Tobacco, originally a Western Hemisphere plant, was used for ceremonies by many American Indians, especially those on the Northern Plains, before the Europeans arrived (7). Its current use by American Indians and Alaskan Natives varies greatly. American Indians from the Southwest smoke very little tobacco, whereas those from the Northern Plains and Alaskan Natives have substantially higher smoking rates than the general US population (Table 1). The mortality rates due to smoking-related diseases in the areas served by the Indian Health Service (IHS) correlate with the differences in smoking prevalence (Table 2).

The IHS, which is a component of the Health Resources and Services Administration of the Pubic Health Service (PHS), has comprehensive responsibilities for the health care of approximately 937,000 American Indians and Alaskan Natives. Facilities include 45 hospitals with a total of 1,989 beds, 65 health centers, and many field clinics throughout the United States. American Indian/Alaskan Native groups also administer six hospitals and numerous clinics through a federally funded tribal program under Public Law 93-638.

To reduce the health hazards of involuntary (passive) smoking and to encourage nonsmoking behavior among American Indians and Alaskan Natives, the IHS has established smoke-free environments in its facilities (8-10). These efforts began on February 19, 1985, with a meeting between IHS representatives and the Surgeon General of the United States to discuss plans for a "Smoke-Free IHS".

To be considered smoke-free, an IHS facility must have no designated smoking rooms for staff, patients, or visitors. In late 1983, the PHS Indian Hospital on the Hopi Reservation at Kearns Canyon, Arizona, became the first to reach this goal (9). Now, virtually all IHS facilities have become smoke-free. In addition, this initiative led to a smoke-free policy in the American Indian schools on the Navajo Reservation at Zuni, New Mexico.

The IHS has taken steps to evaluate the impact of its policy on smoking behavior. For example, results of a survey conducted in the Rapid City PHS Indian Hospital in December 1985 suggest that daily cigarette consumption decreased after implementation of a smoke-free policy.

Reported by: TK Welty, MD, MPH, ES Tanaka, MD, Aberdeen Area Indian Health Svc, Rapid City, South Dakota. B Leonard, PHS Indian Hospital, Zuni, New Mexico. ER Rhoades, MD, WB Hurlburt, MD, Indian Health Svc, Rockville, Maryland. L Fairbanks, MD, Indian Health Svc, Phoenix, Arizona. Office on Smoking and Health, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: Of all behavioral risk factors that adversely affect health, tobacco use is the leading cause of premature mortality (11). The adverse health consequences of involuntary smoking are also well documented and support the need for smoke-free working environments (12). Furthermore, it is logical for health facilities to take the lead both in making nonsmoking the social norm and in reducing opportunities for smoking cigarettes (11). However, although smoking restrictions are generally more common in hospitals than in other worksites, survey data indicate that smoking is still widely permitted in patient-care areas. Relatively few hospitals are entirely smoke free (12). IHS's experience demonstrates that 100% smoke-free health facilities are achievable, and other health facilities are encouraged to set similar standards. *

In addition to protecting nonsmokers from exposure to environmental tobacco smoke, smoking restrictions may also encourage smokers to quit or reduce their smoking. Studies utilizing control groups and based on consumption data collected before and after policy implementation suggest that worksite smoking policies are followed by a decrease in smokers' cigarette consumption at work (12).

By eliminating smoking in all of its health facilities, IHS has launched a strong initiative to reduce the burden of morbidity and mortality resulting from tobacco use among American Indians and Alaskan Natives. On May 5, 1987, following the IHS initiative, the Department of Health and Human Services (DHHS) announced a new policy to establish a smoke-free environment in all DHHS buildings. This policy will affect approximately 120,000 DHHS employees nationwide.

• The University of Minnesota has published a guide for establishing smoke-free health care facilities (13).

References

1. Robicsek F. The smoking gods: tobacco in Mayan art, history and religion. Norman, Oklahoma: University of Oklahoma Press, 1978.

2. Peterson LP, Leonardson G, Wingert RI, Stanage W, Gergen J, Gilmore HT. Pregnancy complications in Sioux Indians. Obstet Gynecol 1984;64:519-23.

3. Gillum RF, Gillum BS, Smith N. Cardiovascular risk factors among urban American Indians: blood pressure, serum lipids, smoking, diabetes, health knowledge, and behavior. Am Heart J 1984;107:765-76.

4. Sievers ML. Cigarette and alcohol usage by Southwestern American Indians. Am J Public Health 1968;58:71-82.

5. DeStefano F, Coulehan JL, Want MK. Blood pressure survey on the Navajo Indian Reservation. Am J Epidemiol 1979;109:335-45.

6. Lee JF. The effects of a smoking prevention program for Alaskan youth. Circumpolar Health 1984;84:357-60

7. CDC. Smoking and health: a national status report. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1986:19; DHHS publication no. (CDC) 87-8396.

8. Fairbanks LL. Tobacco related disease among native Americans {Letter}. NY State J Med 1986;85:464

9. North C. Hospital smoking policy {Letter}. NY State J Med 1985;85:464-5.

10. Rhoades ER, Fairbanks LL. Smoke-free facilities in the Indian Health Service {Letter}. N Engl J Med 1985;313:1548.

11. Foege WH, Amler RW, White CC. Closing the gap: report of the Carter Center health policy consultation. JAMA 1985;254:1355-8.

12. CDC. The health consequences of involuntary smoking: a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1986.

13. Knapp J, Silvis G, Sorensen G, Kottke TE. Clean air health care: a guide to establish smoke-free health care facilities. Minneapolis, Minnesota: University of Minnesota, 1986.

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