Monday, May 29, 2006

Tobacco Use in Bush Alaska

As both a PA and a health educator, I have been involved in efforts to help people quit tobacco use for over twenty years. When I was a graduate student in Public Health, I worked part time doing research in smoking prevention in teens. I taught both small-group and large-lecture type classes in smoking cessation. As a family practice PA, I have always felt that encouraging people to make healthy choices can help them begin to make changes in behavior.

One of the things I was careful to include in most patient visits when I practiced in the Lower 48 was a question regarding smoking, and a recommendation to consider quitting when the response was positive. I didn’t nag, or trot out horror-story photos of blackened lungs, or go on and on about the incidence and prevalence of lung disease directly attributable to first and second hand smoke. I just asked. Every time. And encouraged cessation.

I taught smoking cessation courses as a health educator for several years before becoming a PA. I also was a smoker for five years back in my intemperate youth; I quit on January 18, 1977, when cigarettes cost 50 cents a pack. As a teacher of smoking cessation courses, having quit oneself was a crucial component of credibility among those taking the course. Participants felt that if you haven’t been there, then you don’t know… Tobacco addiction is intense, and quitting is one of the hardest things most people will ever do. And one of the most important.

The year I spent working in Montana before coming to Alaska also taught me that asking about smoking was not enough. Especially when the cowboy pacing uneasily in the exam room has a positive “circle sign”—a worn-through spot on his rear jeans pocket the exact size of a Copenhagen tin. So I started asking about chewing tobacco, as well as smoking it. But my thinking on the subject was still not quite ready for the Alaskan shift; I was still only asking males over the age of 15 about chewing, though both genders about smoking.

When I first came to bush Alaska, I continued asking my usual questions in history-taking, and was surprised by some of the differences I noted. For the most part, in the Lower 48, people either smoke or they don’t. The most common smoking habit is a pack a day; light-weights smoke a half pack a day (small percentage of all smokers), really light-weights smoke only on weekends or when having cocktails (very small percentage), and heavy-weights smoke two plus packs per day. But I found when asking Eskimos about smoking, the answer quite commonly would be some variation of “not much, maybe two sticks a day or less.” Is that all? Two cigarettes a day? That’s not much. You’d breathe more air pollution than that just living in a big city. But really, how can they do that? The demon that is tobacco addiction can only very rarely keep such a tiny hook in someone.

The answer started to become clear one day when an elderly woman answered my question about smoking with “Don’t smoke, only chew.” Only chew?

“You chew tobacco?” I asked, hoping my surprise was not showing. My medical experience had not included women chewing tobacco, though there are some family stories about my hillbilly grannies who dipped snuff.

“No. Blackbull,” she replied. Blackbull? I was quickly losing familiar ground here. Was that a brand of chewing tobacco? Seeing my flash of puzzlement, she added, “only Eskimos can chew it.” Oh. So I recorded on my chart note “patient chews blackbull” and went on with the reason for her visit. I skipped my usual recommendation that she consider stopping; I wanted to know what she was doing before I asked her to stop.

Back in the 1990s there was very little understanding of the prevalence of tobacco use among the Eskimos, and very little cessation education effort being made by the hospital. The water fountain in the hospital lobby had a sign over it (in Yupik and in English) that said “No Spitting,” but that was about it. If I’d been paying attention, I might have wondered just how much that sign represented the tip of an iceberg.

During my first year here, an energetic health educator with a fire-burning passion to eradicate tobacco use, applied for and received grant funding to assess tobacco use among the Yupik Eskimos, and to design interventions for cessation. It was the beginning of a new era.

The first arm of the study brought a stunning realization: the prevalence of tobacco use is incredibly high, and much of it is chewed, not smoked. And most of what is chewed is blackbull, which is also known as iq’mik. A door-to-door survey in the Yukon Kuskokwim Delta in 1999 revealed that 55% of adults smoke, and 45% chew. (unpublished data, E. Provost, 1999) This compares with U.S. rates of 29% for smoking and 8% for chewing. (U.S. Behavioral Risk Factor Surveillance Survey, 2001) Even more stunning is the estimate that among pregnant women in western Alaska, 57% chew and 16% smoke. (State of Alaska Maternal and Child Health Data Book, 2003)

Iq’mik is a combination of tobacco and the ash of a tree fungus. The fungus, called “punk”, forms knobby projections on certain trees that can be broken off. These are collected in burlap sacks and brought home for burning down to an ash. The ash is then mixed (in the mouth) with tobacco and saliva and set out to dry. Often, one family member is mixing for everybody. Once the mixture dries out somewhat, each family member who chews fills a small leather pouch or tin can for personal use. Each chew is described as "dime-sized" or "quarter-sized."

The addition of punk ash to tobacco raises the alkalinity of the final product to a pH of 10.9—much higher than tobacco alone, which varies from 5 to 8. (Renner, The effect in the human body is that chewing blackbull is somewhat like “freebasing” tobacco. It hits the brain many times faster, and loads all nicotinic receptors like a power surge. Speed of onset is a primary factor in determining addictive potential of any substance. Blackbull is more addictive than chewing tobacco.

Many people who chew blackbull also smoke an occasional cigarette, which brings me back to the earlier portion of this tale. The demon has its claws in far deeper than I thought when I heard “two sticks a day” from numerous patients. One thing you must learn when you work here is that Eskimos, on the whole, are very truthful, and tend to be fairly literal. They generally answer exactly what you ask, no more, and no less. The elder who told me she only chews was actually volunteering quite a lot. I had not asked her if she chewed.

The use of “spit” tobacco—plain tobacco or blackbull—is so pervasive and widespread that I now ask every patient old enough to walk whether they smoke, chew, or do both. The youngest patient I have personally identified as a daily chewer is four years old. FOUR YEARS OLD! I am still astonished by that. A young (twentysomething) mom came to see me with her four daughters, ages 12, 10, 6, and 4; all four daughters and mom chew blackbull every day. The youngest is only chewing once or twice a day, but mom and the older girls chew six, eight, ten times a day.

When patients acknowledge chewing, my exam routine has become to ask them exactly where in their mouths they put the chew, and then use a small hand mirror to show them what that spot looks like. I ask them to take a good look at the area at least once a month and note any changes to the skin there—wrinkling, loss of natural color, ulceration, brownish discoloration—and get it checked right away if any occur. The fact that I pay attention to it gets the patient’s attention. Many say that no one ever told them that before (probably not true, many patients leave predominantly educational encounters saying “the doctor didn’t tell me anything about it”). After the oral exam seems to be the most receptive moment to add, “it really would be the best thing for your overall health if you could quit.” Sometimes, they do.

I’m not on a mission by myself on this topic. That fireball health educator who got the first grant to study tobacco use in southwest Alaska got much accomplished here before she left. We now have a very active tobacco cessation program with a strong focus on education about iq’mik. Over a thousand people have registered with the program in the past year and received at least an educational session on tobacco use. Bilingual cessation counselors are available at every patient encounter in all clinics, and patients can be started on nicotine replacement (patches or gum) or wellbutrin the moment they are ready, and at no cost to the patient. Our patient record forms include a box for tobacco use along with the vital signs, and asking every patient/every visit is the goal we strive for. Slowly, we are making inroads into the Natives’ perception of how much spit tobacco can compromise their health. We’ve come quite a way since I first arrived here eight years ago, but there is still much to be done.

Renner CC, Enoch C, Patten CA, Ebbert JO, Hurt RD, Moyer TP, and Provost EM. Iqmik: A Form of Smokeless Tobacco Used Among Alaska Natives. Am J Health Behav. 2005; 29(6):588-594.



Blogger shade said...

You are so right quiting tabaco use is hard. I am trying and will continue to try through different methods... I wish I could just go back in time when I hadn't been smoking very long and slap myself silly for even thinking of starting!!! Good luck to you.

Wednesday, May 31, 2006 10:05:00 AM  
Blogger Christopher Boondoc said...

Excellent post about the tobacco issue in Alaska. Several of us at the office were standing around reading it. It reminds me of the Coca leaves chewed in the high Andes mixed with the ash of a particular plant - needed to release the active ingredients. Maybe they are more moderate, as I didn't see any leukoplakia there. However, I did see some green stuff in the cheek pouches. I have more Peru medicine stuff here:

Monday, May 26, 2008 11:10:00 AM  
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Anonymous Ethel said...

You mean Yu'pik and Inupiaq.

In SE Alaska, it was common in the late 70s for the other kids to have tins of snuff or chew in their pockets, first graders even.
Anyway, yeah - yeah, it's been around a long time for the young in Alaska, throughout the state.

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