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Patients tobacco use status was gathered from electronic medical records, their utilization of services from a TDTS registry, and hospitalization charges from a statewide dataset

Per CDC and NIH/PMC, the tobacco wrap is the defining distinction

In the Karok economy, smoking was not practiced for pleasure but always for some definite end: as a part of the days routine, or as a rite prescribed by the tribal customs. During my field trips with school children, one will invariably ask, How can you smoke this tree tobacco if eating it will kill you? I tell them that eating the plant kills you within a few hours, whereas smoking it kills you slowly