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What happened when smoking was banned in American Indian casinos

Editor's Note: (Patricia Nez Henderson, M.D., MPH, vice president of the Black Hills Center for American Indian Health, is Diné (a citizen of the Navajo Nation) and an authority on commercial tobacco control in American Indian communities. Catherine Saucedo is deputy director of the Smoking Cessation Leadership Center at the University of California, San Francisco. The views expressed in this commentary are their own. View more opinion on CNN.)

(CNN) It took more than a decade to achieve. But anyone who cares about health in Indian country will gladly take the win. American Indian tribes are joining the effort across the nation to ban smoking in casinos, permanently, in the case of the Navajo Nation, the Eastern Band of Cherokee Indians and others.

Catherine Bonniot-Saucedo

Patricia Nez Henderson

This development may have once seemed unthinkable in communities where consuming tobacco is both a sacred ritual and a heavily entrenched public-health burden. But it's happening. It is a striking reversal given that the tobacco industry has pushed its toxic products on American Indian lands for a century or more, and the gambling industry has argued against smoking bans since Indian casinos first emerged in the 1980s.

Advocates for preventing and treating addictions now can learn from this victory. We should work hard to help our tribal nations with only temporary smoking restrictions to make them permanent.

Traditional healers have taken care to explain and preserve the crucial distinction between ceremonial tobacco, which has historically been used in both spiritual and cultural settings, and commercial tobacco products, whose only purpose is pursuit of the almighty dollar. This distinction has been blurred over many years, to the great detriment of American Indian health and well-being.

Federal policies enacted in the 1800s banned American Indians' cultural and religious practices, curtailing the ritual use of traditional plants like tobacco. Another blow to tradition came from the tobacco industry in the misappropriation of Native American Indian culture on commercial tobacco packaging, which began in 1904.

More recently, the commercial tobacco industry has targeted American Indians with their poison by offering price reductions, bingo and casino promotions, and other gimmicks to entice consumers.

Commercial products are far different from the plants used in religious rites -- into American Indian communities—but American Indian iconography and imagery have been used to sell cigars, cigarettes, chewing tobacco and a false history in which Indian culture and nicotine were indelibly linked.

It has taken a lot of effort and education to turn that story around. Casinos worried going smoke-free would cost them customers and precious revenue, but for a number of casinos across the nation, revenue has increased despite smoking bans being in place. The bans do not seem to deter gamblers.

What's more, American Indian communities which used commercial tobacco sometimes conflated tradition with addiction. Public health advocates had their hands full fighting against a range of scourges -- not just commercial tobacco but also other addictive drugs -- and for essentials sorely lacking on reservations, like clean water and air, with little money or support.

Then, two years ago, Covid-19 hit and casino profits plunged. Advocates used the opportunity to present options to industry executives. Many of the casinos reopened with new policies designed to allow customers to breathe easier and not get sick. They included previously unheard-of smoking restrictions. It's hard to smoke with a mask on. But much to everyone's surprise, it seems going smoke-free could be good for business, evidenced by soaring profits in other smoke-free casinos.

Covid and smoking are parallel disasters. The pandemic has killed more than 950,000 people in the United States in the last two years. Use of commercial tobacco products kills about 500,000 people a year.

Many deaths result from illness laid atop injustice. Indian reservations and other communities of color have long been afflicted by poverty, ill health and inadequate health care. For generations, they have also been targets of the tobacco industry's aggressive, predatory marketing. It's no wonder they suffer disproportionately from lung and heart disease, diabetes, lung cancer and other conditions linked to tobacco use.

The industry's deadly products create many opportunities for an opportunistic virus to sweep in and cut down those whom tobacco has left vulnerable.

These are the challenges confronting those trying to improve public health in Indian country. Commercial tobacco is a powerfully addictive drug, and Covid-19 is ruthless, posing a great risk to smokers.

Saving lives often starts with getting people to break their smoking addiction. This can be difficult, but here is the good news: Smokers can free themselves, through proven interventions like counseling, peer and family outreach, and medications like nicotine gum, patches and other pharmacotherapies. Telephone quit lines can double their chances of success.

And yet, on Tribal reservations, where many homes lack electricity and running water, calling a quit line or attending a smoking cessation webinar are not always realistic options for smokers.

But smoke-free casinos are feasible and do not appear to dissuade gamblers. And American Indians seeking to quit may benefit from the role of traditional healers and techniques like mindfulness practices, which were facts of American Indian life centuries before "mindfulness" became a contemporary buzzword. And, as Dr. Nez Henderson has often said, American Indians can decolonize tobacco in every setting.

American Indians themselves can debunk the notion that commercial tobacco is somehow an integral part of Indigenous culture. It's not. The casinos are a fine place to start, but this isn't over. We are continuing to fight to change the system to deliver health equity, and we need help with basic resources to make cessation possible as we continue the decolonization struggle. The sooner commercial tobacco addiction begins disappearing from Indian country, the better we are as tribal nations.