficiently tested to warrant label as “evidence-based” for use with AI populations: An
adaptation of the 16-week Coping with Depression course (Lewinsohn, Clarke, &
Hoberman, 1989) conducted by Manson and Brenneman (1995) was effective in reducing
depression in older AIs living in the Pacific Northwest. The Zuni Life Skills Development
Curriculum, which lasted one year and included nearly 100 sessions was effective in
reducing suicidal ideation and hopelessness in AI students from a Southwest tribal school
(T. LaFromboise & Howard-Pitney, 1995). To improve the mental and behavioral health of
AI populations in California and the United States, inclusion of AI communities, proper
funding for research and programs, and evaluation of existing programs are needed to
bring parity.
Limitations and Strengths
There are several limitations to the results of this study. First, with the cross-
sectional nature of our study we cannot assume causality. With structural equation
modeling in Study 2 and 3, we tested direct and indirect correlations rather than causation.
Therefore, future research should focus on longitudinal data. Second, AI youth provided
self-report information. Third, cultural activities included are not a representation of all CA
Indian traditions. With the numerous California tribes and out of state tribes represented
in our studies, there are many other cultural traditions practiced. Fourth, the items in the
historical trauma measure are negatively worded, which may induce concurrent negative
148

thinking in subsequent items. Additionally, this measure was designed to assess historical
trauma among those who live on or near rural reservations (Whitbeck, Walls, et al., 2009).
Although the measure has not been validated among urban AIs, the consistency of the
Cronbach’s alpha across our reservation and urban subsamples suggests that the measure
would be reliable and valid among urban AIs as well. Fifth, youth in this study live in urban
and reservation areas of California and the findings cannot be generalizable to other tribes
in the United States. However, strength of this study does include traditionally
underrepresented groups in research, such as American Indian youth living in different
regions. There are over 560 distinct tribes with different cultural histories and practices;
therefore, future research should provide empirical evidence that contribute and inform
future prevention and intervention programs geared toward AI youth in urban, rural, and
reservation areas.
Overall, the current studies addressed several gaps and limitations in the existing
literature on behavioral and mental health among AI adolescents. With the lack of specific
and reliable data to understand AI youth in California, this dissertation provided cultural
specific data to further understand the health disparities as it relates to smoking and
mental health. Collecting the dissertation data among numerous tribal organizations,
schools, and urban organizations throughout California, provided the opportunity to build
a relationship with AI community members and AI based organization. Future
collaborating efforts are well on their way to engage with tribal and urban organizations
with future research projects. The guidance by a six member AI Advisory Committee (AC)
assisted in the development of the culturally specific survey, and helped us accomplish our
goal to reach over 1,000 AI youth to participate in the survey. Other community members
149

from tribal organizations and urban programs were included to provide their expertise in
working with AI populations. Additionally, inclusion of specific cultural questions was
included, such as the roundhouse ceremony. This reflected a community participatory
approach where formative research also helped inform this dissertation.
Future Directions
Although American Indians make up the smallest US ethnic group, they have ranked
highest among ethnic and racial groups in health disparities (Whitbeck, 2011).
Undoubtedly, mental health services, smoking prevention and cessation programs are
needed among AI youth, family, and community. Future funding opportunities are
essential for AI communities to develop, administer and evaluate programs to study the
cultural underpinnings of wellness to enhance health.
While it is difficult to disentangle the proximal emotional effects of chronic
economic disadvantage, discrimination, severe health and behavioral and mental health
disparities, future research should continue to examine the origins of the symptoms
attributable to contemporary experiences and past historical experiences among AI youth.
With ample evidence that AI youth experience high rates of stressful life events and
historical trauma thoughts, this intersection of the two deserve future research. One could
examine how historical trauma impacts higher levels of stressful life occurrences and
further risk outcomes. Or how does contemporary life events serve as a contemporary
manifestation of past historical trauma? These variables could also be examined as
mediators or moderators to help further our understanding to mental and behavioral
health outcomes. For example, how does the relationship between stressful life events and
depressive symptoms differ by those with more historical trauma thoughts compared to
150

those with less historical trauma thoughts? And for those who experience historical
trauma thoughts, what emotional symptoms stem from these thoughts and which of these
symptoms signal dysfunction in the individual, family, or the community? The more
research exploring the relationship between contemporary stressful life events and
historical trauma, the more it will lead to culturally specific holistic interventions for AI
populations.
Additional focus could examine the seven subscales individually within the
Multicultural Events Schedule for Adolescents (MESA) scale that assesses family trouble,
family conflict, peer hassles/conflict, school hassles, economic stress, perceived
discrimination, and personal violence. For example, one could examine how perceived
discrimination elicits an impact on smoking behaviors and depressive symptoms mediated
by ethnic identity or participation in cultural activities. This would provide a further
understanding of how youth are experiencing specific daily stressors and how they
emotionally deal and behaviorally cope.
Protective factors should also be examined as traditional spirituality, traditional
practices, and cultural identity have been shown to be protective factors for Indigenous
youth and adults (Garroutte, et al., 2003; T.D. LaFromboise, et al., 2006; Whitbeck, et al.,
2002). According to the AI worldviews, environment, mind, body, and emotional health are
inextricably linked to health behavior, wholeness, and ultimately well-being (Karina L
Walters, et al., 2011). Consideration of a shift to a strength based approach rather than
focusing on risk factors may help better understand protective factors. A focus could be on
communities who exemplify successful outcomes such as those who do not smoke or
report depressive symptoms and have the research spotlight on those individuals. There
151

may be many strengths that might mitigate the relationship between stressful life events
and smoking behaviors such as family (i.e. social support), community (i.e. cultural
activities), and cultural identity. Future research should work with AI urban and tribal
communities to identify resiliency responses, resistance strategies, and positive coping that
can buffer the impact of historical trauma on mental and behavioral outcomes.
Additionally, one might also look at these same resiliency factors and how they buffer the
impact of daily stressors and cultural influences to historical trauma thoughts. Future
studies need to examine the preventive processes that are culturally specific to AI youth to
teach us more about the role of resilience in overcoming life challenges.

152

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Creator Soto, Claradina (author)

Core Title Cultural risk and protective factors for tobacco use behaviors and depressive symptoms among American Indian adolescents in California

School Keck School of Medicine

Degree Doctor of Philosophy

Degree Program Preventive Medicine (Health Behavior)

Publication Date 08/05/2013

Defense Date 06/20/2013

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag American Indian,behavioral health,depressive symptoms,Mental Health,OAI-PMH Harvest,tobacco use,traditional tobacco,Youth

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Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Unger, Jennifer B. (committee chair), Baezconde-Garbanati, Lourdes (committee member), Chou, Chih-Ping (committee member), Lincoln, Karen D. (committee member), Richardson, Jean (committee member)

Creator Email claradinasoto@gmail.com,toya@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-314516

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Document Type Dissertation

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