Maintenance Of Smoking Cessation Research Articles

Effect of 3months and 12 months of financial incentives on 12-month postpartum smoking cessation maintenance: A randomized controlled trial.

Offering financial incentives is effective for smoking cessation during pregnancy. We tested the effectiveness of financial incentives for maintaining postpartum cessation, comparing 12-month and 3-month incentives with each other and with usual care (UC). This study was a pragmatic, multi-centre, three-arm randomized controlled trial involving four English, National Health Service, stop smoking services. A total of 462 postpartum women (aged ≥ 16 years) took part, who stopped smoking during pregnancy with financial incentives, validated as abstinent from smoking at end of pregnancy or early postpartum. Interventions comprised (i) UC; (ii) UC plus up to £60 of financial voucher incentives offered to participants and £60 offered to an optional significant-other supporter, over 3months postpartum, contingent upon validated abstinence ('3-month incentives'); or (iii) UC plus '3-month incentives' plus £180 of vouchers offered to participants over 9months postpartum, contingent upon abstinence ('12-month incentives'). Primary outcome: biochemically validated abstinence at 1year postpartum. To adjust for testing all comparisons between groups with equal precision, P < 0.017 was necessary for significance. self-reported and validated abstinence at 3months postpartum; self-reported abstinence at 1year postpartum. Primary outcome ascertainment: abstinence was 39.6% (63/159) 12 months incentives, 21.4% (33/154) 3 months incentives and 28.2% (42/149) UC. Adjusted odds ratios [95% confidence interval (CI)] = 12-month versus 3-month incentives OR = 2.41 (95% CI = 1.46-3.96), P = 0.001; 12 months versus UC 1.67 (1.04-2.70), P = 0.035; 3 months versus UC 0.69 (0.41-1.17), P = 0.174. Bayes factors indicated that for 12-month versus 3-month incentives and 12 months versus UC there was good evidence for the alternative hypothesis, and for 3 months versus UC there was good evidence for the null hypothesis. This randomized controlled trial provides weak evidence that up to £300 of voucher incentives over 12 months is effective for maintaining smoking abstinence postpartum compared with usual care. There was good evidence that 12-month incentives are superior to those over only 3months, for which there was no evidence of effectiveness relative to usual care.

Evaluating the impact of a prison smoking ban on the cardiovascular health of men in a UK prison

PurposeSmoking rates are known to be higher amongst those committed to prison than the general population. Those in prison suffer from high rates of comorbidities that are likely to increase their risk of cardiovascular disease (CVD), making it more difficult to manage. In 2016, a tobacco ban began to be implemented across prisons in England and Wales, UK. This study aims to measure the effect of the tobacco ban on predicted cardiovascular risk for those quitting smoking on admission to prison.Design/methodology/approachUsing data from a prevalence study of CVD in prisons, the authors have assessed the effect of the tobacco ban on cardiovascular risk, using predicted age to CVD event, ten-year CVD risk and heart age, for those who previously smoked and gave up on admission to prison.FindingsThe results demonstrate measurable health gains across all age groups with the greatest gains found in those aged 50 years and older and who had been heavy smokers. Quitting smoking on admission to prison led to a reduced heart age of between two and seven years for all participants.Originality/valueThe data supports tobacco bans in prisons as a public health measure to reduce risk of CVD. Interventions are needed to encourage maintenance of smoking cessation on release from prison for the full health benefits to be realised.

P.095 Smoking behaviour change is associated with altered functional brain connectivity in older adults

Background: Smoking is the leading cause of preventable morbidity worldwide and therefore developing effective smoking cessation strategies is a public health priority. However, what brain networks support maintenance of smoking cessation in the long term remains unexplored. Methods: We analyzed the baseline resting-state fMRI data acquired in 23 smokers (Mage = 61.52 ± 3.7) who were followed longitudinally in a cohort of cognitively normal older adults. Self-reported smoking status and amount were recorded at baseline and repeated after 4 years. We investigated the effect of smoking behaviour change on functional brain connectivity using seed-to-voxel approach. We examined a-priori regions of interest (ROIs) including the reward network (ventromedial prefrontal cortex (vMPFC) and ventral striatum) and the right insula. These ROIs are promising target mechanisms given prior behavioural research linking it to smoking cessation. Results: Our results revealed that reduced smoking was associated with reduced connectivity between ventral striatum and middle frontal gyrus and enhanced connectivity between right insula and middle temporal gyrus (voxel p &lt;0.001, cluster p&lt;0.05 FDR corrected). However, change in smoking did not reveal any significant effects in the vMPFC. Conclusions: Our findings suggest that successful smoking behaviour change is associated with altered reward network and insular functional connectivity in the long term.

Cost-effectiveness analysis of treatment with varenicline for nicotine dependence compared with smoking cessation without pharmacotherapy in the real world.

Smoking is an important public health issue. Although measures to support smoking cessation have been implemented worldwide, smokers often fail to quit smoking after receiving pharmacotherapies for nicotine dependence. The present study evaluated the cost-effectiveness of varenicline for smoking cessation compared with no pharmacotherapy using actual paid medical cost data in Japan. This was a retrospective cohort study of 3657 subjects who had quit smoking with varenicline or no pharmacotherapy. We extracted health examination and medical claim data from a health insurer database for the period 2012-2015. We calculated the incremental cost-effective ratio (ICER) of varenicline using actual paid medical costs for nicotine dependence and the number needed to treat to maintain smoking cessation compared with no pharmacotherapy, considering sex, age, income, and occupation. The 1- and 2-year smoking cessation maintenance rates were 69.7% and 62.4%, respectively. We found that 8.8% of subjects who quit smoking used varenicline for nicotine dependence and the cost per person was Japanese Yen (JPY) 52 177 (U.S. dollars [USD] 474; USD 1=JPY 110). The ICER of varenicline was dominant when comparing 2-year cessation with 1-year cessation. Male, age <40 years, low income, and manufacturing workers were the most cost-effective variables. The cost-effective variables of varenicline in the real world were investigated. The results of this study strengthen the evidence regarding which type of people should be targeted for measures to support smoking cessation using varenicline.

Maintenance of smoking cessation in Korean single mothers

BackgroundSingle mothers in South Korea are vulnerable to developing smoking habits, due to many difficulties and limitations; however, they have often been overlooked by smoking cessation support services. Therefore, this study aimed to investigate the general and smoking-related characteristics of single mothers registered with the Visiting a Smoking Cessation Service in Seoul, South Korea, to identify factors associated with smoking cessation maintenance at 4 weeks and 24 weeks after they initially quit smoking.MethodsThe participants were 77 single mothers registered in the Smoking Cessation Service Program. Data were included from a three-year span (January 2017–December 2019). Smoking cessation counseling, motivational enhancement, and self-exploration counseling were provided for six months. The participants were evaluated on their smoking cessation status at 4 weeks and 24 weeks.ResultsMost participants were aged 22 years or younger. The rates of smoking cessation maintenance were 58.4 and 18% at 4 weeks and 24 weeks, respectively. The higher the number of counseling sessions, the higher the participants’ chances of maintaining smoking in all non-smoking periods, and whether pregnancy, CO level, and drinking were significant only in a short-term non-smoking period (4 weeks).ConclusionsOur results suggest that the number of smoking cessation counseling sessions is important for long-term smoking cessation beyond short-term cessation in single mothers. To increase the smoking cessation rate of single mothers, it is important to conduct customized smoking cessation counseling at the time of smoking cessation and continue such counseling in the long term.

Smoking Cessation and Preterm Birth in Second Pregnancy Among Women who Smoked in Their First.

The benefit of smoking cessation in reducing the risk of preterm birth is well established. Relatively less well understood is the prevalence of smoking cessation maintenance at the next pregnancy and the associated preterm risk reduction. The aim of this study was to estimate the prevalence of maintenance of smoking cessation at second pregnancy and the associated relative risk of preterm birth. This was a longitudinal study with retrospectively obtained records of births to multiparous women who smoked in the pregnancy of their first birth in New South Wales, 1994-2016 (N = 63 195 mothers). Relative risks (RR) of preterm birth of the second child were estimated for smoking cessation with adjustment for final gestational age of the first birth, maternal age at the first birth, change in socioeconomic disadvantage between the first and second pregnancy, interpregnancy interval, and calendar time. Approximately 34% (N = 21 540) of women who smoked during their first pregnancy did not smoke in the second pregnancy. Smoking cessation among women who smoked at first pregnancy was associated with a 26% (95% CI: 21%, 31%) decrease in risk of preterm birth at a second pregnancy. Despite smoking during the first pregnancy, smoking cessation was achieved and maintained by more than one-third of women in their second pregnancy with encouraging levels of preterm risk reduction. It is well-established that the period after birth provides an opportunity to reduce smoking-related morbidity for both the mother and neonate. Our results indicate that this period also offers an opportunity to prevent morbidity of future pregnancy. A considerable amount of research has been undertaken on the effects of smoking during pregnancy on birth outcomes, the influence of postpartum smoking on the health of the mother and newborn child, and postpartum smoking cessation. However, follow-up of women after giving birth does not tend to be long enough to observe smoking and outcomes of subsequent pregnancies. We show that smoking cessation in the subsequent pregnancy is achievable by a large proportion of women despite smoking in their first pregnancy, which translates to clear reductions in risk of preterm birth in the subsequent pregnancy.

성인 근로자의 금연유지 성공에 영향을 미치는 요인

본 연구는 성인 근로자의 금연유지 성공군과 실패군의 일반적 특성, 건강 관련 특성 및 니코틴 의존도, 우울, 직무스트레스 정도의 차이를 확인하고, 금연유지 성공의 영향요인을 파악하기 위해 시도되었다. 연구 방법은 서술적 조사연구로 연구대상은 20세 이상의 성인 근로자 342명이었다. 수집된 자료는 logistic regression으로 분석하였다. 연구결과 개인 수입이 ‘증상’ 이상일수록, 운동을 하지 않을수록, 우울 점수가 높을수록, 직무스트레스가 높을수록, 1 일 흡연량이 10개피 초과일수록 금연유지 성공 확률이 낮음을 확인하였다. 또한 직업이 사무직, 영업직이나 서비스직, 생산직일수록, 주관적 건강상태가 ‘좋지 않다’라고 지각할수록, 첫 흡연 시작 연령이 19세 초과인 경우 금연 유지 성공 확률이 높은 것으로 나타났다. 본 연구는 향후 성인 근로자의 맞춤형 금연유지 성공 프로그램 개발을 위한 기초자료를 제공한 점에서 의의가 있다.

Clinical, sociodemographic and tobacco-use factors associated with smoking cessation rates at three years follow-up, Ankara, Turkey.

INTRODUCTIONSmoking is a well-known major cause of early preventable mortality and morbidity. Maintenance of smoke-free status is important after a smoking cessation attempt. The present study aims to compare the sociodemographic and clinical characteristics of subjects participating in a smoking-cessation program, according to the duration of smoking cessation.METHODSA study was conducted in 261 smokers who had attended a smoking cessation clinic in a tertiary hospital, in Ankara, Turkey. The smoking status of the subjects at three years follow-up after participating in the smoking-cessation program was assessed. Sociodemographic, employment, environmental, smoking-related, health and clinical characteristics of subjects were compared according to the smoking cessation duration.RESULTSMarital status, having a child, absence of household smoking and lower levels of nicotine dependence were significantly higher in quitters, and anxiety was lower. Parameters that significantly differed between subjects that were and were not abstinent for >36 months were marital status (p<0.001), childbearing status (p=0.007), household smoking (p<0.001), age of smoking initiation (p=0.02), psychiatric illness history (p=0.01), and number of follow-up visits (p<0.001). The number of follow-up visits at the smoking cessation clinic was an important factor of quitting and maintenance of quit status.CONCLUSIONSFamily and home environment as well as smoking-related and mental health characteristics influenced maintenance of long-term smoking cessation. Characteristics such as sociodemographic, clinical and smoking-related conditions should be considered in smoking cessation interventions. Personalized treatment strategies and follow-up visits at the smoking cessation clinic should be planned for maintenance of smoking cessation.

Factors associated with maintenance of smoking cessation in adolescents after implementation of tobacco pricing policy in South Korea: Evidence from the 11th Youth Health Behavior Survey.

As a part of Korea's smoking cessation policy, the price of tobacco was increased in January 2015. Initially, the smoking rate among adolescents began to decrease. The current data, however, show that the adolescent smoking rate is on the rise. Alongside price policies, there is a need to further understand additional preventive measures that promote successful smoking cessation by identifying the factors that influence maintenance of smoking cessation in adolescents. This study aimed to identify the factors that influence smoking cessation in adolescents after attempting smoking cessation after increase in tobacco price. The study used large-scale, nationwide, secondary data obtained from the Korean Youth Risk Behavior Web-Based Survey. The sample included a total of 627 subjects who reported an attempt to quit smoking after the tobacco price increased. Descriptive statistics, t test, the χ2 test, and multiple logistic regression were used. The results showed that household economic status, school type, suicidal ideation, experience of exposure to secondhand smoke at home, and experience of witnessing teaching staff smoking were significant factors related to maintenance of smoking cessation among adolescents. To increase the success rate of smoking cessation, future intervention programs should include school environment structure and address emotional and psychological issues such as suicide.

Short-Term Success Rates of Smoking Cessation Support Programs and Factors Predicting Smoking Relapse: Using Data from a Smoking Cessation Clinic in a Hospital.

BackgroundAlthough the number of medical institutions running a smoking cessation clinic is on the rise, there remains a paucity of research on the long- and short-term success rates of smoking cessation programs, as well as on smoking relapse rates, before and after project implementation. This study assessed the general characteristics of patients visiting the smoking cessation clinic, success rate of smoking cessation in the short term, and risks of relapse.MethodsMedical records from March 2015 to April 2017 were analyzed and telephone surveys were conducted with 151 smokers who visited a hospital smoking cessation clinic from March 2015 to April 2017.ResultsOf the 139 smokers who were eligible for follow-up, 22 (15.8%) failed to quit smoking initially. The clinic’s 6-month success rate of smoking cessation was 64.83%. Those with higher medication compliance had a lower risk of primary failure (odds ratio, 0.056; 95% confidence interval, 0.005–0.609), whereas those with higher age (hazard ratio [HR], 0.128; P=0.0252) and a greater number of visits to the clinic (HR, 0.274; P=0.0124) had a lower risk of relapsing.ConclusionThe risk of primary failure to quit was higher with low medication compliance, and that of relapsing was higher with lower age and fewer number of clinic visits. Various evaluation and analysis methods can be carried out in the future based on the accumulated data for maintenance of smoking cessation and relapse prevention.

Tobacco dependence and smoking cessation: The mediating role of smoker and ex-smoker self-concepts

Tobacco dependence is a complex phenomenon in which physical and psychological components go hand in hand, and it is often considered as one of the major barriers to quit smoking. However, we still need to increase our understanding of the processes through which tobacco dependence relates to smoking cessation. This research aimed to investigating whether changes in smoker versus ex-smoker (abstainer) self-concept account for the association between tobacco dependence and successful smoking cessation. We used longitudinal data drawn from the evaluation of a smoking cessation intervention. A sample of smokers enrolled in the program filled in a questionnaire at the beginning of the intervention (baseline: N = 779), 6 months later (i.e., at the end of the intervention: T1, N = 532), and 9 months later (T2; N = 387). We assessed tobacco dependence (baseline), smoker versus ex-smoker self-concept (baseline, T1, and T2) and smoking status (baseline, T1 and T2). Tobacco dependence was negatively associated with smoking cessation maintenance, and this effect was mediated by changes in self-concept: The greater tobacco dependence, the lower the likelihood that former smokers develop an ex-smoker self-concept during the program, which results in relapse at T1 or T2. Successful smoking cessation interventions should provide strategies preventing the negative effects of tobacco dependence on identity transition.

Evaluation of factors affecting the maintenance of smoking cessation among individuals in Japan

Evaluation of factors affecting the maintenance of smoking cessation among individuals in Japan

Depression and maintenance of smoking cessation after myocardial infarction with focus on education

Objective: The aim of the study was to investigate the association between depression and maintenance of smoking cessation at 1-year follow-up in patients admitted with first-incidence acute myocardial infarction (MI) with a focus on educational level. Methods: From the 1st of September 2002 to the 31st of December 2004, 388 patients < 75 years old were admitted at Aarhus University Hospital in Denmark with first-incidence MI. The patients were screened for depression 6 weeks after admission and offered cardiac rehabilitation (CR). Patients were included if they stopped smoking at admission or in the next 6 weeks, if they were screened for depression and if they gave information concerning smoking status. Results: A quarter of the patients were screened positive for depression. There was no significant difference in the participation at the smoking cessation part of the rehabilitation for patients screened positive or negative for depression, whether the results were adjusted for gender and educational level (OR = 0.84; p -value = .75) or not (OR = 0.75; p -value = .56). There was a significant association between a positive depression screening and failing to maintain a smoking cessation in men (OR = 7.67; p -value = .03) at 1-year follow-up. When adjusted for educational level a significant association was still seen (OR = 7.48; p -value = .01). Conclusions: There was a significant association between a positive depression screening and failing to maintain a smoking cessation in men at 1-year follow-up. The result was consistent after adjusting for educational level.

Exercise to Enhance Smoking Cessation: the Getting Physical on Cigarette Randomized Control Trial.

Exercise has been proposed as a useful smoking cessation aid. The purpose of the present study is to determine the effect of an exercise-aided smoking cessation intervention program, with built-in maintenance components, on post-intervention 14-, 26- and 56-week cessation rates. Female cigarette smokers (n = 413) participating in a supervised exercise and nicotine replacement therapy (NRT) smoking cessation program were randomized to one of four conditions: exercise + smoking cessation maintenance, exercise maintenance + contact control, smoking cessation maintenance + contact control or contact control. The primary outcome was continuous smoking abstinence. Abstinence differences were found between the exercise and equal contact non-exercise maintenance groups at weeks 14 (57 vs 43%), 26 (27 vs 21%) and 56 (26 vs 23.5%), respectively. Only the week 14 difference approached significance, p = 0.08. An exercise-aided NRT smoking cessation program with built-in maintenance components enhances post-intervention cessation rates at week 14 but not at weeks 26 and 56.

Effects of Fatty Acid Amide Hydrolase (FAAH) Inhibitors in Non-Human Primate Models of Nicotine Reward and Relapse.

Inhibition of the enzyme fatty acid amide hydrolase (FAAH) counteracts reward-related effects of nicotine in rats, but it has not been tested for this purpose in non-human primates. Therefore, we studied the effects of the first- and second-generation O-arylcarbamate-based FAAH inhibitors, URB597 (cyclohexyl carbamic acid 3'-carbamoyl-3-yl ester) and URB694 (6-hydroxy-[1,1'-biphenyl]-3-yl-cyclohexylcarbamate), in squirrel monkeys. Both FAAH inhibitors: (1) blocked FAAH activity in brain and liver, increasing levels of endogenous ligands for cannabinoid and α-type peroxisome proliferator-activated (PPAR-α) receptors; (2) shifted nicotine self-administration dose-response functions in a manner consistent with reduced nicotine reward; (3) blocked reinstatement of nicotine seeking induced by reexposure to either nicotine priming or nicotine-associated cues; and (4) had no effect on cocaine or food self-administration. The effects of FAAH inhibition on nicotine self-administration and nicotine priming-induced reinstatement were reversed by the PPAR-α antagonist, MK886. Unlike URB597, which was not self-administered by monkeys in an earlier study, URB694 was self-administered at a moderate rate. URB694 self-administration was blocked by pretreatment with an antagonist for either PPAR-α (MK886) or cannabinoid CB1 receptors (rimonabant). In additional experiments in rats, URB694 was devoid of THC-like or nicotine-like interoceptive effects under drug-discrimination procedures, and neither of the FAAH inhibitors induced dopamine release in the nucleus accumbens shell--consistent with their lack of robust reinforcing effects in monkeys. Overall, both URB597 and URB694 show promise for the initialization and maintenance of smoking cessation because of their ability to block the rewarding effects of nicotine and prevent nicotine priming-induced and cue-induced reinstatement.

Smoking Cessation after Myocardial Revascularization Procedures

Introduction: Smoking is associated with the development of coronary artery disease and influences negatively the prognosis of patients undergoing myocardial revascularization procedures. However, the rate of smoking cessation after these procedures is not well established in the literature. We aimed to evaluate the rate of smoking cessation in patients undergoing revascularization procedures, immediately and after 12 months of follow-up.Methods: We examined smoking patients from a unique cardiology center who underwent myocardial revascularization procedures between January 2010 and December 2011. These patients were allocated to two groups according to the revascularization procedure performed: Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Interventions (PCI). Data related to cessation or maintenance of smoking were obtained at subsequent clinical appointments or telephone calls.Results: Among 173 patients selected, 118 (68.2%) underwent PCI and 55 (31.8%) underwent CABG. After revascularization procedures, the total rate of smoking cessation was 79.3%. Furthermore, there was no significant difference between the two groups (83.6% – CI 95%: 71.2–92.2% for CABG, and 79.3% – CI 95%: 70.8–86.3% for PCI). The maintenance of smoking cessation after one year was 53.2%, similar between groups (52.7% for CABG and 53.4% for PCI). Nevertheless, the average time of smoking cessation was significantly higher in the CABG group (6.9 months versus 4.5 months for PCI).Conclusions: Coronary interventions add important value to smoking cessation, and the smoking cessation rates were similar, independent of the procedure executed.

Improving Understanding of the Quitting Process: Psychological Predictors of Quit Attempts Versus Smoking Cessation Maintenance among College Students

This study examined motivation, positive and negative outcome expectations of quitting, and self-efficacy as predictors of quit attempts and cessation maintenance in a smoking cessation intervention for college students (N = 303). Psychological measures assessed at baseline were used to predict smoking behavior outcomes. Analysis of variance (ANOVA) and logistic regression analysis revealed that motivation and self-efficacy were strong, differential predictors of quit attempts and cessation maintenance, respectively. This study extends the previous findings regarding psychological predictors of quitting processes to college students, and suggests the need for interventions tailored according to phases of quitting processes.

The Effects of Smoking Urges and Withdrawal Symptoms on Maintenance of Smoking Cessation: The Moderating Effects of Coping and Perceived Smoking Cessation Effects

The Effects of Smoking Urges and Withdrawal Symptoms on Maintenance of Smoking Cessation: The Moderating Effects of Coping and Perceived Smoking Cessation Effects

Maintenance of Smoking Cessation in the Postpartum Period: Which Interventions Work Best in the Long-Term?

Smoking during pregnancy has been linked to a variety of adverse outcomes for both maternal and child health. Decades of studies have sought to increase cessation antepartum and reduce relapse postpartum. A number of effective interventions exist to significantly reduce smoking rates during pregnancy; however, less is known about how to prevent relapse in the postpartum period. This review investigates interventions to prevent relapse in the long-term postpartum period. We focus specifically on nonspontaneous quitters (individuals who quit smoking as a result of an external intervention) to reveal differences in long-term response to interventions for this population compared to spontaneous quitters. A systematic literature search yielded 32 relevant studies of pharmacological, behavioral, and incentives-based interventions. Results were compiled, analyzed, and compared in order to evaluate success factors in maintaining cessation postpartum. Though intervention groups showed consistently higher quit rates during pregnancy than control groups, none of the intervention types were effective at preventing relapse in the longer-term postpartum period. One study maintained significantly higher abstinence in the longer-term period postpartum using a mix of behavioral and incentives strategies. Additional research in this area is needed to identify optimal intervention strategies to reduce long-term postpartum relapse, particularly for nonspontaneous quitters.

Long-Term Maintenance of Smoking Cessation in Pregnancy: An Analysis of the Birth Cohort Generation XXI

Pregnancy affords opportunities for health promotion and disease prevention. We worked with a population-based cohort of women who gave birth in Portugal to quantify the proportion of women who quit smoking during pregnancy, the proportion of these women who continued to abstain 4 years after delivery, and the determinants of these outcomes. A birth cohort was assembled in public maternity units of Porto, Portugal, in 2005-2006, and all women were reevaluated at an average of 4 years after delivery. A total of 5,420 mothers were included in the analysis. Smoking status at baseline and at follow-up was ascertained by interview. Adjusted prevalence ratios and 95% CIs were computed using robust Poisson regression. Overall, 47.4% of women who smoked ceased smoking and 41.7% reduced cigarette consumption during pregnancy. Four years after delivery, 32.1% of those who stopped smoking during pregnancy continued to abstain. Older women, first-time mothers, light smokers, those who were living with a partner at the time of follow-up, those who became pregnant again after the index pregnancy, those who breast fed for more than 52 weeks, and those with a child diagnosed with asthma and/or rhinitis were more likely to abstain from smoking. Approximately half of all women stopped smoking during pregnancy and, among these, approximately one third continued to abstain 4 years after delivery. The high proportion of relapse may be attributable to poor awareness or skepticism regarding the adverse effects of secondhand smoke on children or physiological and psychological dependence on nicotine.