INTRODUCTION American Indian adults have the highest smoking rate of any racial group in the nation. By the turn of the twenty-first century, smoking rates for the general adult population were reported to be 24 percent. Among adolescents in the United States, 34.8 percent of high school students reported they currently smoked in 1999. In comparison, American Indian adults report smoking rates ranging from 34 to 79 percent. American Indian youth smoking rates range as high as 50 percent, especially among Northern Plains states. Tobacco use, which includes smoking cigarettes, is the most preventable cause of death in the United States. To date, there is no clear explanation as to why American Indians have extremely high smoking rates. It is known, however, that approximately 90 percent of the general population began smoking in adolescence, most by age eighteen. The age of smoking initiation by American Indians is predicted to be somewhat younger, as young as twelve to sixteen years. Understanding the phenomenon of starting smoking— in terms of how individuals are introduced to cigarettes, influences of smoking initiation, and culture-bound attitudes that facilitated the smoking initiation—is an important step toward ameliorating the problem of smoking-induced health problems. METHODS The purpose of this study was to examine smoking initiation, smoking cessation, and tobacco-control policies among Plains Indian tribes. Seven tribes located in Minnesota, Nebraska, and South Dakota participated in the multi-reservation study from 2002 to 2003. Data presented in this article were collected during the focus-group phase.