Although our small sample of current dual users was more likely to experiment with, and begin regular use of, tobacco Ganetespib at an earlier age, current dual users showed lower dependence scores than users of cigarettes or ST alone. Other studies suggest that people who use both cigarettes and ST demonstrate higher nicotine exposure levels and find cessation even more difficult to achieve than those who use only ST or only smoke (Hatsukami & Severson, 1999; Spangler, Michielutte, Bell, Knick, Dignan, & Summerson, 2001; Wetter et al., 2002). In addition, some studies find that ST use is associated with the use of other tobacco products. In particular, adolescents who use ST are more likely to progress to cigarette smoking (Angstman, 2007).

Contributors to this dual use may be the high prevalence of ST use in general (even among women), varying high price of cigarettes sometimes as high as $10 per pack, depending on the village, and the common practice of disallowing smoking indoors at work or at home. The preferred choice of cigarette brands used by participants (Marlboro and Camel) matched national trends (McClave, Whitney, Thorne, Mariolis, Dube, & Engstrom, 2010; Substance Abuse and Mental Health Services Administration (SAMHSA), 2007). However, the prevalence of ��light�� (17%) and menthol (5%) cigarette use was substantially lower compared with the general population: 58% ��lights�� (Borland et al, 2004) and 34% menthol (SAMHSA, 2009).

It is unclear whether this pattern reflects differences in taste preferences or is a result of product availability in rural Alaska; in the 16 villages where recruitment took place stores carried light and menthol products, with similar pricing compared with other products. A notable number of tobacco users stated they wanted to quit tobacco use in the next 30 days: 28.9% of cigarette and dual users, 26.0% of ST and dual users, and 44.4% of iqmik and dual users. Most of the reasons for quitting focused on concern for the personal health or health of others, the pressure from family and friends, and the price of tobacco. Overall awareness of the health risks associated with tobacco use and exposure was high among NEAM participants; almost all participants acknowledged that no tobacco products are completely safe and tobacco products are all equally dangerous to use during pregnancy.

The majority of the participants did not perceive differences in harm across products, although fewer ST/iqmik tobacco users endorsed ST as safer. About 15% and 20% of ST and iqmik users, respectively, used these products rather than cigarettes because they believed they were safer. Indoor smoking bans at home and work were GSK-3 wide spread. Interestingly, 17% to 25% used ST or iqmik to prevent smoke exposure to children. These findings point out the importance of continuing to educate the population about the hazards of tobacco use on health.