Hookah Smoking Research Articles

Determination of Uranium Concentration in Blood Samples of Cigarette and Hookah Smokers by Means of Track Radiography Detecting Daughter and Fission Products

Determination of Uranium Concentration in Blood Samples of Cigarette and Hookah Smokers by Means of Track Radiography Detecting Daughter and Fission Products

Influence of different types of tobacco smoking on seminal fluid parameters and sex hormones among males from the Gaza Strip

Background: Smoking is a global problem that negatively affects human health and fertility and the endocrine functions of the male reproductive system. Objectives: The present study aims to investigate the influence of the different types of tobacco smoking (cigarette, hookah, and electronic) on semen parameters and sex hormones in males from the Gaza Strip. Methods and Materials: A total of 206 samples were classified into 156 cases and 50 controls. The cases have been classified into three groups depending on the type of tobacco smoking (cigarette smoking "n=52", hookah "n=55", and electronic "n=49"). Semen samples were collected to investigate the semen parameters in smokers compared to non-smokers. Additionally, blood samples were also collected to assess the level of sex hormones (testosterone, follicular stimulating hormone (FSH), and luteinizing hormone (LH)). Results: A significant increase in FSH and LH levels has been found in smokers compared to non-smokers (P < 0.001), while a significant decrease in testosterone level has been observed in smokers’ men compared to non-smokers (P < 0.001). Significant variations have been shown in the sperm concentration (P < 0.001) and the percentages of sperm total motility (P < 0.001), active progressive motility (P < 0.001), slow progressive motility (P = 0.004), and immotile spermatozoa (P < 0.001) among the different tobacco smoking groups. Furthermore, significant variations have been found in the levels of testosterone, FSH, and LH among the different tobacco smoking groups (P < 0.001). The results showed significant positive correlations between sperm concentration, total motility, active progressive motility, slow progressive motility, and testosterone level (P < 0.001) in smokers. Conclusions: The different types of tobacco smoking have negative influences on semen parameters and the levels of testosterone, FSH, and LH of smokers in the Gaza Strip.

Changes in perceived harms of tobacco and cannabis and their correlations with use: A panel study of young adults 2014–2020

PurposePerceived harm is associated with substance use. Changes in product and policy landscapes may impact perceived harms of tobacco and cannabis. This study aimed to examine changes in young adults’ perceived harms of tobacco and cannabis and their associations with use behavior during a period including both before and after legalization of cannabis. MethodsWe conducted a panel survey of California Bay Area young adults (mean age = 23.5 years old, 64.4% female) in 2014 and 2019–2020. Participants (N = 306) reported past 30-day use and perceived harms of tobacco and cannabis at both waves. Perceived harms to health of cannabis and tobacco (cigarettes, e-cigarettes, hookah, smokeless tobacco, and secondhand tobacco smoke) were measured from 1-“Not at all harmful” to 7-“Extremely harmful.” Mixed-effects logistic regressions examined associations between perceived harms and use of tobacco and cannabis, controlling for demographics. ResultsParticipants perceived lower harm for cannabis than for tobacco products. Perceived harms of e-cigarettes, hookah, and smokeless tobacco significantly increased over time; while perceived harms of cigarettes, secondhand tobacco smoke, and cannabis did not change. Increased perceived harm of e-cigarettes was associated with lower odds of any tobacco use (OR = 0.72, 95%CI = 0.56, 0.92), and increased perceived harm of cannabis was associated with lower odds of any cannabis use (OR = 0.51, 95%CI = 0.42, 0.62). ConclusionsFindings suggest that perceived harms of e-cigarettes and cannabis play important roles in driving young adult use behaviors. Risk communication efforts that increase perceptions of health harms related to e-cigarettes and cannabis may decrease use of tobacco and cannabis among young people.

Self-assessment of hearing on hookah smokers

Previous studies have reported adverse effect of smoking on our health. Current study aimed to investigate ill effect of hookah smoking on hearing sensitivity, annoyance evaluation, hookah related attitude and knowledge about hearing loss among hookah smokers of village. A questionnaire of 10 questions related to aim and objectives of the study were administered on 146 men smokers participated in the current study. : The hazardous effect of hookah smoking on hearing and psychological health are well reflected in the present investigation. Lack of awareness regarding adverse effect of hookah smoking was observed in the present study.

Vaping and Hookah Use Among Medical Trainees: A Multinational Survey Study

The increased use of e-cigarettes and hookah among young consumers represents a public health concern. This study aimed to investigate the frequency and patterns of use of e-cigarettes and hookah among medical trainees. This cross-sectional multinational online survey included medical students, residents, and fellows in Brazil (BR), the United States (US), and India (IN) between October-2020 and November-2021. Information on sociodemographics, mental health, and e-cigarettes, hookah, tobacco, marijuana, and alcohol use were collected. Generalized structural equation models were used in 2022 to explore factors associated with current vaping and current hookah use (ongoing monthly/ weekly/ daily use). People reporting previous sporadic/ frequent use or those who never used/ only tried it once were the reference group. Overall, 7,526 participants were recruited (BR =3,093, US =3,067, IN =1,366). The frequency of current vaping was 20% (BR), 11% (US), and <1% (IN) and current hookah use was 10% (BR), 6% (US), and 1% (IN). Higher family income [OR 6.35(4.42-9.12)], smoking cigarettes [(OR 5.88(4.88-7.09)] and marijuana [(OR 2.8(2.35-3.34)], and binge drinking [(OR 3.03(2.56-3.59)] were associated with current vaping. The same was true for hookah use: higher family income [OR 2.69(1.75- 4.14)], smoking cigarettes [(OR 3.20(2.53-4.06)], marijuana [(OR 4.17(3.35-4.19)], and binge drinking [(OR 2.42(1.96-2.99)]. In conclusion, e-cigarettes and hookah were frequently used by Brazilian and American trainees, sharply contrasting with data from India. Cultural aspects and public health policies may explain differences among countries. Addressing the problems of hookah and e-cigarette smoking in this population is relevant to avoid the "renormalization" of smoking.

Predictive Factors of Stages of Change in Hookah Smoking Cessation Among Iranian Adults Based on the Transtheoretical Model.

Hookah, as a traditional method of smoking, is widely used in Iran, especially in Bushehr province. It is essential to identify the most important determinants of modifying hookah smoking behavior. This study aimed to investigate the predictors of the stages of change in quitting hookah smoking in 15-60-year-old individuals in Bushehr province, southern Iran, based on the transtheoretical model (TTM). This descriptive-analytical study was conducted on 1173 Hookah smokers in Bushehr province. The samples were selected by two-stage random sampling from 10 cities. Data were collected using a valid and reliable questionnaire consisting of 5 sections (demographic characteristics, stages of change, processes of change, decisional balance, and self-efficacy). Data were analyzed by R version.3.3.1 using analysis of variance and ordinal logistic regression at a significant level of 0.05. The data revealed 82% of the participants were in the preparatory phase (55.3% in pre-contemplation and 26.7% in contemplation stages). Marital status, family members smoking hookah, cigarette smoking, level of education, number of family members, number of quitting attempts, self-efficacy, self-reevaluation, counter-conditioning, reinforcement management, and stimulus control were predictors of quitting hookah smoking. Given that most study participants were in the inactive stages of quitting hookah smoking, it seems necessary to design and implement behavioral interventions based on the predictive TTM constructs in this population.

Appraisal and characterization of candida load isolated from the oral cavity of smokers

Cigarette smoking is regarded as a major global health risk, therefore the aim of this work was to investigate the association of oral Candida spp. as one of the etiological agents of denture stomatitis with smokers of cigarette, hookah (shisha), and electronic smoking, also a dose–response relationship between the duration of smoking and the probability of denture stomatitis between volunteers. Oral rinse samples were collected from 47 male volunteers including 34 smokers and 13 non-smokers, also data of volunteers were collected via a questionnaire forum. Patterns of smoking were shown that smokers using tobacco cigarettes 17 (36.2 %), electronic cigarettes 16 (34.04 %), and hookah smokers 8 (17.02 %). A comparison of smokers and non-smokers regarding effects on oral health showed significantly finding (P < 0.05) indicating that smoking affects oral health in all evaluated parameters (an oral mucosal abnormality, mouth ulcers, bad breath, and feeling of dry mouth). Out of 19Candidaisolates, 18 (94.7 %) were identified asCandida albicansand 1 (5.3 %) asCandida tropicalis. Among the volunteers who presented with oralCandida(19 volunteers), 17 (89.5%) were smokers, while non-smoker volunteers were 2 (10.5 %), so it can be concluded that smoking was a significant positive correlation to the presence ofCandidain the oral cavity. Five volunteers suffered from chronic diseases; 4 (8.5%) diabetes mellitus and 1 (2.1%) anemia as a systemic predisposing factor for oropharyngeal infection.Amphotericin and Nystatin had varying degrees of activity against isolatedCandidaisolates.

Central retinal vein occlusion in a young patient following hookah smoking

Central retinal vein occlusion in a young patient following hookah smoking

Prevalence and Determinants of Non-daily Smoking Among Iranian University Students: A Web-based Survey

Background and aims: Usually non-daily smokers do not consider themselves smokers, and they are at a higher level of health risks due to smoking compared to non-smokers. This study aimed to identify the prevalence of non-daily smoking (NDS) and its associated factors among university students. Methods: This cross-sectional web-based study was performed in Tabriz, Iran. A proportional random sample of 3666 students from all universities of Tabriz were recruited from July to August, 2019, and an online questionnaire was used to collect data. Predictors of NDS were investigated using a multiple logistic regression model. Results: A total of 15.7% and 7.8% of the students were daily and NDSs, respectively. Compared to the non-smokers, the NDSs were more likely to exhibit high-risk behaviors such as substance abuse (odd ratio [OR]=2.96; 95% CI: 2.12-4.13), alcohol drinking (OR=2.54; 95% CI: 1.78-3.62), hookah smoking experience (OR=9.30; 95% CI: 6.06-14.25), and regular hookah use (OR=24.22; 95% CI: 14.86-39.46). Compared to daily smokers, NDSs were more likely to be female gender (OR=0.16; 95% CI: 0.10-0.24), denial of being a smoker (OR=11.69; 95% CI: 6.86-19.91), not addicted to nicotine (OR=10.02; 95% CI: 4.21-23.85), and less likely to have an intention for quitting in recent months (OR=2.27; 95% CI: 1.28-4.04). Conclusion: Non-daily smokers do not consider themselves smokers and have no intention to quit smoking. They are more prone to present high-risk health behaviors. Health policymakers should pay more attention to NDSs while planning smoking cessation programs.

Evaluating the Effect of Smoking on COVID-19 Severity in Patients Admitted to Shahid Mohammadi Hospital in Bandar Abbas During 2021-2022

Background: The coronavirus disease 2019 (COVID-19) is a newborn virus that has become an emergency since December 2019. A severe form of this disease is accompanied by intensive care unit (ICU) admission and death. The COVID-19 pandemic is still occurring in several countries; however, few facts are available about the disease. Risk factors and protective factors of this disease are still unknown. We know that smoking is a risk factor for several respiratory infections. However, considering some previous studies and nicotine’s anti-inflammatory mechanism, a smoking paradox in COVID-19 still persists as an obscure issue. Thus, we decided to evaluate the association between smoking and COVID-19 disease. Materials and Methods: In this study, sampling was performed simply and randomly from all admitted COVID-19 patients in 2020-2021. This is a retrograde case-control study, and 92 COVID-19 patients with a history of smoking were enrolled in the case group, and 92 COVID-19 patients without any smoking history were selected for the control group. Data were collected through a checklist. In this checklist, information such as the patient’s age, gender, and medical condition was recorded. In the end, collected data were analyzed by SPSS software version 26.0. Results: In this study, we used a logistic regression test to indicate that smoking had a significant relationship with subsequent plasmapheresis (P=0.001). We also found a significant relationship between cigarette smoking and plasmapheresis (P&lt;0.001). Furthermore, old age and diabetes were related to ICU admission (P=0.001 and P&lt;0.000, respectively), and male gender and hypertension were related to plasmapheresis (P=0.007 and P=0.001, respectively). Moreover, only old age was related to mortality caused by COVID-19 infection (P=0.025). Conclusion: Considering the issue of the smoking paradox in COVID-19, the association between smoking and COVID-19 disease was evaluated in this study. it was found that smoking is related to the need for plasmapheresis and was not related to ICU admission or death. Cigarette smoking had the same association. It should be noted that plasmapheresis had no significant relation with ICU admission and death. Moreover, hookah smoking had no relationship with plasmapheresis, ICU admission, and death. This study also evaluated other factors such as age, gender, and medical conditions such as hypertension, diabetes, and cardiovascular disease and their effect on COVID-19. We found that only old age was related to mortality caused by COVID-19.

The prevalence of hookah smokers among Belarussian children and adolescents.

The purpose of this survey was to assess the prevalence of hookah smokers among children and adolescents aged 12-16 years in Belarus. This survey involved 3485 people, including 1737 girls and 1726 boys, and included 6 questions from the main questionnaire of the GYTS aimed at hookah consumption. The statistical processing was performed using the SUDAAN software package; a 95% confidence interval was calculated to calculate weighted prevalence estimates and standard errors. According to the GYTS carried out in the Republic of Belarus in 2021, hookah smoking is becoming increasingly popular. The number of adolescents who have ever smoked a hookah is 9.3%. The prevalence of regular hookah smokers is quite low (0.9%). But there are justified fears that teens who have never smoked cigarettes but have tried hookah are more likely to start smoking cigarettes and become regular cigarette smokers two years later.The frequency of hookah use naturally increases with age. The number of adolescents who have ever smoked a hookah among those aged 14, 15 and 16 years (10.7%, 11.7% and 18.2%, respectively), was higher than among students aged 12 years (5.5%) or 13 years (5.6%) (p<0.001); hookah smoking was higher among students in the 9th and 10th grades (13.0% and 14.2%, respectively), then among students in the 7th grade (5.1%) (p<0.001). This national survey provides the first data of prevalence of hookah smoking among children and adolescents in Belarus and allows us to conclude that the growing popularity of waterpipe tobacco smoking dictates the need for timely recommendations on waterpipe smoking policy.

The Impact of Hookah Smoking on AMH Levels in Women: A Pilot Study

Purpose: Hookah (water pipe) smoking, an ancient tobacco smoking method, is gaining widespread popularity worldwide. Although research in this field is still lacking, its harmful effect on human health through the increased risk of cardiovascular disease, infection, and cancer has been proven. Cigarette smoking has been found to have a detrimental effect on reproductive function. However, data about the effect of hookah smoking on human fertility or reproductive outcomes are scarce. In this study, we aimed to determine if smoking hookah has a harmful effect on the human ovarian reserve test, anti-Mullerian hormone levels, and cycle regularity. Materials and Methods: A total of 100 healthy non-cigarette smoking women in the 25-35 age range undergoing laboratory investigations were randomly chosen to participate. After obtaining consent, they completed a questionnaire about smoking habits and menstrual data. Blood samples were withdrawn for anti-Mullerian hormone testing. The anti-Mullerian hormone levels of 50 women hookahonly smokers were compared to 50 non-smoking women. Results: There were no significant differences in mean anti-Mullerian hormone levels and cycle regularity between hookah smokers and non-smokers. However, period pain was significantly associated with hookah smokers relative to non-smokers (p = 0.036). There was an inverse relationship between log10 anti-Mullerian hormone levels and log10 hookah smoking index. This correlation was significant as measured by Spearman’s rho test, and the correlation coefficient was -0.331 and p-value = 0.02. Moreover, binary logistic regression for cycle regularity showed that hookah smoking was associated with an increase in the likelihood of having an irregular cycle, but the effect was not significant (p = 0.514) for hookah smoking. Conclusion: Under the conditions of this study, no significant association between hookah smoking and neither AMH levels nor cycle regularity could be observed.

Evaluation of Risk Factors in Patients with Head and Neck Cancer: A Case Control Study.

Head and neck squamous cell carcinoma (HNSCC) is one of the most common types of cancer worldwide. Since there are many factors that influence the development of cancer, identifying risk factors plays an important role in cancer prevention. The aim of this study was therefore to identify the risk factors for HNSCC in Mashhad, Iran. In this case-control study, 76 patients with HNSCC were included as the case and 91 healthy people as the control group. A checklist of risk factors was completed for each participant and the two groups were compared for the presence of risk factors. Chi-square, t test, and Mann-Whitney tests were used to compare the data. Odds ratios (ORs) for several factors have also been determined. The educational level and body mass index (BMI) of the patients in the case group were significantly lower than in the control group (P<0.001). Moreover, there were significant differences between the two groups in terms of risk factors such as tobacco smoking, the number of cigarettes smoked per day, and its duration (P=0.001, P<0.001, P=0.05), as well as the duration of hookah smoking, opium consumed per day and use of alcohol (P=0.023, P<0.001, P=0.015). There was a direct relationship between HNSCC and risk factors such as cigarette smoking, number of cigarettes smoked per day, duration of cigarette consumption and hookah, opium consumed per day, and alcohol use. However, extensive studies with larger sample sizes are needed to better assess the impact of these factors and generalize the results.

Active and Passive Smoking in Adults Undergoing a Long-Term Multi-Setting Healthy Lifestyle Education: Tehran Lipid and Glucose Study.

We aimed to investigate the effects of a multi-setting lifestyle education on men's cigarette, hookah, and passive smoking, and women's passive smoking, in Iran. Data of Tehran Lipid and Glucose Study (TLGS) were used. TLGS started in 1999 with every-3-year follow-ups. Multi-stage cluster random sampling was used to recruit participants under the coverage of three health centers. One health center implemented multi-setting lifestyle education at school, family, and community setting. Our analytic sample for generalized estimating equation was restricted to 1322 and 3593 adults (respectively as intervention and control) who were followed for 15.8 years. Intervention reduced the odds of men's cigarette smoking by 27%. The estimated mean cigarettes/day was 1.58 lower in intervention men. The intervention reduced the odds of men's hookah use by 42% in short term. Intervention women had 33% lower odds of passive smoking. Lifestyle education with community outreach can help achieve pragmatic tobacco control goals.

Verification of radon, radium, polonium concentrations and lung cancer rates in blood of female hookah smokers

Abstract Hookah smoking has become very popular in Iraq among women and men. Hookah tobacco contains natural radioactive elements, such as radon, radium, and uranium, as well as toxic elements, such as polonium, which are released during the combustion of tobacco and are inhaled by smoking. Most reviews focus on hookah tobacco, and only a few have investigated the blood of hookah smokers. In this study, a CR-39 detector was used to measure radon, radium, and polonium concentrations and conduct risk assessments in female hookah smokers of different ages. The results show that the concentrations of radon-222, polonium-218, and polonium-214 varied between 61.62 and 384.80, 5.45–33.64 on the wall of the can, and 2.43–15.00 Bq/m3 on the surface of the detector, respectively. The effective radium-226 concentration varied between 4.52 and 56.31 Bq/kg. The absorbed effective dose varied between 1.55 and 9.71 mSv/y, which is within the recommended limit (3–10 mSv/y) by International Commission on Radiological Protection (ICRP). The average case of lung cancer 107.91 cppp, which exceeds the European Union (EU) limit (96.9–104.8 cppp). The rates of radon activity and radon exhalation from the intake of a natural radionuclide due to hookah smoking in a female’s blood were calculated and discussed. This study aimed to establish preliminary results on the risks of radioactivity concentrations and assess the dose in the blood of women who smoke hookah and assess the possibility of developing cancer.

Survey of the Relationship between Extroversion and Transition in Cigarette and Hookah Smoking Stages in High-School Students in Tabriz: A Longitudinal Study.

Smoking is a public health problem that affects the adolescent population's health. This study aimed to investigate the relationship between extroversion (compared with introversion) and transition in cigarette and hookah smoking stages in high-school students to use the results in smoking prevention programs. A sample of 2312 students aged 15-16 years in Tabriz were included in the study. Demographic characteristics, cigarette, hookah smoking status, and Eysenck's extroversion questionnaires were completed by all students in the selected schools. Eight months later, cigarette and hookah smoking status were assessed again to determine transition in smoking stages. The marginal homogeneity (MH) test was used to compare the smoking status at the beginning and 8 months later. The generalized estimating equation (GEE) method with the ordinal link was applied to estimate the effect of extroversion on transition in smoking stages. The mean (standard deviation) age of the students participating in the study was 15.5 (0.5) years. MH test results showed that, in general, transmission in the stages of both cigarette and hookah smoking in 8 months was significant in students (P-value < 0.0001). Extrovert personality had a significant positive effect on the transition from lower stages to higher cigarette and hookah smoking stages according to the GEE with ordinal link (P = 0.01). In cigarette and hookah smoking, extrovert persons transited to higher stages 1.64 and 1.55 times more than introvert persons. Being an extrovert person had a significant effect on the transitioning to higher stages of smoking cigarettes and hookah. In designing cognitive programs to prevent people from smoking or encourage them to quit smoking, considering this dimension of personality trait can be useful in the efficacy of the program.

Possible Harmful Effects of Smoking Hookah on Sperm DNA Fragmentation Index and Protamine Genes Expression in Normozoospermic Men

In recent years, smoking water pipes or hookah has increased among adolescents in most countries. Although there is evidence in support of the negative effects of this type of smoking on human health, such as the increased risk of lung disease, little is known about the potential effects of hookah smoking on the male reproductive system, especially on the molecular aspects of sperm. This cross-sectional study examined sperm DNA fragmentation index, protamine 1 and 2 (PRM1 and PRM2) genes expression, and oxidant status in normozoospermic hookah smokers in comparison with non-smoker controls. Our results showed significantly higher rates of DNA fragmentation, protamine deficiency, and abnormal chromatin condensation in the spermatozoa of hookah smokers (P < .0001). Also, protamine gene expression showed a remarkable decrease in hookah smokers (1.55 ± 2.54 and 0.33 ± 0.54) compared to the controls (3.49 ± 5.41 and 1.22 ± 1.96), although the reduction was not statistically significant (P = .155 and P = .066, respectively). Moreover, a significantly higher level of semen MDA was observed in the case group compared to the controls (0.39 ± 1.04 vs 0.15 ± 0.21; P = .013). According to our study, although hookah smoking does not have a significant effect on sperm parameters, it may have deleterious effects on DNA integrity, oxidative status, and nuclear protein levels of spermatozoa.

Hookah Smokers, Beware!! Severe Erythrocytosis noted in Hookah Smokers: A Case Series of 13 Patients

Hookah Smokers, Beware!! Severe Erythrocytosis noted in Hookah Smokers: A Case Series of 13 Patients

Prevalence and Epidemiological Characteristics Associated with Hookah Smoking and Alcohol Consumption among Medical Students in Najaf, Iraq

Background: Reporting patterns of hookah smoking (HS) and alcohol consumption (AC) in Iraq are limited. Objectives: This study aims to investigate the prevalence of HS and AC among medical undergraduates in Najaf, Iraq. Materials and Methods: A pilot-tested online self-administered questionnaire was used to conduct a descriptive cross-sectional study. The sampling followed the “snowball” technique. The associations of HS and AC with the participants’ characteristics, perceived risk of harm, motives, and consequences were tested. Results: The preceding month’s prevalence of HS and AC (at least once) was 13.8% and 2%, respectively. The age at initiation was mainly &lt;15 years (59.3% of smokers and 92.3% of drinkers). The presence of a friend who drinks or smokes and skipping life problems were statistically significant motives for the habits (P-value &lt; 0.05). Smoking mainly caused problems with parents (10.1%) and poor performance at school or work (7%), whereas AC mainly caused problems with teachers (8.5%) and fights (5.2%). Conclusion: In conclusion, the prevalence of HS and AC among medical undergraduates in Najaf, Iraq, was reported, and several associated characteristics were discerned. The findings help develop targeted interventions to protect future generations of medical professionals from the hazards of HS and AC.

Study of the Effect of the Smoking on Blood Proteins in Diyala Province

After the widespread phenomenon of smoking in all societies, cultures and age groups, smoking hookah, a social phenomenon common among different members of society, has recently spread. The purpose of this study was to find out how smoking affects blood proteins. Place of collection of Diyala University sample the level of full blood protein was determined by the serums of 20 smokers and all age groups and compared to the serum of 20-25 from male non-smokers and according to the results of the tests conducted showed a clear rise and "means" in the level of blood protein in people who smoke at a rate (1.500+ 6.180) compared to non-smokers who had a protein level (1.00+4.160) at (0.01) >P level of albumin as measured and recorded. Smokers had (1,400+ 3.50) fewer album levels than non-smokers compared to (3,400 + 0.600) for non-smokers, which may be due to the role of albumin as an extracellular antioxidant. The results also revealed that smokers have a higher level of Globulins (1.408+3.53) than non-smokers (1.345 = 1.700), indicating that the high total protein in smokers is due to the high rate of Globulins , which shows that smoking has a negative effect on blood proteins, causing imbalances in body function and eventually leading to chronic diseases and death if smoking continues for a long time.