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All of these occur simultaneously

It includes what is present in smoke, long term and short term effects, lung cancer, COPD, asthma, Nicotine, Carbon monoxide, affects on the blood system, including atherosclerosis, thrombosis, stroke, cardiovascular disease, finishing with evidence of disease linked to smoking

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Well, that's only one ceremonial use of tobacco in native american culture- it's also given as an offering to the gods, or as a gift to tribal leaders it's a crucial part of the purification rituals performed in a sweat lodge