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The tobacco and bettle nut combination burns mucosa and soft tissue which leads to ulcerations

"Some only assessed whether a person had ever tried an e-cigarette or if they had tried one recently, not whether they were using it regularly or frequently," Bauld says

Dimensions: 2791 x 3972 px | 23.6 x 33.6 cm | 9.3 x 13.2 inches | 300dpi Date taken: 1 December 2017

Tribes are already very aware of the health and community impacts of commercial tobacco and have created campaigns, such as Keep It Sacred as a means of refocusing Native American tobacco use back to cultural tradition rather than deadly commercial tobacco use