Different Types Of Smokers Research Articles

Effect of different types of smoking on oral health and on cellular changes in oral mucosa

ObjectivesSmoking is known to be a major risk factor for several diseases. Recently, electronic cigarettes have been introduced to the market; however, their effect on oral health has not been well studied yet. We aim to compare the effect of different types of smoking on oral health and to evaluate cytomorphological changes in oral mucosa among different types of smokers. Study designA total of 112 participants were recruited, conventional cigarette smokers (n = 28), electronic cigarettes smokers (n = 26), hookah smokers (n = 29) and non-smokers (n = 29). Oral examination, brush cytology and salivary flow test were performed. Cytological smears were stained and examined for cytomorphological changes. Oral symptoms, type, and frequency of smoking were obtained through questionnaires. SPSS program was used for statistical analysis. ResultsMost of the oral symptoms reported in this study were among conventional and electronic cigarettes smokers. While hookah smokers reported the least oral symptoms. Increase in DMFT and gingival index were observed among all smokers, mainly among conventional cigarettes smokers. Conventional cigarette and hookah smokers were found to have the most significant cellular changes. Electronic cigarette smokers had certain cellular changes as well. ConclusionAll types of smoking adversely affect oral health and can induce cellular changes in the oral mucosa.

Nicotine dependence and intention to quit among electronic, conventional and dual cigarette users in Karachi.

To compare nicotine dependence and intention to quit among different types of smokers. The comparative cross-sectional study was conducted from November 2018 to October 2019 in Karachi after approval from the ethics review committee of the Jinnah Sindh Medical University, and comprised conventional, electronic and dual cigarette users. Data was collected using a structured questionnaire regarding socio-demographics, usage characteristics, and intention to quit. The validated Hooked on Nicotine Checklist was also used. Data was analysed using SPSS 22. Of the 246 subjects, 82(33%) were conventional cigarette users with a mean age of 27.41±8.7 years, 82(33.3%) were electronic cigarette users having mean age of 30.37±9.16 years, and 82(33.3%) were dual cigarette users with a mean age of 28.89±9.07 years. The use of electronic cigarette was more in people with higher age (p=0.01), married (p=0.001) and having higher income (p=0.05). Compared to conventional cigarette users, electronic cigarette users showed lower odds of high nicotine dependence (odds ratio: 0.38, 95% confidence interval: 0.18-0.80). No significant difference was observed in intention to quit among different types of cigarette users (p>0.05). Electronic cigarettes users were comparatively less nicotine-dependent compared to the users of other types of cigarettes. Electronic cigarettes should only be recommended to conventional users with the intention to quit.

Comparing of the effects of perceived injunctive and descriptive norms on the willingness to quit smoking among Chinese low‐rate and regular smokers

Although social norms play a significant role on smoking cessation, the different impacts of injunctive and descriptive norms on the willingness to quit smoking among different types of smokers and underlying mechanisms are relatively little known. The current study aimed to investigate the influence of injunctive and descriptive norms on willingness to quit, respectively, for Chinese low‐rate and regular smokers and to examine the mediated effects of the decisional balance of smoking. For this study, 132 Chinese low‐rate smokers and 208 regular smokers completed questionnaires that assessed injunctive norms, descriptive norms, the decisional balance of smoking, and the willingness to quit smoking. The results showed that the stronger willingness to quit was associated with stronger injunctive norms among low‐rate smokers and was associated with stronger descriptive norms among regular smokers. Decisional balance of smoking mediated the relationship between injunctive norms and the willingness to quit among low‐rate smokers, but not among regular smokers. These findings highlight the importance of different functions of injunctive and descriptive norms for different types of smokers, and deepen the understanding of the role of decisional balance of smoking on the relationship between the different types of social norms and willingness to quit, respectively, among low‐rate and regular smokers.

Environmental tobacco smoke exposure among electronic cigarette users

IntroductionExposure to environmental tobacco smoke (ETS) from combustible tobacco products causes various diseases and makes quitting smoking more difficult. However, little is known about exposure of e-cigarette users to ETS from combustible tobacco products. This study aimed to investigate e-cigarette users' exposure to ETS from tobacco smokers. MethodsThe association between ETS exposure frequency and different types of smokers including e-cigarette users was examined using ordered logistic regression analysis and nationally representative survey data on 28,765 individuals who were interviewed in the Canadian Tobacco, Alcohol and Drugs Surveys conducted during 2013 and 2015. Survey respondents were classified into one of five smoker types: smokers of tobacco only, dual users of tobacco and e-cigarettes, users of e-cigarette only, former smokers and never smokers. The analyses were conducted using the entire sample and by age group. ResultsYoung to mid-age (15–54) dual users of both regular cigarettes and e-cigarettes have higher ETS exposure than even tobacco smokers. Young to mid-age single users of e-cigarettes are less exposed to ETS than tobacco smokers, but still have higher ETS than never smokers. At older age (55+), both dual and single e-cigarette users face similar risks of ETS exposure as tobacco smokers. ConclusionsE-cigarette users are at high risk of ETS exposure. Policies that target the behaviour of e-cigarette users as well as the environments surrounding them to address their high ETS exposure risk would be beneficial.

Identification of three different types of smokers who are not motivated to quit: Results from a latent class analysis.

The majority of smokers are not motivated to quit within 30 days. We examined whether these smokers are a homogeneous group, hypothesizing that subtypes of unmotivated smokers could be identified. Included were 500 smokers not ready to quit within 30 days who completed an online survey assessing variables known to be associated with quitting. Latent Class Analysis revealed 3 unmotivated smoker subtypes. "Health-Concerned Smokers," (HCS; n = 166) had a significantly greater proportion of previous smoking-related illness and high risk perceptions. "Smokers with Psychosocial Barriers" (SPB; n = 192) had a significantly greater proportion of younger smokers, partners who smoked, other household smokers, and children. "Unconvinced Smokers" (UCS; n = 142) had the lowest proportion of those who: were motivated and confident to quit, had smoking-related illnesses, and perceived the risks of smoking and benefits of quitting. UCS had the highest proportion with optimistic bias, and no prior quit attempts. A greater proportion of HCS had high motivation to quit versus SPB and UCS. In model validation, 60.6% of UCS said they "never plan to quit" versus 31.8% of SPB and 22.3% of HCS; SPB and HCS had lower odds of never planning to quit versus UCS. Of those who plan on quitting at some point, 75.2% of HCS and 62.6% of SPB plan on quitting within 1 year, versus 46.4% of UCS; the cumulative odds of planning to quit later were higher among UCS. Smokers who are not motivated to quit are not a homogeneous group; tailored intervention approaches and targeted messages might be needed to motivate quitting. (PsycINFO Database Record

To Be Or Not to Be: the “Smoker’s Paradox” – An in-Vitro Study

Background/Aims: Clinical studies have reported a better outcome of smokers after myocardial infarction compared to non-smokers. The data are controversial, as some clinical studies did not observe this effect. The cell biological processes involved, which might account for a ‘Smoker’s Paradox’, have not been investigated yet. Therefore, the aim was to elucidate the effect of cigarette smoke on the viability of cardiomyocytes in the context of hypoxia and reperfusion. Methods: HL-1 cells were incubated with different concentrations of cigarette smoke extract (CSE) and subjected to hypoxia/reperfusion to further evaluate influence of CSE on viability of HL-1 cells using flow cytometry analyses, Western Blot and immunofluorescence staining. Results: Incubation with CSE led to a concentration-dependent reduction in HL-1 viability. Adding hypoxia as a stressor enhanced cell death. Caspase-independent apoptosis was the observed type of cell death partly induced by P53 and apoptosis-inducing-factor. Yet a significant increase in LDH release in cardiomyocytes incubated with 4%, 8% and 16% CSE suggests necrosis with rapid DNA depletion. Interestingly, after hypoxia a decreased LDH release under lower CSE concentrations was observed. Moreover, a concentration-dependent increase in proliferation and a trend for increased ATP availability under hypoxic conditions was shown. Conclusions: The trend for less LDH release in hypoxia after low-level CSE incubation might represent a switch from necrosis to apoptosis, which in combination with the increase in metabolic activity and ATP availability might account for the ‘Smoker’s Paradox’. These findings could partly explain inconsistent results of previous clinical studies as the data showed strong evidence for the crucial relevance of the amount of cigarettes smoked. We are in need of future studies distinguishing between different types of smokers to finally verify or falsify the ‘Smoker’s Paradox’.

The impact of public smoking bans on well-being externalities: Evidence from a policy experiment

Recent studies on the effects of anti-smoking policies on subjective well-being present mixed results and do not account for potential externalities, especially among couples. We contribute to the literature by evaluating the impact of smoking bans on well-being externalities among smokers and non-smokers as well as couples of different types of smokers. We exploit the policy experiment provided by the timing of the UK public smoking bans and measure well-being via the GHQ. We employ matching techniques combined with flexible difference-in-differences fixed effects panel data models on data from the British Household Panel Survey. The joint use of matching methods with fixed effects specifications allows building more comparable treatment and control groups, producing less model-dependent results and accounting for individual-level unobserved heterogeneity. We find that public smoking bans appear to have a statistically significant short-term positive impact on the well-being of married individuals, especially among women with dependent children. These effects appear to be robust to alternative specifications and placebo tests and are discussed in the light of the economic theory and recent evidence.

Offering smoking treatment to primary care patients in two Wisconsin healthcare systems: Who chooses smoking reduction versus cessation?

Smokers unwilling to make a quit attempt can still benefit from smoking intervention. However, it is unclear what proportion of smokers will enter such a Motivation phase intervention, and whether such an intervention attracts different types of smokers than does abstinence oriented treatment. We conducted a study from June 2010 to October 2013 based on a chronic care model of tobacco treatment among study eligible primary care patients (N=1579; 58% women, 89% White) presenting for regular health care visits in southern Wisconsin, U.S. Medical assistants, prompted via the electronic health record (EHR), invited smokers (n=10,242) to learn more about treatment options to help them either reduce their smoking or quit. Of those invited to learn more who were then reached by study staff, 10.2% (n=1046) reported interest in reduction treatment and 24% (n=2465) reported interest in cessation treatment. Patients who selected and ultimately entered reduction (n=492) versus cessation (n=1087) were more likely to report: older age; a history of anxiety; lower motivation to quit; lower primary dependence motives; more close friends or family who smoke; and a greater interval since their last quit attempt. Results suggest that Motivation phase treatment aimed at smoking reduction may increase the proportion and range of smokers inducted into tobacco treatment.

Beyond experimentation: Five trajectories of cigarette smoking in a longitudinal sample of youth.

The first goal of this study was to identify the most appropriate measure of cigarette smoking for identifying unique smoking trajectories among adolescents; the second goal was to describe the resulting trajectories and their characteristics. Using 15 annual waves of smoking data in the National Longitudinal Survey of Youth 1997 (NLSY97), we conducted an exploratory latent class growth analysis to determine the best of four outcome variables for yearly smoking (cigarettes per day on days smoked, days smoked per month, mean cigarettes per day, and total cigarettes per month) among individuals aged 12 to 30 (n = 8,791). Days smoked per month was the best outcome variable for identifying unique longitudinal trajectories of smoking and characteristics of these trajectories that could be used to target different types of smokers for prevention and cessation. Objective statistics were used to identify four trajectories in addition to never smokers (34.1%): experimenters (13.6%), quitters (8.1%), early established smokers (39.0%), and late escalators (5.2%). We identified a quitter and late escalator class not identified in the only other comparable latent class growth analysis. Logistic regressions were used to identify the characteristics of individuals in each trajectory. Compared with never smokers, all trajectories except late escalators were less likely to be black; experimenters were more likely to be out of school and unemployed and drink alcohol in adolescence; quitters were more likely to have a mother with a high school degree/GED or higher (versus none) and to use substances in adolescence and less likely to have ever married as a young adult; early established smokers were more likely to have a mother with a high school diploma or GED, be out of school and unemployed, not live with both parents, have used substances, be depressed, and have peers who smoked in adolescence and to have children as young adults and less likely to be Hispanic and to have ever married as young adults; and late escalators were more likely to be Hispanic, drink alcohol, and break rules in adolescence and less likely to have ever married as young adults. Because of the number of waves of data analyzed, this analysis provided a clearer temporal depiction of smoking behavior and more easily distinguishable smoking trajectories than previous analyses. Tobacco control interventions need to move beyond youth-focused approaches to reach all smokers.

Does Methamphetamine Abuse Affect Serotonin Signaling in the Maternal-Placental-Fetal System?

Although methamphetamine (METH) is the most commonly abused drug during pregnancy, there is surprisingly little data on METH effects on gestational tissues. This study, building on our recent research describing the effects of METH on antioxidant status and catecholamine signaling in gestational tissues, assesses serotonin levels in the umbilical cord during pregnancy and effects of demographics and neonatal variables. We hypothesized that METH ingestion and/or smoking may alter serotonin signaling in the umbilical cord. Umbilical cords (n = 85) were collected, processed to total lysates and standardized to 2 mg/mL protein. Serotonin levels were determined by ELISA then correlated to different demographic and pregnancy variables, antioxidant and catecholamine levels then the effects of METH and/or smoking determined. Levels of serotonin in umbilical cords were not significantly different between METH users nor smokers and control cords. Additionally, there were no significant correlations with delivery type, parity, gravidity neonatal baby weight, or maternal age. Serotonin levels were positively correlated with maternal diabetes (P=0.04) and negatively correlated with Gestational age (P = 0.05, r = 0.2310) and placental weight (P = 0.04, r = -0.3527). Serotonin levels may also be affected by maternal hypertension (P = 0.06) as well as preeclampsia (P = 0.08). While umbilical serotonin was not related to levels of noradrenaline and dopamine nor to the antioxidant enzymes glutathione-S-transferase, catalase, super-oxide dismuatse or xanthine oxidase levels; serotonin increased as thioredoxin reductase (TRX, P = 0.0003, r = 0.40) and glutathione peroxidase (GPx, P = 0. 01, r = 0.28) activities increased. A potential association between serotonin and with Vitamin C levels was also noted (P = 0.07, r = 0.2942). When stratified for METH and smoking, patients with diabetes showed that umbilical serotonin may be further lowered by smoking but not METH (P = 0.06 non smokers vs. smokers, P = 0.08 smokers vs. Meth+smokers). Furthermore, THC caused a significantly higher gravida (P = 0.01) than non-smokers. When stratified, smokers showed a significantly higher chance in getting pregnant than those that do not smoke (P=0.0002). Those that smoke in addition to THC, however, have a significantly lower chance of getting pregnant than those that only smoke (P=0.0173). THC also suggestively causes a lower neonatal baby weight (P = 0.02). Whilst THC did not show any significant differences in CAT levels with respect to different types of smokers, those who smoke THC have significantly higher levels of Vitamin C (P = 0.0383) ,a significantly lower level of GPx activity than those who do not smoke (P =0.05) and a significantly higher level fof noradrenaline (P = 0.02). Serotonin signaling in umbilical cords is affected by hypertension and diabetes as well as oxidative stress, which may itself be caused by the two clinical syndromes.

A Qualitative Study of Smoker Identity Among College Student Smokers

Background: This research was motivated by findings that college students who smoke cigarettes often self-categorize as nonsmokers, that is, they reject the social identity of “smoker.” Objectives: The goal of the present study was to shed light on college students’ smoker identities beyond the smoker/nonsmoker dichotomy. Methods: Focus groups were conducted to investigate how college students categorize their own smoking patterns and to identify what behaviors and attitudes are associated with these different categories of smoker identities. Forty-one students from a western university participated in this study in November 2011. Results: The focus group results indicated that there were five distinct smoker identities on campus. Light and regular smokers were the daily smoker identities present, while stress, social, and drunk smokers were the occasional smoker identities. Moreover, each of these smoker identities was defined by a unique pattern of smoking behavior, attitudes, and motives. Conclusions/Importance: These findings support the notion that there are different types of smokers, both daily and occasional, in the college population. We suggest that researchers, healthcare providers, and prevention/intervention programs may all benefit from distinguishing between these different types of smokers.

Amitifadine, a triple monoamine re-uptake inhibitor, reduces nicotine self-administration in female rats

A wider diversity of drug treatments to aid smoking cessation is needed to help tailor the most efficacious treatment for different types of smokers. This study was conducted to determine whether amitifadine, which inhibits re-uptake of dopamine, norepinephrine and serotonin, would decrease nicotine self-administration at doses that do not cause adverse side effects. Adult female Sprague–Dawley rats were trained to self-administer nicotine intravenous (IV) and were given acute doses of amitifadine in a repeated measures counterbalanced design. Effects of amitifadine on locomotor activity and food motivated responding were also evaluated. Chronic amitifadine effects were also examined. The 30mg/kg amitifadine dose significantly reduced nicotine self-administration. The 5 and 10mg/kg doses reduced nicotine self-administration during the first 15min of the session when the greatest amount of nicotine was self-administered. The 30mg/kg amitifadine dose, but not the lower doses caused a significant reduction in locomotor activity averaged over the one-hour session and reduced food motivated responding. The 10mg/kg dose caused hypoactivity at the beginning of the session, but 5mg/kg did not cause any hypoactivity. The effects of chronic amitifadine treatment (10mg/kg) over the course of 15 sessions was also determined. Amitifadine caused a significant reduction in nicotine self-administration, which was not seen to diminish over two consecutive weeks of treatment and a week after enforced abstinence. Amitifadine significantly reduced nicotine self-administration. This prompts further research to determine if amitifadine might be an effective treatment for smoking cessation.

Using motives for smoking to distinguish between different college student smoker typologies.

Relatively little is known about how to categorize different types of smokers, especially occasional smokers. Because of the prevalence of occasional smoking among college students, the current study aimed to gain an understanding of the different typologies of smokers on campus. To accomplish this, a latent class analysis (LCA) was conducted using 17 motives for smoking items (N = 327). The LCA revealed that four smoker groups were present: (1) addicted smokers who endorsed smoking due to pleasure and habit/addiction; (2) stress smokers, who endorsed smoking to relax, to reduce levels of stress, and to regulate mood; (3) social smokers, who endorsed smoking because of social factors such as to fit in or because friends smoke; and (4) nonendorsing smokers, who had a low endorsement for all the items. An additional LCA with covariates revealed that age of initiation, current smoking patterns, smoker self-classification, and quit likelihood differentiated these groups of smokers whereas current age and alcohol use did not. These typologies should be considered when designing interventions for occasional smokers.

Lung Cancer Screening With Low-Dose Computed Tomography After the National Lung Screening Trial. The Debate is Still Open

The aim of this article is to highlight some concerns regarding lung cancer screening with computed tomography (CT) through an analysis of scientific literature. The publication of the National Lung Screening Trial in 2011 has revealed that CT screening of smokers and ex-smokers in three annual rounds reduces lung cancer mortality a 20% when compared with thorax X-ray screening. The first limitation of this screening modality is its lack of downstaging in successive screening rounds compared with the initial round. Also, lung cancer screening with CT has a low positive predictive value, similar to the percentage of unnecessary surgeries performed in false positives. Another problem is that, at present, the burden of lung cancer overdiagnosis is not known. It is to be expected that if overdiagnosis occurs when thorax X-ray screening is used it will be greater when using CT. CT, even at low doses, exposes patients to high levels of radiation. Dealing with positive nodules entails an even higher radiation dose and the number of cancer cases induced by radiation in patients screened with CT is not known. Lastly, published studies on lung cancer CT screening are vastly heterogeneous. They include different age groups, different types of smokers and ex-smokers and different tomogram thickness, making the results hardly comparable. In this context we do not recommend lung cancer screening with CT for smokers or ex-smokers outside of the context of individual counseling.

Cribado de cáncer de pulmón con tomografía computarizada de baja dosis después del National Lung Screening Trial. El debate continúa abierto

The aim of this article is to highlight some concerns regarding lung cancer screening with CT through a thorough analysis of scientific literature. The publication of the National Lung Screening Trial in 2011 has revealed that CT screening of smokers and ex-smokers in three annual rounds reduces lung cancer mortality a 20% when compared with thorax x-ray screening. The first limitation of this screening modality is its lack of downstaging in successive screening rounds compared with the initial round. Also, lung cancer screening with CT has a low positive predictive value, similar to the percentage of unnecessary surgeries performed in false positives. Another problem is that, at present, the burden of lung cancer overdiagnosis is not known. It is to be expected that if overdiagnosis occurs when thorax x-ray screening is used it will be greater when using CT. CT, even at low doses, exposes patients to high levels of radiation. Dealing with positive nodules entails an even higher radiation dose and the number of cancer cases induced by radiation in patients screened with CT is not known. Lastly, published studies on lung cancer CT screening are vastly heterogeneous. They include different age groups, different types of smokers and ex-smokers and different tomogram thickness, making the results hardly comparable. In this context we do not recommend lung cancer screening with CT for smokers or ex-smokers outside of the context of individual counseling.

Retail tobacco distribution in Australia: Evidence for policy development

Despite a variety of long-standing tobacco control policies in most countries, smoking remains a source of considerable economic and health costs, resulting in ongoing discussion of potential policy changes. The contribution of retail tobacco distribution to prompting, facilitating and normalising smoking has received increasing attention, but the effect of retail outlets on tobacco consumption is relatively under-researched. In particular, there has been almost no empirical research on whether different retail outlets types have different effects on tobacco consumption by different types of smokers. This paper reports on two large studies examining the purchase behaviour of independent samples of smokers. The results provide the first evidence on the frequency of exposure of adult smokers to tobacco outlets, and show differences in tobacco purchase size across different retailers, and differences in the use of tobacco retailers by different smoker types. Implications for public health and tobacco control policy are discussed.

Marketing of menthol cigarettes and consumer perceptions

In order to more fully understand why individuals smoke menthol cigarettes, it is important to understand the perceptions held by youth and adults regarding menthol cigarettes. Perceptions are driven by many factors, and one factor that can be important is marketing. This review seeks to examine what role, if any, the marketing of menthol cigarettes plays in the formation of consumer perceptions of menthol cigarettes. The available literature suggests that menthol cigarettes may be perceived as safer choices than non-menthol cigarettes. Furthermore, there is significant overlap between menthol cigarette advertising campaigns and the perceptions of these products held by consumers. The marketing of menthol cigarettes has been higher in publications and venues whose target audiences are Blacks/African Americans. Finally, there appears to have been changes in cigarette menthol content over the past decade, which has been viewed by some researchers as an effort to attract different types of smokers.

D-cycloserine selectively decreases nicotine self-administration in rats with low baseline levels of response

Expanding the variety of treatments available to aid smoking cessation will allow the treatments to be customized to particular types of smokers. The key is to understand which subpopulations of smokers respond best to which treatment. This study used adult female Sprague–Dawley rats to evaluate the efficacy of d-cycloserine, a partial NMDA glutamate receptor agonist, in reducing nicotine self-administration. Rats were trained to self-administer nicotine (0.03mg/kg/infusion, IV) via operant lever response (FR1) with a secondary visual reinforcer. Two studies of d-cycloserine effects on nicotine self-administration were conducted: an acute dose–effect study (0, 10, 20 and 40mg/kg, sc) and a chronic study with 40mg/kg given before each test session for two weeks. Effects on rats with low or high pretreatment baseline levels of nicotine self-administration were assessed. In the acute study there was a significant interaction of d-cycloserine×baseline level of nicotine self-administration. In the low baseline group, 10mg/kg d-cycloserine significantly decreased nicotine self-administration. In the high baseline group, 40mg/kg significantly increased nicotine self-administration. In the repeated injection study, there was also a significant interaction of d-cycloserine×baseline level of nicotine self-administration. Chronic d-cycloserine significantly reduced nicotine self-administration selectively in rats with low baseline nicotine use, but was ineffective with the rats with higher levels of baseline nicotine self-administration. NMDA glutamate treatments may be particularly useful in helping lighter smokers successfully quit smoking, highlighting the need for diverse treatments for different types of smokers.

Latent class and mixture models' potential contributions to understanding connections between menthol and other cigarette smoking characteristics.

Latent class and mixture models' potential contributions to understanding connections between menthol and other cigarette smoking characteristics.

Do behavioral smoking reduction approaches reach more or different smokers? Two studies; similar answers

There is a need for innovative approaches capable of reaching smokers who would not otherwise participate in efforts to modify their smoking. This paper reports on two studies to determine whether a smoking reduction intervention would appeal to additional or different types of smokers than do cessation interventions. Study 1 attempted to contact 160 HMO smokers scheduled for outpatient surgeries. In Study 2, actual pilot reduction and cessation programs were offered to 531 smokers about to undergo out-patient surgeries or procedures. In Study 1, 39% of those eligible elected smoking reduction; and 38% selected cessation. In Study 2 of those eligible, 22% began participation in the smoking reduction program; 12% preferred a cessation approach; and 65% declined. There were few demographic or smoking history differences among those who elected smoking reduction, cessation, or declined. Among this understudied population, a sizable proportion in both studies agreed to participate in smoking reduction. If replicated, this suggests that comprehensive programs that include a smoking reduction component could substantially increase their reach.