Get on the Path to Lung Health

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Get on the Path to Lung Health Supported by: National Center for Minority Health and Health Disparities Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811] 1.

Distinguish between ceremonial / traditional tobacco use and habitual use among Indian people. 3.

1 Get on the Path to Lung Health Supported by: National Center for Minority Health and Health Disparities Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811] 1. Introduction Objectives; By the end of the session the participant will: 1. Identify key issues related to the history of tobacco and American Indians 2. Distinguish between ceremonial / traditional tobacco use and habitual use among Indian people. 3. Distinguish between common myths and accurate information about lung cancer and habitual tobacco use in Indian Country. Objectives; By the end of the session the participant will: 4. Identify anatomical structures of the lungs. 5. Identify geographic regions where lung cancer deaths are highest among Natives. 6. Identify at least 3 risk factors of lung cancer. 7. Identify at least 3 symptoms of lung problems. 8. Identify the potential benefits and limitations of lung cancer screening tests. Jeannie Harris Morris [Mohawk] Lung Jennie s story: Background Mohawk Tribal Nation Jennie was a heavy smoker for most of her life She was diagnosed with lung cancer in 1994 Part of Jennie s story I have lung cancer. It s a rare one. It started with the, the bones were sore, were my only symptoms. They sent me to, I forgot... an arthritis specialist. There they did a bone scan and said the line was deteriorating and that I had to be in the hospital within twenty-four hours, that somehow it had affected somewhere in my chest. Why me? What did I do? Because I m a very healthy woman except for that one flaw. Well, I was a heavy smoker. They blame smoke. 5 6

2 Part of Jennie s story I didn t have no chest pains or anything. The only symptoms was the swollen ankles and the soreness of the legs. The doctors to me, should be more faster with the catscan because that was April, and I never got mine until July. That was four months that elapsed. Part of Jennie s story Well it [life] changed a lot. I started to think more of myself, where before it was always everyone, or the children came first, and I came last. Now I ve been traveling, because that was one of my dreams of my whole life was to travel, which I never did. And since I ve been diagnosed this is my second trip. I ve been in Vancouver now and Phoenix. And I ve been more alert, more aware, life is so short, its unbelievable Yesterday and Today Tobacco and Lung Facts and Myths Tobacco Industry Traditional Use Cigarette smoking is not our tradition. Paul Ortega, Mescalero Apache, it is not respectful use of the sacrament, tobacco when you hold the cigarette away from the body, drop it to the ground, and ground it out with your foot that is not how we treat our sacraments. personal communication w. Linda B, Bethesda, MD, What makes tobacco a bigger risk or cause for cancer? Frequency Duration Intensity how often does the risk or behavior happen? (e.g., smoke >2 packs of cigarettes a day) how long does the risk or behavior last? (e.g., smoked since 14 years old) how strong is the dosage of the risk or behavior? (e.g., smoke Marlboro -- high nicotine cigarettes) Native American Tobacco Use Facts Ceremonial tobacco use is not likely to be connected to the typical health problems associated with habitual cigarette smoking. QUESTION: Why? 11 12

3 Why ceremonial tobacco use is unlikely to cause cancer or other health problems? Frequency Duration Intensity Most ceremonies are conducted less than once a month The ceremony may be several hours long, but then if not a habitual smoker, your body recovers from the tobacco If true ceremonial tobacco is used, it is less potent than commercial tobacco. If commercial cigarettes are broken up for use in the ceremony, the tobacco has more poisons What is the history of Tobacco for American Indians? Each Tribe has its own beliefs about Tobacco and its origins. Tribal stories carry the story of the origin of tobacco or how the gift of tobacco came to the people. Tribal stories also tell how to use tobacco and take care of it for future generations Botanist, John Gerard, 1597 Wrote that tobacco induced vision Tobacco cured kidney pain, toothache, worms, ulcers, scabies, burns and gunshot wounds. A snake-bite antidote and its oil cured deafness. Native People used tobacco sparingly and ceremonially. Tobacco Abuse Is Not Traditional Use Of Tobacco Tobacco has been used for many generations as offerings to the spirits, for planting, for gathering food, for healings, and for ceremonies. Tobacco is medicine Arrival of Lewis & Clark Then the two leaders, observed what the Indians were using, for smoking, the leaves of some plants, a plant very much alike to our tobacco plant, asked for some to filled their pipes; but as soon they tried to smoke, they pronounced the Indian tobacco no good. Cutting some of their own tobacco they gave it to the Indians Four Sacred Plant Gifts There are four plants that are very important to Native People. Native People use these medicines for offering, smudging, and praying. Different Tribes have varying traditions for the use of these plants. These medicines are sacred

When it is smoked it is said that the smoke carries the prayers to the Creator. The tobacco leaf is 6-12 inches long, dark green, large, broad and pointed.

4 Four Sacred Plants Mother Earth has many gifts. These gifts must be respected and used in their proper way: Tobacco Sagebrush Sweet Grass Cedar Tobacco Tobacco is considered to be an herb whose smoke can bring clarity. When it is smoked it is said that the smoke carries the prayers to the Creator. The tobacco leaf is 6-12 inches long, dark green, large, broad and pointed Sagebrush (Sage) Sweet Grass Sagebrush grows in many forms around the world. Sagebrush is a shrub with slender branches that hold many long light green leaves. Sage is often used as a smudge, with the smoke providing protection and peace. Sweet Grass is also know as the hair of Mother Earth. It is usually braided before it is picked. Sweet Grass smoke calls to the good spirits of a place and invites them to join in whatever ceremony is occurring there Sweet Grass (cont.) Cedar It is a perennial that can be found near wet areas such as marshes or ponds. It looks long and red like. The roots are left to soak up the earth s deepest energy and to prepare for the next year. Cedar is a strong plant, a tree whose inner bark and boughs are used ceremonially. It is often burnt and used as a smudge. It is a purifier and cleanser frequently used when there is illness

Tribal Medicinal Uses of Tobacco Tobacco paste to put on an infant s gums during teething Tobacco paste put on wounds or injuries to provide some anesthesia Thin tobacco solution to ward off insects

5 Tribal Medicinal Uses of Tobacco Tobacco paste to put on an infant s gums during teething Tobacco paste put on wounds or injuries to provide some anesthesia Thin tobacco solution to ward off insects (e.g., mosquito repellant) Tribal Medicinal Uses of Tobacco Examples of other traditional medicinal uses Asthma Rheumatism Chills Fevers Headaches Earaches Toothaches Intestinal disorders Childbirth pains Tribal Spiritual Uses of Tobacco Habitual Use of Manufactured Tobacco Examples of traditional spiritual uses Symbolism of agreement between people or groups. Prayers Smoking pipes to come to mutual agreement Tobacco ties Because AIs use tobacco within different tribal ceremonies, Natives tend to think of habitual tobacco use or exposure as harmless The tobacco industry leads people to believe that smoking is harmless Tobacco and Lung Facts and Myths Tobacco Industry What the tobacco companies know "Studies of clinical data tend to confirm the relationship between heavy and prolonged tobacco smoking and incidence of cancer of the lung." (internal memo, RJ Reynolds, 1953) Steven Gladstone Chairman and CEO of RJR 30

What the tobacco companies know What the industry knows Steven Gladstone Chairman and CEO of RJR There still isn't a single shred of substantial

com Teens and youth are the tobacco companies primary source of replacement smokers They target youth through advertising and marketing. http://www.

com 31 32 What They ve Said Today s teenager is tomorrow s potential regular customer the smoking patterns of teenagers are particularly important to

1981, Philip Morris Report American Indians and the Tobacco Industry Natives have been targeted through products such as American Spirit implies it is

6 What the tobacco companies know What the industry knows Steven Gladstone Chairman and CEO of RJR There still isn't a single shred of substantial evidence to link cigarette smoking and lung cancer directly. (public statement, RJ Reynolds, 1954) Teens and youth are the tobacco companies primary source of replacement smokers They target youth through advertising and marketing What They ve Said Today s teenager is tomorrow s potential regular customer the smoking patterns of teenagers are particularly important to Philip Morris. 1981, Philip Morris Report American Indians and the Tobacco Industry Natives have been targeted through products such as American Spirit implies it is spiritual / ceremonial form of tobacco which it is not. Get -Geoffrey on the Bible, Path Chairman to Health ; and Native CEO American of Philip Morris Cancer Research Corporation (NACR); Advertising and marketing Are you a target? Rolling Stone Magazine, December 6-13, 2001 Nationwide, more than $9 billion is spent in advertising and marketing each year Magazine ads Music and sports sponsorships Retail displays Free stuff 35 36

Additives to Commercial Cigarettes and Chew Tobacco There are at least 81 cancer causing chemicals in cigarettes and chew tobacco There are over 4,000 other additives QUESTION: Why are chemicals and

To make the commercial tobacco products: Burn evenly Go out when not being smoked Smell a certain way when burning Taste better And more.

7 Additives to Commercial Cigarettes and Chew Tobacco There are at least 81 cancer causing chemicals in cigarettes and chew tobacco There are over 4,000 other additives QUESTION: Why are chemicals and other additives mixed with tobacco in commercial tobacco products? To make the commercial tobacco products: Burn evenly Go out when not being smoked Smell a certain way when burning Taste better And more. Get on the Path to Presentation Health ; Native Skills American for NNACC Cancer Navigators Research (Burhansstipanov) Corporation (NACR); ; Native Navigators and the Continuum Native (NNACC) Navigators [NCMHD and R24MD002811] the Cancer Cancer Causing Chemicals in Commercial Cigarettes Toxic Metals in Commercial Cigarettes Vinyl Chloride Used to make pipes Benzene Found in Gasoline Formaldehyde Used to embalm dead bodies Polonium-210 Radioactive and very toxic Arsenic Used in Pesticides Lead Used in Paint Cadmium Used in Making Batteries 39 Get on the Path to Presentation Health ; Native Skills American for NNACC Cancer Navigators Research (Burhansstipanov) Corporation (NACR); ; Native Navigators and the Continuum Native (NNACC) Navigators [NCMHD and R24MD002811] the Cancer 40 Poison Gases in Commercial Cigarette Smoke Butane Used in lighter fluid Carbon Monoxide Found in car exhaust Toluene Found in Paint Thinners Tobacco Facts Get on the Path to Presentation Health ; Native Skills American for NNACC Cancer Navigators Research (Burhansstipanov) Corporation (NACR); ; Native Navigators and the Continuum Native (NNACC) Navigators [NCMHD and R24MD002811] the Cancer 41

8 Interactive Activity: Lung Cancer and Tobacco Knowledge Let s see how much you already know about tobacco and lung cancer Statements will appear Using your ARS keypad, please answer the statement If you got the answer correct, please keep score for yourself Native American Natives smoke fewer cigarettes each day and are less likely to be heavy smokers (more than 24 cigarettes a day) than whites. U.S. Department of Health and Human Services. Tobacco Use among U.S. Racial/Ethnic Minority Groups African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: a Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Each cigarette is carefully engineered to deliver nicotine, which is addictive. They are also designed for Smoothness Taste Ease of inhale Tobacco kills one out of every two people that regularly use it. Smoking remains the leading cause of preventable death and has negative health impacts on people at all stages of life Tobacco kills more than 1,300 people a day in America. Tobacco kills over 400,000 Americans each year, and 3 million people worldwide Tobacco is responsible for more deaths a year than AIDS, murder, suicide, fires, car accidents and illegal drugs Combined Cigarette smoking is the single most preventable cause of cancer in the US About 30% of all cancer deaths are directly related to habitual smoking Smoking is a risk factor for several types of cancer in addition to lung

9 About 70-75% of all lung cancer deaths are caused by habitual smoking 15-20% of all lung cancer deaths are caused by secondhand smoke Tobacco smoke is a known carcinogen that can cause the onset and growth of lung cancer. For those who quit habitual tobacco use, the benefits are seen immediately and continues over one s lifetime Smoking cigarettes along with exposure to radon, uranium or fine dust particles (e.g., coal dust) increases the risk of lung cancer Natives working in uranium mines are also at high risk for lung cancer So were their partners (laundry with uranium particles) Smokeless Smokeless tobacco should not be substituted for cigarette smoking It can cause mouth and lip cancers It is just as addictive as smoked tobacco Cancer from smokeless tobacco takes fewer years to develop in the mouth and throat than in the lungs Secondhand Smoke (SHS) Secondhand smoke, or environmental smoke, is the smoke from burning tobacco. According to the Surgeon General, an hour spent in a smoke-filled room is equal to smoking one cigarette. CO Quitline secondhand smoke fact sheet, October 2001 Secondhand smoke kills 53,000 nonsmokers in American every year Secondhand Smoke (SHS) Involuntary exposure to tobacco smoke can cause lung cancer 20% of all lung cancers occur in nonsmokers who are involuntarily exposed to tobacco smoke Secondhand smoke is poisonous. Native American Rehabilitation Association (NARA) of the Northwest, Inc

Secondhand Smoke (SHS) It contains over 4,000 dangerous chemicals, including: Carbon monoxide (car exhaust) Ammonia (floor / toilet cleaner) Formaldehyde (preserves dead bodies) Benzene (gasoline)

10 Secondhand Smoke (SHS) It contains over 4,000 dangerous chemicals, including: Carbon monoxide (car exhaust) Ammonia (floor / toilet cleaner) Formaldehyde (preserves dead bodies) Benzene (gasoline) Arsenic (rat poison) Native American Rehabilitation Association (NARA) of the Northwest, Inc Secondhand Smoke (SHS) A nonsmoker s risk of lung cancer increases 30% when living with someone who smokes in the home. CO Quitline secondhand smoke fact sheet, October Secondhand Smoke (SHS) Babies and children are more susceptible to secondhand smoke problems than are adults. CO Quitline secondhand smoke fact sheet, October 2001 Their body cells do not have the defenses than adult cells have to fight the poisons. CO Quitline secondhand smoke fact sheet, October 2001 Secondhand Smoke (SHS) Tobacco Facts QUESTION: What types of health problems do you think are associated with secondhand smoke? Sudden Infant Death Syndrome (SIDS) Asthma and other respiratory / breathing problems Sinus infections Secondhand Smoke Facts Secondhand Smoke Facts Health problems continued More colds, infections, coughing, More wheezing means in comparison to others who are not More exposed middle to ear secondhand infections smoke More eye and nose irritation More likely to develop heart problems More likely to develop respiratory types of cancer Pregnant females who smoke increase their chances of having a low birth weight baby by up to 39% CO Quitline Tobacco Use in Colorado fact sheet, October 2001 Low birth weight may cause stillbirths and newborn deaths. CO Quitline Tobacco Use in Colorado fact sheet, October

3. Anatomy of the Lung Anatomy of the Lungs 62 Anatomy of the Lungs The body has 2 lungs There are a total of 5 lobes Right lung = 3 lobes Left lung = 2 lobes (need room for the heart) Most lung

Lung Cancer Risk Factors 63 Will I get Lung Cancer? Lung Cancer in the US The more cigarettes you smoke and the longer you smoke, the higher your risk.

11 3. Anatomy of the Lung Anatomy of the Lungs 62 Anatomy of the Lungs The body has 2 lungs There are a total of 5 lobes Right lung = 3 lobes Left lung = 2 lobes (need room for the heart) Most lung cancer starts in the bronchi Non SmallCell/OverviewGuide/lung cancer nonsmall cell overview non small cell lung cancer Non SmallCell/OverviewGuide/lung cancer non small cell overview non small cell lung cancer 5. Lung Cancer Risk Factors 63 Will I get Lung Cancer? Lung Cancer in the US The more cigarettes you smoke and the longer you smoke, the higher your risk. Other factors include: The age at which you started smoking The kind (e.g., Brand, like Marlboro ) of cigarettes Lung cancer is the second most common cancer among men and women Lung cancer is the leading cause of cancer-related death in the US Lung cancer is leading type of cancer death for both sexes for all IHS areas 65 66

12 What makes a behavior more likely to be a risk factor? Frequency Duration Intensity how often does the risk or behavior happen? (e.g., smoke >2 packs of cigarettes a day) how long does the risk or behavior last? (e.g., smoked since 14 years old) how strong is the dosage of the risk or behavior? (e.g., smoke Marlboro -- high nicotine cigarettes) QUESTION: Why do some people smoke for their entire life and yet never get lung cancer? Genetics may be protective for some people Some people light a cigarette, but rarely actually smoke it Dumb luck Risk Factors Primary Risk Factor Smoking and second-hand smoke 85+% of lung cancer is related to smoke or chew Tobacco use and/or exposure continues to be #1 risk factor Smoking is by far the most important risk factor in lung cancer. Total exposure includes: Number of cigarettes smoked Age when smoking began Duration of smoking Synergistic Risk Factors Secondhand / environmental smoke Air pollution Tuberculosis Asbestos Radon Metals: nickel, silver, chromium Being overweight and sedentary Not eating enough fresh vegetables and fruits 71 Lung Cancer Risks Tobacco (inhaled carcinogens): 85% - 87% Second-Hand Passive Smoke 5% - 7% Scar/Fibrosis 1% - 2% Others 5% - 7% 72

Lung Cancer in Indian Country Habitual Users of Manufactured Tobacco Habitual tobacco use is associated with an increase in both sexes for cancers of the Lung Mouth Lips Stomach Pancreas Colon and

13 Some Potential Genetic Risks Heredity is NOT a common cause of lung cancer in Native people Women are 1.5 times more likely to develop lung cancer, despite smoking fewer cigarettes and inhaling less deeply No one knows why Lung Cancer in Indian Country Habitual Users of Manufactured Tobacco Habitual tobacco use is associated with an increase in both sexes for cancers of the Lung Mouth Lips Stomach Pancreas Colon and cervix cancer in women 76 DEATH RATES, LEADING CAUSES: AGES 45 TO 64 YEARS Diseases of the Heart Malignant Neoplasms Cancer Accidents Chronic Liver Disease Diabetes Mellitus ; Deaths Native Navigators per 100,000 and the Population Cancer Office of Planning, Evaluation Continuum and Legislation, (NNACC) Indian [PI: Burhansstipanov, Health Services, Regional R24MD002811] Differences in Indian Health: 1997 R k ill MD I di H lth S i ) QUESTION: Where is your AIAN community located on this map?

AIAN Cancer Incidence Data (finally) THANK YOU!

Cervix Colon Incidence Rates (1999-2004)* AIAN 368.4 85.3 9.4 46.3 Kidney 17.9 Lung 48.

2 21.3 87.1 156.7 NHW 461.2 129.6 9.1 51.8 12.4 82.2 146.5 No Plains AIAN NHW 538.1 464.8 115.

2 Source: Cancer registries in Centers for Disease Control and Prevention's (CDC) National Program

Cancer Research Corporation (NACR); Epidemiology, and End Results Program (SEER) D.

14 AIAN Cancer Incidence Data (finally) THANK YOU! CHSDA Counties = IHS Contract Health Service Deliver Areas NHW = Non- Hispanic White 79 All Breast Cervix Colon Incidence Rates ( )* AIAN Kidney 17.9 Lung 48.5 Prostate US NHW So. Plains AIAN NHW No Plains AIAN NHW Source: Cancer registries in Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries (NPCR) and National Cancer Institute's (NCI) Surveillance, Native American Cancer Research Corporation (NACR); Epidemiology, and End Results Program (SEER) D. Espey, Monograph Group IHS Cancer Mortality Note cancers other than breast, cervix, colon, lung and prostate This is why AIAN comprehensive cancer plans cannot be limited to only those sites! 83

Native Americans, Lung Cancer and Tobacco Alaska, East, Northern Plains, Pacific Coast and the Southwest For the five geographic regions in Indian Country, lung cancer is the most common type of

15 Native Americans, Lung Cancer and Tobacco Alaska, East, Northern Plains, Pacific Coast and the Southwest For the five geographic regions in Indian Country, lung cancer is the most common type of cancer in four of the five areas In the southwest, lung cancer is the second most common type of cancer death Native Americans, Lung Cancer and Tobacco Habitual cigarette smoking among Natives varies greatly by region and tribal affiliation Northern Plains = 44-70% Alaska = 39-60% Southwest = 14-25% Native Americans, Lung Cancer and Tobacco Native youth s current smoking behaviors are higher in comparison to all other ethnic and racial groups in the U.S. AIAN habitual use ranges from 20-75% Natives use of smokeless tobacco is higher in comparison to all other ethnic and racial groups in the U.S. typically higher for males than for females Bovee F, Jumper Thurman P. Tri-ethnic Center, Fort Collins, CO present Screening for Lung Cancer How is a Lung Screening Done? At present there are no recommended screening tests for lung cancer If lung cancer is found when it is very small and has not spread, it may be curable But, only a small proportion of lung cancer is found in this early stage of growth Lung Screening (cont.) BUT, new tests are being investigated (like spiral CT) that may be able to find very small tumors that are more likely to be curable New tests are trying to find pre-cancerous changes that may make the cancer more treatable 89 90

If it is decided There that is no I definitive answer should be screened, Possibly chest X-ray investigational what should I have done?

16 Some Common Concerns About Lung Screenings Some Common Concerns About Lung Screenings Should I get lung screening? There is no definitive answer Providers disagree on the value This graphic is from IHS Four Corners Area. If it is decided There that is no I definitive answer should be screened, Possibly chest X-ray investigational what should I have done? Spiral CT of the chest (looks at all parts of the lung and from different directions) Lung cytology (examines your sputum that you hack up) This graphic is from IHS Four Corners Area. Saliva test (only if can be treated aggressively) Payment for Lung Screening How do I get Lung Screening? Medicaid, Medicare and the VA may pay for lung screening. It will pay for diagnostic tests if you have symptoms Private insurance may pay for lung screening and may pay for diagnostic tests. You need to ask your provider if you should have lung screening You need to find out if IHS / tribal / Contract Health Services cover these tests Tribal programs vary Benefits of Quitting Benefits of Quitting Within 20 minutes of quitting, blood pressure and pulse rate decrease. Within 8 hours of quitting, carbon monoxide and oxygen levels in the blood return to normal. Within 1 day of quitting, the likelhood of heart attack decreases. Most Smokers regret the day they started smoking. CO Quitline QUIT or 96

17 Benefits of Quitting Benefits of Quitting Within 2 days of quitting, nerve endings regenerate; sense of smell and taste improve. Within 2 weeks, circulation improves and lug function increases. After quitting for 1-9 months, coughing, sinus congestion, fatigue and shortness of breath decrease. Most Smokers regret the day they started smoking. CO Quitline QUIT or 97 Within 1 year of quitting, the likelihood of heart attack is cut in half. Within 5 years of quitting stroke risk is reduced to the same levels as a nonsmoker. Within 10 years of quitting, risk of dying from lung cancer is about half that of a current smoker. Most Smokers regret the day they started smoking. CO Quitline QUIT or 98 Benefits of Quitting Within 15 years of quitting, risk of coronary heart disease and death become roughly equivalent to those who have never smoked. 7. Symptoms that may be related to Lung Cancer Most Smokers regret the day they started smoking. CO Quitline QUIT or 99 QUESTION: What are warning signs or symptoms of lung cancer? Warning Signs Chronic cough Coughing up blood (does not need to be a lot, can be mucous streaked with blood) Shortness of breath Chest or shoulder pain unrelated to an injury Loss of appetite Fatigue (tiredness) Unplanned weight loss Pneumonia or other lung infection that doesn t get better Hoarseness Recurrent bronchitis

18 2 Main Types of Lung Cancer Small cell lung cancer 10-15% of all lung cancers Almost all is caused by tobacco smoke Non-small cell lung cancer (NSCLC) 85% of all lung cancers 3 types of NSCLC 3 Types of NSC Lung Cancer (85% of lung cancers) Squamous cell carcinoma Found in the middle of the lungs 25-30% of lung cancer Caused by smoking Adenocarcinoma 40% of all lung cancers Found in outer part of the lung Types of NSC Lung Cancer (85% of lung cancers) Large-cell (undifferentiated) 10-15% of lung cancers Starts in any part of the lung Grows and spreads quickly 105

Four Sacred Plant Gifts

Lisa D. Harjo, Choctaw Omaha, NE August 2011 Traditional Tobacco - Harjo CDC Northern Plains Cancer Conference 2011 1 Four Sacred Plant Gifts! There are four plants that are very important to Native People.!