Abstract Background American Indians/Alaska Natives have the highest commercial tobacco use in the United States, resulting in higher tobacco-caused deaths and diseases than the general population. Some American Indians/Alaska Natives use commercial tobacco for ceremonial as well as recreational uses. Because federally recognized Tribal lands are sovereign, they are not subject to state cigarette taxes and smoke-free laws. This study analyzes tobacco industry promotional efforts specifically targeting American Indians/Alaska Natives and exploiting Tribal lands to understand appropriate policy responses in light of American Indians’/Alaska Natives’ unique sovereign status and culture. Methods We analyzed previously secret tobacco industry documents available at the Truth Tobacco Documents Library (https://industrydocuments.library.ucsf.edu/tobacco/). Results Tobacco companies used promotional strategies targeting American Indians/Alaska Natives and exploiting Tribal lands that leveraged the federally recognized Tribes’ unique sovereign status exempting them from state cigarette taxes and smoke-free laws, and exploited some Tribes’ existing traditional uses of ceremonial tobacco and poverty. Tactics included price reductions, coupons, giveaways, gaming promotions, charitable contributions, and sponsorships. In addition, tobacco companies built alliances with Tribal leaders to help improve their corporate image, advance ineffective Youth Smoking Prevention programs, and defeat tobacco control policies. Conclusions The industry’s promotional tactics likely contribute to disparities in smoking prevalence and smoking-related diseases among American Indians//Alaska Natives. Proven policy interventions to address these disparities including tobacco price increases, cigarette taxes, comprehensive smoke-free laws, and industry denormalization campaigns to reduce smoking prevalence and smoking-related disease could be considered by Tribal communities. The sovereign status of federally recognized Tribes does not prevent them from adopting these measures. Implications American Indians/Alaska Natives suffer disparities in smoking prevalence and smoking-related diseases as compared with other groups. The tobacco industry has used promotional tactics including price reductions, coupons and giveaways, casino and bingo promotions, charitable contributions and sponsorships, and so-called Youth Smoking Prevention (YSP) programs to specifically target American Indians/Alaska Natives and exploit Tribal sovereignty, which likely contribute to disparities in tobacco use and related diseases and deaths among this population. Tribal and public health policy makers should consider rejecting ineffective YSP programs and instead consider adopting proven policy interventions including tobacco price increases, cigarette and casino taxes, comprehensive smokefree laws, and anti-industry denormalization campaigns to reduce smoking and smoking-related disease. Introduction Federally recognized Tribes have inherent rights and a political relationship with the US government that do not derive from race or ethnicity. American Indians/Alaska Natives are members of 566 federally recognized sovereign Tribal nations1 that have sovereign status and that establish their own civil laws and are not subject to the tax, licensing, and smokefree laws of the states where they are located.2,3 The tobacco industry has used promotional4 and coalition-building tactics to specifically target particular groups (including African Americans5–7; Hispanics6,8,9; lesbian, gay, bisexual, transgender, queer, and questioning community10,11; and women12–14). While the National Cancer Institute’s Monograph 194 explores targeting of groups in general, it does not provide details about commercial tobacco marketing to American Indians in particular. The American Cancer Society’s “Manipulating a Sacred Tradition” report15 documents strategies used by commercial tobacco companies to manipulate and target some American Indians’ sacred use of tobacco in an attempt to increase sales, resulting in increased commercial tobacco consumption and addiction among Tribal members. (Most ceremonial tobacco plants are not nicotiana-containing plants, but other types of plants. For example, the Lakota people use cansasa [red willow scrapings] for their ceremonies. Alaska Native Tribes generally do not use ceremonial tobacco.16) Our study builds on this literature to provide evidence of the specific strategies tobacco companies used to target American Indians using previously secret industry documents. American Indians/Alaska Natives have the highest tobacco use in the United States;17 in 2013, 40.1% of American Indians/Alaska Natives reported current commercial tobacco (cigarettes, cigars, or smokeless tobacco) use including 56.7% of young adults (18–25) and 20.3% of youth (12 to 17).18 As a result, they have disproportionately higher risks of tobacco-related death and diseases than the general population.19,20 Unlike other targeted groups, some American Indian Tribes use traditional tobacco for ceremonial, sacred, and medicinal purposes,21 a practice that predates (by centuries) the advent of commercial recreational use.22–24 Because of 19th- and 20th-century policies prohibiting American Indians from using traditional tobacco in ceremonies, some American Indian groups substituted commercial tobacco,23,25 and commercial tobacco continues to be used for traditional as well as recreational purposes among some American Indians,24,25 including among youth.26 Because of these traditional uses of tobacco and the mixing of commercial tobacco with traditional tobacco, some American Indian youth are exposed to commercial tobacco in their home and community environments and have easy access to tobacco at an early age. The tobacco industry’s internal research in the 1990s showed that companies understood that social environments in general could encourage increased smoking consumption among young adults,27,28 and these factors may contribute to health disparities among some American Indians/Alaska Natives. The federally recognized Tribes’ uniquely sovereign status provides additional opportunities for the tobacco industry to promote its products to American Indians/Alaska Natives. Methods Note on Terminology The 2010 census reported29 the total American Indian/Alaska Native (AI/AN) alone population as 2.9 million or ~0.9% of the US population, and the total AI/AN population alone or in combination with other races as 5.2 million or 1.7% of the US population. Although the 2010 census chose the terminology “American Indian or Alaska Native,”30 historically there are no “American Indians”; rather, there are members of specific nations, Tribes, villages, and bands. According to the National Congress of American Indians,1 as of March 2017, there were 566 federally recognized Indian Nations or Tribes in the United States, including ~229 nations in Alaska. In addition, there are other Tribes recognized by respective state governments. Recognizing the importance of avoiding bias in language and the difficulty of assigning one name or identity to such a widely diverse group of peoples, the American Psychological Association (APA) recommended in its APA style guide for academic publishing31 using the term “Native American” to include American Indians, Pacific Islanders, and Alaskan Natives (or preferably specific group names such as Navajo or Hopi when available). In May 2016, federal legislation was passed amending the language used in certain federal acts from “American Indians” to “Native Americans,”32 and the Census Bureau is considering new ways to ask Americans about their race or origin in the 2020 census.33 The issue of appropriate terminology (eg, Native American, Native, Indian, American Indian, Indigenous) is still unsettled, and there is no broad consensus among Tribal peoples and academics.34–36 In September 2017, the National Cancer Institute released its new Monograph 2237 entitled, A Socioecological Approach to Addressing Tobacco-Related Health Disparities, which uses the terminology “American Indian/Alaska Native” in its discussion of the disparities in tobacco-related disease and death affecting this particular population group. In addition, we consulted with several Tribal members and experts to determine what terminology we should use for this study and have consequently adopted the term “American Indian/Alaska Native,” except when we are specifically referencing either American Indians, Alaska Natives, or peoples from particular tribes or geographic regions, or when we are quoting a source that uses different terminology. Similarly, we used the term “reservations” instead of the term “Tribal lands” when quoting or discussing an industry document that used that term. We recognize that using any one term may result in generalizations that do not apply to every member of every nation or Tribe. Tobacco Industry Document Searches Between April 2013 and September 2017, we searched previously secret tobacco company documents available at the University of California San Francisco Truth (formerly Legacy) Tobacco Documents Library (https://industrydocuments.library.ucsf.edu/tobacco/) on industry efforts regarding American Indians/Alaska Natives. We used standard snowball search techniques38 in which earlier searches inform subsequent searches to both define search terms and develop themes and subthemes, flowing from our initial hypothesis that tobacco companies specifically target American Indians to increase commercial tobacco use among this group. Starting with this broad hypothesis, we generated a list of search terms likely to return relevant documents, beginning with ((Indian OR “American Indian” OR “Native American”) AND (marketing OR promotion OR advertis*)) (74558 results), “Tribal” (11637 results), (Indian OR “American Indian” OR “Native American”) AND (charit*) (8135), (Indian OR “Native American”) AND “marketing youth”~4 (1940), (Indian OR “American Indian” OR “Native American”) AND (contribution) (1552). After qualitative analysis of some documents produced by these searches, we refined our research questions and search terms and subsequently added terms including “Alaska Native” (2574), “American Indian/Alaska Native” (557), and “American Indian/Alaska Native” AND (marketing OR promotion OR advertis*) (477), (Indian OR “Native American”) AND “advertising youth”~4 AND “G&G” (611), (“Tribal promotion”~5) (24), (“Tribal marketing”~5) (20), (“Tribal target*”~5) (11), and “AI/AN Tribes” (2). (We did not include the term “Pacific Islanders” in our searches because the issues concerning tobacco industry involvement with Pacific Islanders are outside the scope of this study.) We found additional documents by reviewing adjacent documents (Bates numbers). After an initial survey of the metadata and portions of the documents, we identified ~500 documents that merited closer review and used 94 documents pertinent to our research questions. Data Analysis As noted earlier, this study uses well-established methods for tobacco industry documents research that have been described in detail in methods studies.38,39 See Supplementary Material for more details on these methods. Results Tobacco Industry Marketing and Promotional Strategies Since at least the 1980s, tobacco companies implemented coordinated strategies to increase sales to minority consumers, improve contacts and influence with minority leaders (especially government leaders at all levels), and improve the companies’ overall image and credibility among minorities with Corporate Responsibility programs. While earlier strategies targeted primarily African Americans and Hispanics, in 1991 they included American Indians/Alaska Natives using comprehensive approaches that coordinated all company activities touching minorities and built relationships with key American Indian/Alaska Native organizations.40–43 Like other targeted groups, companies targeted American Indians/Alaska Natives using price reductions, coupons and giveaways, casino and bingo promotions, and charitable contributions and sponsorships and indirectly targeted youth (as young as 8 years old) with so-called youth smoking prevention (YSP) efforts. Companies also took advantage of the sovereign status of Tribal lands, stores, and casinos to sell cheaper cigarettes to both Tribal and non-Tribal customers. Price Reduction Strategies As national laws and policies limited other promotional channels such as TV advertising and sampling, tobacco companies increasingly directed marketing expenditures to commercial tobacco price reduction,44–48 including discounts, promotional allowances paid to retailers and wholesalers, volume rebates, and coupons.47–49 These strategies accounted for 96% of the total $8.9 billion advertising and promotional spending in 2013, including $7.6 billion (85%) on price discounts.50 Because federally recognized Tribal lands are sovereign nations, Tribal stores there are exempt from all but federal tax and are not required to collect state cigarette or sales taxes.2,3 The resulting lower prices attract and keep customers and are especially attractive to price-sensitive young buyers.44,46,51 (Many Tribes have formed a compact with the state in which the Tribal lands are located to collect taxes. For example, Arizona’s American Indian cigarette stores collected a “Tribal Tax” of $4.00 per carton in 1996. However, because the general market cigarette tax was $5.80, Tribal cigarette stores still had a $1.80-per-carton tax advantage over the general market.52) Beginning as early as the mid-1980s, the cigarette companies complemented already lower cigarette prices on Tribal lands with further price reductions to target Tribal and non-Tribal customers. Many commercial tobacco stores on Tribal lands are owned by non-Tribal members. RJ Reynolds’ (RJR) 1986 Indian Reservation Program (IRP) in Ft. Lauderdale, Las Vegas, and Albuquerque markets offered customers deep discounts for purchasing more than one carton of Winstons,53 reducing the price of some cigarettes to as low as $4.99 per carton (10 cigarette packs)54,55 to counter aggressive discounting by Philip Morris (PM) and other companies at Tribal smokeshops. Lorillard offered $6.00 coupons on Heritage cigarettes cartons on the Oneida reservation.56 In 1994, Lorillard’s IRP offered $2 coupons for Kent, True, Old Gold, and Newport cigarettes, and $5-per-carton coupons for Style.57 (In 1994, the average undiscounted price per carton of cigarettes, excluding state taxes for cigarettes sold on reservations, was $14.60.58) Lorillard offered $2.00 to $5.00 coupons and discounts on reservations between 1995 and 2000.59–64 Lorillard recognized that promotions such as “buy one, get one free” and mail-in coupons for dollars off the next multi-carton purchase were useful to “strengthen the bond with loyal smokers, as well as induce quality trial and conversion among competitive smokers.”65 In 1998, RJR’s IRP discounted cartons at one rate ($1.50 or $2.00/carton) when PM was not offering promotions and increased the discount to $2.50 or $3.00 when PM was promoting.66,67 RJR increased the bonus payments to retailers to compete with PM,68 including offering Oneida retailers a 40-cent/carton bonus for keeping their Gold Coast brand the lowest price in their stores. In addition, major tobacco manufacturers reduced prices to compete with Tribes that manufactured and sold their own cigarettes at low prices.69 Besides coupons, these companies offered discounts for volume purchases to “value-conscious” customers at Tribal stores,70–74 resulting in high weekly carton sales. In 1996, Lorillard’s Phoenix Division Manager analyzed Lorillard’s carton-per-week (CPW) sales volume at all Tribal stores in Region 19 (Arizona, New Mexico, North Dakota, and South Dakota) to see how Lorillard could improve their presence in merchandising, advertising, and special promotions.74 The analysis emphasized promoting volume sales in Tribal stores at lower than general market prices to increase customers and profits: “Indian store sales lean heavily toward price value products, or discounted full revenue. Price value sales in Indian stores always exceed the general market sales ratios of price value to full value, and in some cases, price value sales and discounted full revenue account for over 85% of [Indian stores’] business” and recommended “continued promotional support for our full price brands. Indian store customers are almost always looking for value.”52 In 1996, Tribal stores sold a disproportionate percentage of cigarettes in the United States by concentrating on volume sales at lower than market prices.52,75 Tribal stores were a significant source of Lorillard’s total sales in the western states.74 with 5,000–10,000 CPW (more during seasonal peaks) sold in reservation stores.52 The 31 Tribal cigarette stores in Arizona accounted for “over 14%” of the total overall industry volume in the state; the 16 Tribal stores in New Mexico accounted for 13.4% of the state total, and as a group were the highest volume contributor to the cigarette business; and the eight American Indian stores in North and South Dakota accounted for 2.7% of the total industry business.52 Tribal stores attracted non-Tribal tourists, residents, and casino patrons, as well as Tribal customers.52 In addition to price reductions, other industry strategies included PM’s gift promotions with volume purchases on Tribal lands including free Marlboro windbreakers70 and the “Marlboro Unlimited” sweepstakes featuring themed gifts and train trips through Tribal lands highlighting Tribal cultural attractions.76–80 Casinos and Bingo Tribal gaming establishments (casinos and bingo halls), like Tribal stores, operate under Tribal, rather than state authority, and are commonly associated with Tribal cigarette stores. However, unlike Tribal cigarette stores, Tribal gaming was established in 1988 by federal law and is governed by the Indian Gaming Regulatory Act.81 Although gaming operations on Tribal lands have enabled a number of Tribes to reduce unemployment and generate increased revenues, gaming on Tribal lands has not appreciably lowered the high levels of poverty.82,83 Since at least 1992, PM,84–86 RJR,87,88 and Lorillard52,89,90 understood that Tribal gaming could support Tribal cigarette store volumes by attracting large numbers of non-Tribal tourists as well as Tribal residents. In 1992, PM reported large sales increases at Tribal establishments in Minnesota and expected more substantial increases after casinos were opened or expanded.84 In addition to selling cigarettes at casino stores, in 1999 RJR considered advertising Dorals on video poker and slot machines in Tribal casinos.91,92 An RJR Regional Sales Manager successfully lobbied Congress in 1997 to defeat legislation that would tax Tribal gaming and affect RJR’s business with an Oneida casino.93,94 Oneida business people may have cooperated with RJR to help defeat Tribal gaming taxes; RJR had a “handshake” agreement with Oneida retailers to keep their brands the lowest price in their stores in exchange for 5-cents-per-pack/50-cents-per-carton incentives.68 Tobacco companies also promoted cigarettes in Tribal bingo halls. In 1991, Lorillard engaged an advertising agency to explore promoting cigarettes at Tribal bingo halls.95 The agency noted that, like Tribal casinos, Tribal bingo halls were attractive venues because they were unregulated by state agencies so could operate 24 hours per day/7 days per week and offer unlimited prize amounts, and many already sold commercial tobacco.95 Proposed promotions included free T-shirts with commercial tobacco purchases, free samples, games with gifts for every player, and direct mail advertising with discount coupons. Volume sales would be promoted by offering free admission to customers who brought in three packs of Kent or free T-shirts for customers who bought two cartons.95 In August 1993, PM created a 511-page plan for its Tribal Bingo Promotion Program96 including Tribal gaming customer demographics, industry surveys, lists of gaming Tribes and operations, and regulatory information. To increase brand recognition/awareness, stimulate trial among smokers playing bingo, and encourage repeat purchases, the program proposed putting cigarette brand logos on bingo cards, a “call out for Virginia Slims (or brand of choice)” promotion, offering incentive items with multipack purchases and placing coupons in bingo flyers and newsletters.96 Industry Sponsorships and Contributions and Community Engagement The tobacco industry sponsored events and made corporate contributions to minority groups since as early as 1956.97 PM’s Corporate Contributions program made thousands of grants annually since 1956 to nonprofits concerning health, culture, environment, and education, including to American Indian/Alaska Native groups.97 As early as 1988, PM made contributions to American Indian/Alaska Native organizations including the American Indian College Fund, American Indian Higher Education Consortium, Native American Rights Fund, Baltimore American Indian Center (BAIC), Native American Educational Services, and to Arizona Food Banks serving American Indians.41,98 In 1988, PM contributed $14200 to six American Indian/Alaska Native organizations41 and supported at least 22 from 1993 to 1997,99 including Native American Educational Services, American Indian College Fund, and Association of Arizona Food Banks (which distributed food on reservations). In a 1990 list of “community networks to reach” by “smoking target groups,” PM identified five American Indian groups in Wisconsin alone.100 By 1998, PM increased contributions to American Indian/Alaska Native organizations and causes to $564800, 9% of its total corporate contributions for 1998 ($6.3 million42), despite the fact that American Indians/Alaska Natives were 1.5% of the US population.101 PM’s Corporate Contributions and Cultural Programs’ mission was “to build and maintain relationships critical to creating a political, regulatory and attitudinal environment for PM’s business success” while making strategic grants for programs that “serve undeniable human needs” and “demonstrate a commitment to diversity.”102 While the political goal of any particular contribution was not always explicit, PM’s table of 1988 corporate contributions indicated that $2500 given to BAIC (affiliated with the National American Indian Council representing American Indians/Alaska Natives living off reservations) for its 14th annual pow-wow was to garner support for PM’s opposition to taxes.41 In addition to direct contributions, PM created its Community Marketing Programs department (later called Community Events Marketing, CEM) in 1989 to enhance brand awareness and build market share by sponsoring major events (festivals, air shows, state and county fairs, and ethnic fairs and concerts) in key ethnic markets (American Indian/Alaska Native, Hispanic, Asian American, and Black).103 CEM sought to build brand equity by becoming “part of the fabric of the community at the grassroots level”104 and “creat[ing] stronger bonds with third-party allies.”105 The 1992 CEM plan called for increased participation among American Indians/Alaska Natives at two major American Indian/Alaska Native events featuring Marlboro coordinated with incentive programs at on-site retail locations and recommended continued research to identify the most prominent American Indian/Alaska Native events.106 The expected attendance was 160000 at the Oklahoma City Red Earth Day and 30000 at the Viddles Festival.107 CEM grew from 48 events in 1989 to 125 in 1991,103,107 but dropped to 21 events in 1998.108 Between one and four events specifically targeted the American Indian/Alaska Native market annually.103–115 In its 2008 Corporate Social Responsibility report, RJR described its “commitment to community” demonstrated by its Santa Fe Natural Tobacco Company Foundation providing grants to “preserve, promote and advance American Indian self-sufficiency, language and culture.”116 (RJR acquired Santa Fe Natural Tobacco Company in January 2002.117) The Santa Fe Foundation granted almost $500000 in 2006–2007 to American Indian/Alaska Native organizations including American Indian College Fund, Indigenous Languages Institute, Institute for American Indian Arts, Women Weavers of Chiapas, Native American Rights Fund, and Total Immersion Treaty School.116 Before Food and Drug Administration prohibited sports event sponsorship in 2010,118 tobacco companies sponsored rodeo events and pow-wows popular with youth119 and highlighted American Indian/Alaska Native performers popular with both Tribal and general audiences. Since its inception in 1976, the Indian National Finals Rodeo (INFR) recognized American Indian/Alaska Native rodeo champions from throughout North America and attracted representatives of almost every Tribe in the United States and Canada.120 In addition to the rodeo, the 4-day event featured American Indian/Alaska Native ceremonial dances, pow-wow, arts-and-crafts fair, and Miss Indian Rodeo pageant. In 1983120 and 1984,121 United States Tobacco was a major INFR sponsor, providing cash purses for rodeo winners, placing full-page ads for Skoal Bandits in rodeo programs,120 promoting a “Skoal Bandit Performance” before the rodeo,121 and awarding $135000 annually to rodeo students.120 Between 1995 and 1998, Lorillard supported the Guilford Native American Association (GNAA), a nonprofit established to improve the socioeconomic and educational status of American Indian people in Guilford, North Carolina, and placed full-page ads in GNAA Annual pow-wow brochures.122–124 Lorillard’s Senior Vice President of Leaf Operations and Support Services arranged the sponsorship contracts.122,123 In 1997, he informed Arthur Stevens, Lorillard’s Senior Vice President and General Counsel, that the Guilford County Board of Health smoke restrictions were repealed after a 3.5-year controversy.125 YSP Programs PM introduced youth smoking education and prevention (YSP) campaigns in the 1980s purportedly to prevent youth smoking by educating youth and their parents about the harms of tobacco use through four strategies: “Communication” (advertising directed towards youth and parents), “Education” (partnerships with credible organizations to promote youth programs and curricula), “Community Action” (partnerships with credible organizations to implement outreach and create relationships), and “Access” (align with industry antiyouth access programs such as “We Card”).126 In the late 1990s, PM targeted American Indians/Alaska Natives by modifying existing YSP to create a strategy “culturally relevant” to American Indians/Alaska Natives.127 PM hired G&G Advertising, an American Indian/Alaska Native marketing agency staffed by American Indians/Alaska Natives.128 G&G gave PM overviews of the American Indian/Alaska Native market, including lists of the most popular American Indian/Alaska Native media vehicles and the top 50 American Indian/Alaska Native-designated market areas they proposed to penetrate with YSP messaging specifically targeting American Indian/Alaska Natives including urban, reservation, and near-reservation American Indians//Alaska Natives.129 G&G’s overviews and proposals described American Indian/Alaska Native traditional values, parent–child relationships, and tobacco use among their target audience (“tweens,” teens, and their parents) and developed “culturally relevant” messages and themes tailored to specific American Indian/Alaska Native audiences in Alaska and the lower 48 states.127–131 G&G noted that many American Indian/Alaska Native youth came from “broken homes,” are “subject to extreme poverty,” and “are a group which suffers from lack of direction and productive activity. With little to do on the reservations and a sense of hopelessness, these youths may turn to smoking,”127 and American Indian/Alaska Native youth are more likely to start smoking at younger ages, typically around age 8 or 9.128 Because of the increased youth smoking incidence and younger age of trial on reservations in American Indian/Alaska Native communities compared with the general population, G&G proposed developing strategic YSP messaging relevant to younger American Indian/Alaska Native preteens and teens (age 8–15).127 Television132 and print ads targeting American Indian/Alaska Native tweens and teens were developed, including three television commercials (“I Stand Out,” “Basketball,” and “Shawl Dancer”132).133 To reach American Indians/Alaska Natives, G&G recommended creating emotional, “culturally relevant” messaging and relied on research finding that “seeing Indians and hearing Indian music immediately attracts [American Indians/Alaska Natives’] attention” and seeing American Indians/Alaska Natives in advertising made them feel “good” and “proud.”134 At the request of PM’s YSP division, K Group conducted qualitative market research in 1999 and 2000133,135–138, and MarketView Research Group conducted quantitative market research in 2001139–142 to evaluate whether the American Indian/Alaska Native YSP commercials clearly and effectively delivered a “don’t smoke” message to the targeted population. Researchers interviewed children aged 10–14 and 15–17 and their parents after they watched a commercial twice. One study evaluating “Shawl Dancer” (which focused on impressionistic themes of American Indian/Alaska Native culture, including dancing, drumming, and music) showed that only about half of 10- to 14-year-olds who viewed the ad said they understood the basic “don’t smoke” message, <0.5% understood that “smoking is not good for you,” 2% understood that “smoking causes cancer,” and 3% understood that “you can die from smoking/smoking can kill you.”139 However, because the research methodology counted messages such as “be proud of yourself,” “not all Native Americans smoke,” and “smoking affects your athletic ability” as correct “don’t smoke” responses, the study concluded that 90% of respondents understood the commercial’s “don’t smoke” message.139 A summary of market research effectiveness evaluations noted that the main themes in the ads targeting American Indians/Alaska Natives were “role models” and cultural pride messages (consistent with G&G’s recommendations for reaching American Indians/Alaska Natives),134 with nothing specific about the dangers of smoking. Regarding “Shawl Dancer,” the report noted, “Few respondents found any particular reason why not to smoke.”137 Another report noted that the “I Stand Out” ad did not provide a strong no smoking message, but mainly featured role models and was “more about being proud of who you are.”138 A more detailed study found that only 30% of the teens (15–17) viewing “I Stand Out” understood the “not to smoke/don’t smoke” message, 2% understood the “smoking causes cancer” message, and less than 0.5% understood the “smoking affects your body/harms/damages your body” and that “you can die from smoking/smoking can kill you” messages.142 K Group conducted focus groups in 1999 for PM’s YSP team analyzing the effectiveness of television and advertising campaigns developed for American Indian/Alaska Native teenagers and pre-teenagers and their parents. 133 They found that reactions to the ads were “considerably mixed” among teenagers, pre-teenagers, and their parents, and many of the ads, which focused on “Native culture” and traditional music, “came up short in delivering a clear, concise youth smoking prevention message.”133 They stated that American Indian/Alaska Native teens’ and pre-teens’ unenthusiastic reaction to the ads likely reflected their desire to integrate with modern western life and be seen as part of the general population, rather than to embrace their cultural traditions.133 Rather, American Indian/Alaska Native youth believed that “the more impactful messages are those that exemplify the negative physical manifestations of smoking – poor physical performance, unattractiveness, wrinkles, bad breath and debilitating physical diseases…. The older segment, 12–14 years old, seemed to be looking for a more intense smoking prevention message. This age segment seems to need a tangible reason why they should not smoke.”133 Parent focus groups revealed that the ads were much less effective for smoking than non-smoking parents.133 Despite the 1999 market research reports showing that the YSP American Indian/Alaska Native ad campaigns did not effectively deliver a “don’t smoke” message, the total 2001 PM YSP Budget for tweens, African American tweens, parents, African American parents, Hispanics, Puerto Ricans, and American Indians/Alaska Natives was $52.0 million, including $0.5 million for 8 weeks of television ads targeting American Indian/Alaska Native tweens.143 G&G and Starcom developed a rotation list of markets where PM’s American Indian/Alaska Native YSP commercial spots would be aired and recommended that “I Stand Out” would do better in all markets;144the commercials started running in October, 2001.145 PM sought proposals in 2000 to develop other YSP initiatives reaching minority youth, including American Indians/Alaska Natives,146 and in 2001 granted the Native American Educational Services $476161147,148 for its “Native Youth Wellness Initiative” to develop a program with PM encouraging healthy lifestyles and activities among American Indian youth in five states (Arizona, Montana, New Mexico, Oklahoma, and South Dakota), strengthening the capacity of Native-run youth organizations, and increasing the number of youth served by these groups with an overall goal to reduce the 55% smoking prevalence rate.149,150 Discussion Tobacco companies developed marketing and promotional strategies targeting American Indians/Alaska Natives and exploiting Tribal sovereignty, including price reductions, sales and promotions on or near reservations and in Tribal casinos and bingo halls, industry sponsorships and contributions to American Indian/Alaska Native organizations, and YSP programs. As with other minority groups,6,7,151 strategies targeting American Indians/Alaska Natives were designed not only to increase sales to American Indians/Alaska Natives (as well as non-Tribal peoples), but also to maintain goodwill among American Indian/Alaska Native leaders, improve overall image and credibility, and garner opposition to cigarette tax and smokefree policies. In addition, companies exploited federally recognized Tribes’ unique sovereign status and culture to attract non-Tribal customers distinguishing American Indians/Alaska Natives from other targeted groups. Ceremonial Tobacco Use Traditional and ceremonial uses of tobacco may have contributed to the disproportionate prevalence of commercial tobacco use among American Indians (commercial tobacco is generally not used for ceremonial purposes in traditional Alaska Native culture),16 especially because the tobacco industry has manipulated the important role of tobacco in traditional American Indian life and has misappropriated American Indian/Alaska Native imagery to promote their products.15 Greater integration of tobacco in religious practices and social relationships among Northern Plains versus Southwest American Indians is associated with higher smoking rates and more smoking-related deaths.152 Further, the ready availability of heavily discounted commercial tobacco on reservations may have contributed to widespread use of commercial tobacco in spiritual ceremonies that previously used only traditional tobacco.25 Some American Indian spiritual healers who use tobacco in ceremonial practices believe that commercial tobacco is dangerous, but traditional tobacco is “natural” and “good for our children,”25 while others believe commercial tobacco use threatens traditional values as well as health.153 Ceremonial use of commercial tobacco may facilitate other industry marketing and promotional strategies targeting American Indians and thwart tobacco control efforts. American Indian leaders and health professionals have worked to retain the cultural use and value of tobacco while educating their communities about the harms of mixing ceremonial and recreational commercial tobacco uses.24,153,154 Industry Price Reduction and Volume Discount Strategies Since the 1980s, tobacco companies leveraged the fact that cigarettes sold on federally recognized Tribal lands are exempt from state taxes with price reduction strategies specifically targeting American Indians/Alaska Natives and also reaching non-Tribal peoples. These tactics are likely to be especially effective because of the poverty155 that afflicts American Indians/Alaska Natives, especially on reservations. Poverty contributes to disparities in commercial tobacco use and associated morbidity and mortality among American Indians/Alaska Natives.37,49 However, because of the sovereign status of federally recognized American Indian/Alaska Native Tribes, Tribes can enact policies increasing the price of commercial tobacco products to discourage youth uptake, including raising cigarette taxes and prices, instituting minimum price initiatives,156–158 and working with states to harmonize tax rates to collect tax revenue from non-Tribal consumers.159 The WHO Framework Convention on Tobacco Control (FCTC),160 to which 181 countries are parties and using evidence-based best practices, recommends price and tax increases to reduce the demand for commercial tobacco. Tribes could consider restricting commercial tobacco product price promotions, including prohibiting or minimizing coupon redemptions and multipack or carton discount offers. Commercial Tobacco Stores, Casinos and Bingo Halls, and Promotions on Tribal Lands Tobacco companies have adopted strategies taking advantage of American Indian/Alaska Native communities to increase commercial tobacco consumption and purchases by Tribal peoples while increasing the companies’profits.15 While Tribal commercial tobacco retail stores, casinos, and bingo halls attract non-Tribal as well as American Indian/Alaska Native patrons, environmental factors such as easy access to cheap cigarettes at Tribal stores and tobacco industry promotion of cigarettes on Tribal lands may influence heavy commercial tobacco use among American Indians/Alaska Natives.21 While many Tribal casinos are paying state taxes on commercial tobacco products, to increase consumer trial and purchases, tobacco companies leveraged already low prices due to state cigarette tax exemptions in many federally recognized Tribal stores, casinos, and bingo halls by offering coupons, discounts, and gift promotions as rewards for purchasing multiple packs or cartons. Tobacco companies understood that as many Tribal casinos are smoke-friendly environments and exempt from state taxes, they were good places to encourage cigarette purchases. Recognizing this advantage, RJR successfully lobbied New York legislators to defeat casino taxes in the Oneida Nation. Coincidentally, RJR gave Oneida retailers bonuses on each pack and carton of cigarettes sold to keep the price of their brands lower than any other manufacturer. It is possible that these financial incentives were part of a concerted effort to forge an alliance and garner Oneida support to defeat American Indian/Alaska Native gaming taxes, as similar strategies have been used to defeat tobacco control efforts among other vulnerable groups.6,7,151 It is important to recognize efforts by industry representatives at stores, casinos, and bingo halls on Tribal lands to defeat evidence-based policies such as cigarette and gaming taxes that would help control commercial tobacco use by increasing prices. In recent years, many Tribes have adopted commercial tobacco–free policies on Tribal lands and in Tribal gaming establishments,161 and other Tribes could consider adopting and enforcing similar smokefree policies for all workplaces and public places on Tribal lands, including in all restaurants, bars, casinos, bingo halls, and other gaming and hospitality venues. Industry Sponsorships and Contributions The tobacco industry sponsored events and made corporate contributions to American Indian/Alaska Native charitable organizations, including education, arts, culture, and rodeos. PM’s corporate contributions program’s mission was “to build and maintain relationships critical to creating a political, regulatory and attitudinal environment for PM’s business success,”102 and PM explicitly said that a contribution given to a National American Indian Council affiliate was to garner support for PM’s position on excise tax issues.41 PM’s Community Marketing Programs’ mission was to “create stronger bonds with third-party allies.”105 RJR’s Santa Fe Natural Tobacco Company Foundation grants in its “Corporate Social Responsibility” program nominally advanced American Indian/Alaska Native self-sufficiency and culture. Although no direct link was found, the defeat of proposed Guilford County Board of Health smoke restrictions closely followed Lorillard’s support of the GNAA’s pow-wows. These various programs improved the industry’s poor image and credibility, developed community support, forged alliances to defeat tobacco control efforts, built brand awareness, and increased commercial tobacco sales, echoing successful strategies tobacco companies used with other targeted groups.6,7,151 YSP Programs PM specifically designed YSP programs for American Indian/Alaska Native audiences. While nominally created to prevent youth smoking, the tobacco industry’s YSP campaigns did not reduce tobacco sales to minors162 and instead were associated with lower perceived harm and stronger approval of smoking among youth, and greater likelihood to smoke in the future.163–166 Like the industry’s general market YSP, research firms PM hired found that the American Indian/Alaska Native YSP ads were not effective, with only about half of the preteen viewers understanding the basic “don’t smoke” message, and <0.5% understanding that “smoking is not good for you.”133,135–137,139 Most respondents did not learn any specifics about the dangers of smoking from the ads and did not get a clear, concise smoking prevention message.133,134,137 The WHO FCTC160 and The Guidelines for Implementation of FCTC Article 12167 recommend using education and communication campaigns to change social, environmental, and cultural norms and perceptions regarding commercial tobacco use and marketing. Tribes, tobacco control groups, and governmental and nongovernmental agencies could consider using the industry’s research documented in this study to inform policies that would effectively minimize commercial tobacco use among American Indian/Alaska Native youth. Limitations Because this research is based primarily on the Truth Tobacco Industry Documents, there are gaps in information. Many documents, especially industry marketing reports and correspondence with industry lawyers, are not viewable because they are marked “Confidential.” Conclusions This study documents strategies adopted by tobacco companies to take advantage of American Indian/Alaska Native traditions and imagery and to target Tribal peoples, thereby increasing commercial tobacco consumption, addiction, and tobacco-related diseases among American Indians/Alaska Natives. The information can be used to help educate Tribal leaders on the industry’s influence and strategies and to suggest approaches that could be considered to address these issues. While there are 566 federally recognized Tribes in the Unites States and American Indian/Alaska Native communities are diverse, they are similar in that they are all sovereign nations that are not subject to the tax, licensing, and health laws and regulation of the states where they are geographically located. Therefore, cigarettes sold on federally recognized Tribal lands are not subject to state taxes and are cheaper than other cigarettes, attracting both American Indian/Alaska Native and non-Tribal customers. In addition, tobacco is used for ceremonial purposes in many American Indian communities. Tobacco companies have leveraged these unique aspects of American Indian/Alaska Native governance and culture to adapt pricing and promotional strategies they used to target other groups to specifically target American Indians/Alaska Natives. These strategies likely contribute to the disparities in smoking prevalence and smoking-related diseases found among the American Indian/Alaska Native population as compared with other groups. While industry YSP programs are not effective to reduce smoking and should not be used, American Indian/Alaska Native communities and policy makers could consider adopting proven interventions including commercial tobacco price increases, cigarette and casino taxes, comprehensive smokefree laws, and anti-industry denormalization campaigns to reduce smoking prevalence and smoking-related disease. Price and tax strategies would be particularly effective in low-income American Indian/Alaska Native communities. The sovereign status of federally recognized American Indian/Alaska Native Tribes does not prevent them from adopting these measures. Supplementary Material Supplementary data are available at Nicotine & Tobacco Research online. Funding This work was funded by grants from the National Cancer Institute (CA-087472 and CA-061021) and National Institute of Drug Abuse (DA-043950). The funding agencies played no role in the conduct of the research or preparation of the manuscript. Declaration of Interests None declared. Acknowledgments We thank the reviewers for assistance in using appropriate terminology with regard to use of tribal terminology and culture. References References 51–167 are available online as Supplementary Material 1. National Congress of American Indians. Tribal Nations and the United States: An Introduction. http://www.ncai.org/about-tribes. Accessed February 14, 2017. 2. Williams v. Lee, 358 U.S. 217 (1959) . 3. Bureau of Indian Affairs, US Dept. of the Interior. 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Published: Mar 12, 2018
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