Understanding American Indian tribal college student knowledge, attitudes, beliefs, and behaviors surrounding alternative tobacco products.

OBJECTIVES: To examine knowledge, attitudes, beliefs, and behaviors about alternative tobacco products among American Indian tribal college students. PARTICIPANTS: One hundred and five tribal college students. METHODS: Focus groups, one interview, and demographic surveys. RESULTS: Tobacco use varied across the sample with 35.2% of the participants being users of ENDS products and 29.5% were cigarette smokers. Overall, participants viewed electronic nicotine delivery systems and chewing tobacco as primary examples of alternative tobacco products and described a generational divide between alternative and conventional tobacco product use. Alternative tobacco products were not considered suitable for use in traditional contexts. CONCLUSIONS: Previously successful cessation programs in this population have relied on cultural tailoring related to traditional tobacco use in American Indian communities. Our findings suggest that this strategy may be less effective for addressing alternative tobacco use. Reliance on the importance of family relationships may prove more impactful in future programming.

A Frameshift Variant of GluN2A Identified in an Epilepsy Patient Results in NMDA Receptor Mistargeting.

N-methyl-D-aspartate receptors (NMDARs) are crucial for neuronal development and synaptic plasticity. Dysfunction of NMDARs is associated with multiple neurodevelopmental disorders, including epilepsy, autism spectrum disorder, and intellectual disability. Understanding the impact of genetic variants of NMDAR subunits can shed light on the mechanisms of disease. Here, we characterized the functional implications of a de novo mutation of the GluN2A subunit (P1199Rfs*32) resulting in the truncation of the C-terminal domain. The variant was identified in a male patient with epileptic encephalopathy, multiple seizure types, severe aphasia, and neurobehavioral changes. Given the known role of the CTD in NMDAR trafficking, we examined changes in receptor localization and abundance at the postsynaptic membrane using a combination of molecular assays in heterologous cells and rat primary neuronal cultures. We observed that the GluN2A P1199Rfs*32-containing receptors traffic efficiently to the postsynaptic membrane but have increased extra-synaptic expression relative to WT GluN2A-containing NMDARs. Using in silico predictions, we hypothesized that the mutant would lose all PDZ interactions, except for the recycling protein Scribble1. Indeed, we observed impaired binding to the scaffolding protein postsynaptic protein-95 (PSD-95); however, we found the mutant interacts with Scribble1, which facilitates the recycling of both the mutant and the WT GluN2A. Finally, we found that neurons expressing GluN2A P1199Rfs*32 have fewer synapses and decreased spine density, indicating compromised synaptic transmission in these neurons. Overall, our data show that GluN2A P1199Rfs*32 is a loss-of-function variant with altered membrane localization in neurons and provide mechanistic insight into disease etiology.

Leveraging National Data and Regional Innovations to Right-Size Tobacco Treatment Policy for Behavioral Health in a Midwestern State.

BACKGROUND: People with mental health (MH) and substance use disorders (SUD) have high rates of tobacco use and tobacco-related mortality. They want to stop smoking and studies have shown they can quit, but few behavioral health facilities provide tobacco treatment. The purpose of this paper is to describe how a midwestern statewide behavioral health collaboration used regional data to pinpoint strengths and weaknesses in tobacco treatment trends, identified policies in neighboring states that were associated with high rates of tobacco treatment, and worked with state leaders to implement these policies to enhance treatment. METHODS: We used publicly available data from 2 SAMHSA annual national surveys of MH/SUD facilities to describe tobacco treatment services and policies in behavioral health facilities in Kansas and 3 neighboring states (Missouri, Nebraska and Oklahoma). We interviewed neighboring state leaders to identify policies they had implemented to boost tobacco recovery services in behavioral health. We collaborated with our state behavioral health agency to encourage adoption of similar policies. RESULTS: Using 7 years of survey data (2014-2020), rates for screening, counseling, and medications for tobacco dependence were highest in Oklahoma and Missouri facilities. Oklahoma had the highest percentages of facilities reporting smoke-free campuses. In all states, rates of tobacco service provision and smoke-free campuses were lower among SUD facilities than in MH facilities. State leaders associated several policies with high performance, including (a) requiring programs contracting with the state to conduct screening, provide counseling, and adopt smoke-free campuses (Oklahoma and Missouri); (b) state-based collection of tobacco treatment service provision data (Oklahoma); (c) providing facilities with free NRT for clients (Oklahoma); (d) setting benchmarks for service provision (Oklahoma); (e) comprehensive Medicaid coverage of cessation medications (Missouri). Upon review of these findings, Kansas behavioral health officials adopted a 2-year process to implement similar policies and are integrating tobacco treatment requirements into the state Certified Community Behavioral Health Clinic program. CONCLUSIONS: Summarizing and sharing freely-available data across states laid the groundwork for cross-border networking and policy change. State and federal agencies should integrate these policies into contracts and block grants to reduce tobacco-related disparities among individuals with behavioral health conditions.

Using Bayesian hierarchical models for controlled post hoc subgroup analysis of clinical trials: application to smoking cessation treatment in American Indians and Alaska Natives.

Clinical trials powered to detect subgroup effects provide the most reliable data on heterogeneity of treatment effect among different subpopulations. However, pre-specified subgroup analysis is not always practical and post hoc analysis results should be examined cautiously. Bayesian hierarchical modelling provides grounds for defining a controlled post hoc analysis plan that is developed after seeing outcome data for the population but before unblinding the outcome by subgroup. Using simulation based on the results from a tobacco cessation clinical trial conducted among the general population, we defined an analysis plan to assess treatment effect among American Indians and Alaska Natives (AI/AN) enrolled in the study. Patients were randomized into two arms using Bayesian adaptive design. For the opt-in arm, clinicians offered a cessation treatment plan after verifying that a patient was ready to quit. For the opt-out arm, clinicians provided all participants with free cessation medications and referred them to a Quitline. The study was powered to test a hypothesis of significantly higher quit rates for the opt-out arm at one-month post randomization. Overall, one-month abstinence rates were 15.9% and 21.5% (opt-in and opt-out arm, respectively). For AI/AN, one-month abstinence rates were 10.2% and 22.0% (opt-in and opt-out arm, respectively). The posterior probability that the abstinence rate in the treatment arm is higher is 0.96, indicating that AI/AN demonstrate response to treatment at almost the same probability as the whole population.

Everyday discrimination for American Indian tribal college students enrolled in the Internet All Nations Breath of Life program.

OBJECTIVE: Identify factors associated with perceived discrimination, including depression, body image satisfaction, body mass index (BMI), social support, stress, and self-reported social status. PARTICIPANTS: A total of 249 American Indian tribal college students. METHODS: Students were recruited for an Internet-based smoking cessation program. A total of 249 students answered the Everyday Discrimination Scale questions to assess perceived discrimination. We conducted bivariate analyses to determine potential significant associations between perceived discrimination and health outcomes at baseline. RESULTS: We found 63% of the sample reported racial discrimination. Among those who reported moderate/severe depression, 87% reported discrimination. Among those who were not satisfied with their body image, 70% reported racial discrimination. CONCLUSION: Reports of racial discrimination are highly prevalent among our participants. We found reports of discrimination are significantly associated with depression and dissatisfaction with body image. Our study highlights a high priority population that perceives racial discrimination, potentially increasing their risk for adverse health outcomes.

Warm ischemia time length during on-clamp partial nephrectomy: does it really matter?

BACKGROUND: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT>30 min on the long-term renal function following on-clamp partial nephrectomy (PN). METHODS: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year follow-up, and preoperative eGFR≥60 mL/min/1.73m2. Patients were divided into two groups according to WIT length: group I "WIT≤30 min" and group II "WIT>30 min." A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages. RESULTS: The primary cohort consisted of 3526 patients: group I (N.=2868) and group II (N.=658). After matching the final cohort consisted of 344 patients in each group. At last follow-up, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group I vs. 87% in group II, P=0.638) and (-10 in group I vs. -11 in group II, P=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group I vs. 81% in group II, log-rank, P=0.763) and the matched groups (78.8% in group I vs. 76.3% in group II, log-rank, P=0.905). Univariable Cox regression analysis showed that WIT>30 min was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, P=0.764) nor upgrading into CKD stage ≥III (HR:0.972, 95%CI 0.805-1.173, P=0.764). Retrospective design is a limitation of our study. CONCLUSIONS: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR≥60 mL/min/1.73m2.

Pilot Testing All Nations Snuff Out Smokeless (ANSOS): A Culturally Tailored Smokeless Tobacco Cessation Program for American Indians.

American Indians have the highest rates of smokeless tobacco (SLT) use of any racial/ethnic group in the United States, yet no proven effective cessation programs exist for them. Because tobacco is a sacred plant to many American Indians, cessation programs must not portray it in a completely negative manner. Based on our successful All Nations Breath of Life smoking cessation program, we developed and pilot-tested the All Nations Snuff Out Smokeless (ANSOS) program. Of 48 participants who began the program, 33 completed to six months (68.8% retention rate). Among participants who completed the program, 11 (34%) self-reported abstinence. When those lost to follow-up are considered current users, the cessation rate is 22.9%. An additional 14 individuals reported decreasing use (29.2% of all participants), with an average of 3.4 days per week decrease. All Nations Snuff Out Smokeless shows promise as a culturally appropriate SLT cessation program and is ready for efficacy testing.

The medical student's guide to pathology residency, fellowships, and careers.

Recent studies have shown that relatively few MD, DO, and underrepresented in medicine (URM) students and physicians are matching into pathology residency in the United States (US). In the 2021 Main Residency Match, just 33.6% of filled pathology residency positions were taken by senior year students at US allopathic medical schools. This has been attributed to the fact that pathology is not a required rotation in most US medical schools, pathology is often taught in an integrated curriculum in the US where is does not stand out as a distinct field, and because the COVID-19 pandemic led to a suspension of in-person pathology rotations and electives. Ultimately, many US medical students fail to consider pathology as a career pathway. The objective of this article is to provide medical students with basic information, in the form of frequently asked questions (FAQs), about pathology training and career opportunities. This was accomplished by forming a team of MD and DO pathology attendings, pathology trainees, and a medical student from multiple institutions to create a pathology guide for medical students. This guide includes information about post-sophomore fellowships, 5 major pathology residency tracks, more than 20 fellowship pathways, and allopathic and osteopathic board examinations. This guide also contains photographs and descriptions of major pathology sub-specialties, including the daily and on-call duties and responsibilities of pathology residents. The exciting future of pathology is also discussed. This guide supports the agenda of the College of American Pathologists' (CAP) Pathologist Pipeline Initiative to improve student recruitment into pathology.

Deep Learning-Based Software Improves Clinicians' Detection Sensitivity of Aneurysms on Brain TOF-MRA.

BACKGROUND AND PURPOSE: The detection of cerebral aneurysms on MRA is a challenging task. Recent studies have used deep learning-based software for automated detection of aneurysms on MRA and have reported high performance. The purpose of this study was to evaluate the incremental value of using deep learning-based software for the detection of aneurysms on MRA by 2 radiologists, a neurosurgeon, and a neurologist. MATERIALS AND METHODS: TOF-MRA examinations of intracranial aneurysms were retrospectively extracted. Four physicians interpreted the MRA blindly. After a washout period, they interpreted MRA again using the software. Sensitivity and specificity per patient, sensitivity per lesion, and the number of false-positives per case were measured. Diagnostic performances, including subgroup analysis of lesions, were compared. Logistic regression with a generalized estimating equation was used. RESULTS: A total of 332 patients were evaluated; 135 patients had positive findings with 169 lesions. With software assistance, patient-based sensitivity was statistically improved after the washout period (73.5% versus 86.5%, P < .001). The neurosurgeon and neurologist showed a significant increase in patient-based sensitivity with software assistance (74.8% versus 85.2%, P = .03, and 56.3% versus 84.4%, P < .001, respectively), while the number of false-positive cases did not increase significantly (23 versus 30, P = .20, and 22 versus 24, P = .75, respectively). CONCLUSIONS: Software-aided reading showed significant incremental value in the sensitivity of clinicians in the detection of aneurysms on MRA without a significant increase in false-positive findings, especially for the neurosurgeon and neurologist. Software-aided reading showed equivocal value for the radiologist.

Engrailed 2 deficiency and chronic stress alter avoidance and motivation behaviors.

Autism spectrum disorder (ASD) is a pervasive neurodevelopmental disorder characterized by impairments in social interaction, cognition, and communication, as well as the presence of repetitive or stereotyped behaviors and interests. ASD is most often studied as a neurodevelopmental disease, but it is a lifelong disorder. Adults with ASD experience more stressful life events and greater perceived stress, and frequently have comorbid mood disorders such as anxiety and depression. It remains unclear whether adult exposure to chronic stress can exacerbate the behavioral and neurodevelopmental phenotypes associated with ASD. To address this issue, we first investigated whether adult male and female Engrailed-2 deficient (En2-KO, En2-/-) mice, which display behavioral disturbances in avoidance tasks and dysregulated monoaminergic neurotransmitter levels, also display impairments in instrumental behaviors associated with motivation, such as the progressive ratio task. We then exposed adult En2-KO mice to chronic environmental stress (CSDS, chronic social defeat stress), to determine if stress exacerbated the behavioral and neuroanatomical effects of En2 deletion. En2-/- mice showed impaired instrumental acquisition and significantly lower breakpoints in a progressive ratio test, demonstrating En2 deficiency decreases motivation to exert effort for reward. Furthermore, adult CSDS exposure increased avoidance behaviors in En2-KO mice. Interestingly, adult CSDS exposure also exacerbated the deleterious effects of En2 deficiency on forebrain-projecting monoaminergic fibers. Our findings thus suggest that adult exposure to stress may exacerbate behavioral and neuroanatomical phenotypes associated with developmental effects of genetic En2 deficiency.

Accident prevention activity and accident experience in the Republic of Korea military.

INTRODUCTION: According to data released by the Korea National Statistical Office, the number of accidents has been decreasing since 2012. However, a considerable number of deaths related to safety accidents (23-46 deaths) are still reported annually. This study aimed to observe the correlation between accident prevention activities in the Republic of Korea (ROK) military and the incidence of safety accidents. METHODS: The study used data from the 2014-2015 Military Health Survey and included 13 618 responses (Army: 8414 (61.8%); Navy/Marine: 2262 (16.6%); Air Force: 2942 (21.6%)) from the ROK military personnel. Accident experiences and thoughts on accident prevention activities were self-reported. Multiple logistic regression analysis was used to examine the validity of accident prevention activity and accident experience. RESULTS: Of the 13 618 military personnel who responded, 12.0% reported experiencing safety accidents in the military and 1020 (7.5%) felt that accident prevention activities in the military were insufficient. On logistic regression analysis, we found a significant difference (insufficiency OR=1.56, CI 1.31 to 1.86). In particular, military personnel who belong to the Army and Navy were more likely to think that accident prevention activities were insufficient. In addition, military personnel who experienced falls/slips, crash, and laceration/puncture wound/amputation/penetrating wound accidents were more likely to think accident prevention activities were insufficient. CONCLUSIONS: Our study found that accident prevention activities in the military and accident experiences were related. It is necessary for the ROK Ministry of Defense, Army, Navy and Air Force headquarters to re-evaluate their accident prevention systems.

Associations between earplug use and hearing loss in ROK military personnel.

INTRODUCTION: The easiest way to prevent noise-induced hearing loss (NIHL) is to wear earplugs. The Republic of Korea (ROK) Ministry of National Defense (MND) is supplying earplugs to prevent NIHL, but many patients still suffer from this. We speculated that earplugs would have a high NIHL rate, depending on the rate of use of earplugs, regardless of the rate of supply. Therefore, we conducted this study to investigate the relationship between the use of earplugs and hearing loss by ROK military personnel. METHODS: The study used data from the Military Health Survey conducted in 2014-2015, which included 13 470 questionnaires completed by ROK military personnel. Hearing loss and earplug use were self-reported. Logistic regression analysis was used to assess associations between earplug use and hearing loss. RESULTS: The study sample included 13 470 ROK military personnel (response rate of 71.2%) (Army, 8330 (61.8%); Navy/Marines, 2236 (16.6%); and Air Force, 2904 (21.6%)). Overall, 18.8% of Korean military personnel reported that they always wore earplugs, and 2.8% reported hearing loss. In logistic regression analysis, there were significant differences in the rates of hearing loss associated with wearing earplugs sometimes (OR=1.48, 95% CI 1.07 to 2.05) and never wearing earplugs (OR=1.53, 95% CI 1.12 to 2.10). In subgroup analysis, in Air Force, non-combat branch, forward area and long-term military service personnel increased hearing loss was associated with not wearing earplugs. CONCLUSION: Our study confirmed that within the ROK military, there is an association between hearing loss and lack of earplug use. In the ROK MND, Army, Navy/Marines and Air Force headquarters must provide guidelines for the use of earplugs during field training to protect military personnel's hearings and, if necessary, need to be regulated or institutionalised.

Cardiovascular Outcomes Associated With Adult Electronic Cigarette Use.

Electronic cigarettes (E-Cigs) have been advertised as a safer alternative to smoking. However, E-Cigs use, like smoking, delivers ultra-small aerosol particles, which may be associated with cardiovascular disease. This study aimed to look into the association between E-Cigs use and cardiovascular disease outcomes. The study involved self-reported data from 16,855 participants from the National Health Interview Survey data from years 2014, 2016, 2017, and 2018. Results from the logistic regression analysis report E-Cigs users had higher odds of having myocardial infarction (OR 4.09, 95% CI [1.29, 12.98], P<0.05) when compared to non-users. Dual users had higher odds of myocardial infarction (OR 5.44, 95% CI [2.90, 10.22], P<0.05), stroke (OR 2.32, 95% CI [1.44, 3.74], P<0.05), and coronary artery disease (OR 2.27, 95% CI [1.37, 2.44], P<0.05) when compared to non-users.

Bi-allelic mutations in EGR2 cause autosomal recessive demyelinating neuropathy by disrupting the EGR2-NAB complex.

BACKGROUND AND PURPOSE: Mutations in the early growth response 2 gene (EGR2) cause demyelinating, but also axonal, neuropathies differing in severity and age of onset. Except for one family, all reported cases have autosomal dominant inheritance and mutations are localized within the three zinc finger (ZNF) DNA-binding domain. The aim of this study was to provide a clinical and molecular analysis of a novel recessive mutation in EGR2. METHODS: Clinical and electrophysiological assessments of three affected patients, from a consanguineous family, were performed. Genetic analyses of EGR2 were carried out by Sanger sequencing. Functional effects of clinical recessive mutations were assessed using a mammalian two-hybrid assay. RESULTS: A novel missense mutation (c.791C>T; p.P264L) in the homozygous state was detected outside the ZNF domains of the EGR2 gene. Three affected siblings presented with distal demyelinating polyneuropathy with severe sensory loss, progressive thoracolumbar scoliosis and trigeminal neuralgia. Respiratory compromise and cranial nerve dysfunction were also found. Our data indicate that the p.P264L mutation prevents interaction of EGR2 transcription factor with NAB corepressors, suggesting that a disruption of the NAB-EGR2 protein interactions can result in dramatic neuropathy. CONCLUSION: Mutations in, or next to, the R1 domain of EGR2 should be considered with extreme caution for genetic counseling, since these could cause a severe neuropathy with an autosomal recessive manner of transmission.

Retzius-sparing robot-assisted radical prostatectomy versus open retropubic radical prostatectomy: a prospective comparative study with 19-month follow-up.

BACKGROUND: The aim of the present study was to compare the surgical outcomes of retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and open retropubic radical prostatectomy (ORP). METHODS: We included patients with clinically localized prostate cancer who underwent RS-RARP or ORP and met our inclusion criteria. We compared the perioperative, oncological, and continence outcomes between both surgical approaches. Continence function was assessed using the validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form. Continence was defined as using 0-1 safety pad per day. Biochemical recurrence (BCR) was defined as two consecutive rises in serum PSA more than 0.2 ng/mL. Events of local recurrence, distant metastasis, and cancer death were reported and compared using Kaplan-Meier survival analysis. RESULTS: Between 1 June 2013 and 1 October 1 2016, 184 men were enrolled, of whom 125 underwent RS-RARP and 59 underwent ORP. Baseline demographic and pathological characteristics were similar between both groups (P>0.05). Patients in RS-RARP group had significantly lower blood loss, fewer transfusion rates, lower VAS score, and shorter hospital stay than patients in ORP group (P<0.05). Major complications (≥grade 3b) did not differ between both groups (P=0.121). Positive surgical margins were 28.8% and 24.8% in ORP and RS-RARP, respectively (P=0.494). The BCR free-survival rates in ORP and RS-RARP at 1-year was 87.3% and 92.3%, respectively (Log-rank, P=0.740). At 1-, 6-, and 12-month after surgery, 42.4%, 79.7%, and 84.7% of men undergoing ORP were continent, compared with 72.8%, 90.4%, and 92% undergoing RS-RARP, respectively. Men in RS-RARP group achieved faster recovery of urinary continence compared to men in ORP group (Log-rank, P=0.001). CONCLUSIONS: RS-RARP had better perioperative outcomes and faster recovery of urinary continence compared with ORP. Short-term oncological outcomes were comparable between both surgical approaches.

A mortality analysis of septic shock, vasoplegic shock and cryptic shock classified by the third international consensus definitions (Sepsis-3).

INTRODUCTION: This study aimed to compare the 28-day mortality of patients with septic shock, defined by Sepsis-3 criteria and patients with vasoplegic or cryptic shock who are excluded from this new definition. OBJECTIVES: This retrospective observational study was performed using a tertiary emergency department's septic shock registry and investigated the records of patients managed between January 2010 and December 2015. In 2,138 total patients, 1004 (47.0%) had septic shock, 476 (22.2%) had vasoplegic shock and 655 (30.6%) had cryptic shock. RESULTS: There was significant variation in 28-day mortality among the three groups: 23.4% for septic shock, 8.8% for vasoplegic shock and 12.2% for cryptic shock (P < .001). In subgroup analysis of cryptic shock or septic shock according to lactate levels (2-3, 3-4 and >4 mmol/L), the mortality rate increased as lactate increased (cryptic shock: 9.5%, 14.8% and 18.0%; septic shock: 18.6%, 22.6% and 27.0%, respectively; P < .001). Multivariable analysis revealed odds ratios for mortality of 0.31 (95% CI 0.22-0.44; P < .001) for vasoplegic shock and 0.46 (95% CI 0.35-0.61; P < .001) for cryptic shock relative to septic shock. Survival curve analysis showed significant differences among patients with septic shock, vasoplegic shock and cryptic shock (Log rank test: P < .0001). CONCLUSION: The new septic shock definition may be useful for identifying high-risk patients requiring intensive care. However, cryptic shock-associated mortality increased to 18.0% as serum lactate increased, which suggests that some cryptic shock patients may also require intensive management.

Baseline characteristics of American Indian smokeless tobacco users participating in two pilot cessation studies.

American Indians have higher rates of smokeless tobacco (SLT) use than other racial/ethnic groups in the US, yet no efficacious cessation program exists for them. Because tobacco is a sacred plant to many American Indians, it is imperative that a program respect the scared nature of tobacco while encouraging quitting recreational use. All Nations Snuff Out Smokeless (ANSOS) was designed to help American Indian SLT users quit recreational tobacco use while still using it for traditional purposes. We pilot tested the ANSOS 6-month group-based counseling program (N = 48) and a shortened version consisting of a one-time education session (N = 80). Here, we discuss the tobacco characteristics of participants at baseline in both studies. Participants across studies were more likely to be male (74.2%) and have at least a college education (65%). Participants in the one-time education sessions were younger (age 35 vs age 39) and used SLT fewer days per week (4.9 vs 5.7). Two-thirds of those in the full program reported that they often substitute SLT in locations where smoking is not allowed compared to 26%. Participants in the education sessions were more likely to report daily use of traditional tobacco (20% versus 0%). Results suggest that dual use of SLT and cigarettes needs to be addressed, as does the use of SLT to circumvent public smoking rules. The role of traditional tobacco and its relationship to lower SLT use also warrants further investigation.