Development and Validation of the Smoking Cue Appeal Survey

In this two-study investigation, a measure of sensory smoking cue appeal was developed and evaluated relative to smoking behavior, smoking severity, and craving. In the first study, 101 participants completed the Smoking Cue Appeal Survey (SCAS) and self-reported smoking status (current, former, or non-smoker). In the second study, 54 participants completed the SCAS and craving was measured following a cue exposure procedure. Data were collected between 2008 and 2009. The SCAS demonstrated good psychometric properties and was associated with smoking status. Additionally, craving was significantly associated with the SCAS, but there was no association with frequency of smoking or severity of nicotine dependence. Limitations include a cross-sectional design, small sample size, and focus on trait factors. Future directions are discussed.     

The Influence of Religious Attendance on Smoking Among Black Men

Background: Cigarette smoking poses a major public health problem that disproportionately affects Blacks and men. Religious attendance has been shown to be positively associated with health promotion and disease prevention among the Black population. In light of this evidence, this study examined if a similar relationship could be found for religious attendance and smoking in Black men. Methods: The National Survey of American Life (NSAL) study sampled 1,271 African American men and 562 Black Caribbean men. Multivariate logistic regression was used to determine the association between religious attendance and cigarette smoking. Results: After adjusting for age, marital status, household income, education, foreign born status, importance of prayer and major stress, men who reported attending religious services almost every day (odds ratio (OR) = 0.21, 95% confidence interval (CI) = 0.07, 0.62) and weekly (OR = 0.47, 95% CI = 0.29, 0.77) had lower odds of being a current smoker compared to men who reported never attending religious services. Conclusions/Importance: Findings suggest a health benefit in attending religious services on cigarette smoking among Black men in a nationally representative sample. In spite of lower church attendance in Black men in general, our results demonstrate that religious service attendance may still serve as a buffer against cigarette use. Given the emergent attention on faith-based health promotion among men, this conclusion is relevant and timely.     

Smoking Status and Cost of Illness in Patients with Depressive Disorder Based on the National Health Survey in Spain

Background: Twenty-one percent of subjects with depressive disorder (DD) smoke. This prevalence is expected to be related to healthcare resources utilization (HRU) and sick leave, thereby accounting for substantial costs to the National Health System (NHS) and to society that still need to be characterized. The objective was to estimate cost of illness in patients with DD according to their smoking status. Methods: We used the 2011/2012 National Health Survey to document HRU and lost-workday equivalents (LWDE). Men and women 18+ years old with a DD self-reported to a physician in the past 12?months were categorized into: smokers (daily smokers), former smokers, and never smokers. HRU and LWDE were computed on an annualized basis. Multivariate general linear models adjusted for sex, age, and comorbidities were applied. Results: Data from 1,816 subjects (381 smokers, 290 former smokers, and 1,145 never smokers) were analyzed. Smokers had higher total per patient annual costs (thousands, €3.14), and higher annual healthcare costs (€2.53) than former smokers (€2.35, p?<?.1; and €1.93, p?<?.05) and never smokers (€2.42, p?<?.05; and €2.06, p?<?.1): with excess costs of €0.79 and €0.72 for total annual costs and €0.60 and €0.47 for annual healthcare costs (p?=?.029 and p?=?.056, respectively). Conclusions: Smoking DD subjects were associated with higher HRU and costs from both the societal and healthcare perspectives, when compared with former and never smokers in the Spanish general population. Supporting people with DD to quit smoking might therefore be a value-for-money health policy in Spain.     

Intra-Ethnic Racial Differences in Waterpipe Tobacco Smoking among Latinos?

Background and Objectives: This study examined differences in waterpipe smoking (both lifetime and current) by race and ethnicity. More specifically, we evaluated intra-ethnic racial differences among Latinos using a nationally representative sample. Methods: Pooled data from the National Adult Tobacco Survey (NATS) [2012-2014] was used, in which Log-Poisson multivariable regression models were deployed to determine the prevalence of waterpipe smoking behavior. Models were stratified by gender and we further investigated acculturation, controlling for relevant sociodemographic characteristics. Results: In fully-adjusted models assessing lifetime WTS, Black Latinos and White Latinos exhibited an increase prevalence of lifetime WTS compared to their non-Hispanic white counterparts. Once stratifying by gender, Black Latino men (PR = 1.49; 95% CI = 1.16, 1.90) exhibited increased prevalence of lifetime WTS compared to their non-Hispanic white men counterparts; although white Latino men (PR = 0.88; 95% CI = 0.80, 0.98) exhibited decreased prevalence compared to their non-Hispanic white male counterparts. Similar trends were found for current WTS among men. In fully adjusted models assessing lifetime WTS, among women, only white Latina's (PR = 1.23; 95% CI = 1.04, 1.46) exhibited increased prevalence compared to their non-Hispanic white women counterparts. When evaluating current WTS, Black Latina's (PR = 2.19; 95% CI = 1.32, 3.65) and white Latinas (PR = 1.28; 95% CI = 1.00, 1.63) exhibited increased prevalence of WTS compared to their non-Hispanic white women counterparts. Conclusions/Importance: Among the U.S. general adult population, intra-ethnic racial differences in WTS behaviors exist among Latinos; and is shaped by gender. Future efforts to eliminate racial disparities in WTS should be attentive intra-ethnic racial differences among Latinos.     

Estimating the Determinants of Smoking Behavior in Taiwan

This paper investigates the determinants of the smoking behavior of people in Taiwan based on data obtained from the 2004 Taiwan Panel Study of Family Dynamics. The sample size consists of 3,015 individuals whose ages range from 33 to 75. Probit models are estimated separately for the smoking behavior equations. The results indicate that gender, marital status, age, health, employment, and the presence of young children have a relatively important impact on an individual's smoking behavior. In addition, the results of the estimated predictors, such as having higher educational attainment, having smoking family members and smoking peers, and being aware of the harmful effects of smoking, also bring to light crucial policy implications. Study limitations are noted.     

Current Frequent Cigarette Smoking Among U.S. Middle and High School Students, 2000–2011

This study assessed trends in current frequent smoking among United States middle and high school students. Methods: Data were obtained from the National Youth Tobacco Survey (2000–2011). Current frequent smoking was defined as smoking cigarettes on ≥20 days during the past 30 days. Trends were assessed using linear coefficients in a binary logistic regression (p < 0.05). Results: Current frequent cigarette smoking among all students declined between 2000 (6.4%) and 2011 (3.6%) (p < 0.001 for linear trend). Significant declines were observed by age, sex, race/ethnicity, school and grade level. Conclusion: Sustained efforts are needed to further reduce youth use of all tobacco products.     

The impact of e-cigarette price changes on vaping and smoking behaviors

Background: Understanding the relations between e-cigarette prices and e-cigarette/cigarette use may shed light on the possible impact of e-cigarette regulations on public health. Objectives: This study aimed to assess potential impacts of e-cigarette price changes on vaping and smoking behaviors by smoking status (current, former, and never smokers) and e-cigarette type (pre-filled only vs. refillable). Methods: A total of 918?US-based adult e-cigarette users completed an online survey, designed to assess behavioral intention of e-cigarette/cigarette use in hypothetical situations with varying prices of e-cigarettes, in 2017. Results: With reduction in e-cigarette prices, more than 50% of current smokers reported they would reduce or quit smoking, but with greater increases in price, the rates of not only those who would quit (12.5–19.4%), but also those who would increase smoking rose (15.1–25.1%). Current smokers (vs. former/never) were more likely to increase e-cigarette use at reduced e-cigarette prices. Among current smokers, pre-filled users were less likely to quit smoking with reduced prices. At higher prices, pre-filled users were more likely to quit e-cigarettes (former smokers), but also more likely to start smoking (never smokers). Among former smokers, recent quitters were more likely to restart smoking with any e-cigarette price changes, and less likely to reduce or quit e-cigarettes with increased prices. Conclusions: Both smoking and e-cigarette use seem to be sensitive to e-cigarette price changes. Increases in e-cigarette price may have both positive and negative effects on smoking behavior, and e-cigarette price changes may disproportionately affect pre-filled users and recent quitters.     

Online Comments on Smoking Bans in Psychiatric Hospitals Units

Objective: Individuals with mental health concerns are disproportionately affected by and suffer the negative consequences of tobacco use disorder, perhaps because smoking has historically been part of psychiatry's culture. In the early 1990s, psychiatric inpatient facilities were exempted from U.S. hospital smoking bans, in response to public outcry with national media attention. Almost 2 decades later, the current study characterizes online conversation about psychiatric hospital smoking bans. Previous commenting studies have demonstrated commenting's negativity, documenting the “nasty effect” wherein negative comments color perceptions of neutral articles. Thus, we focused particular attention on cited barriers to implementing health-positive smoke-free policies. Methods: We collected online comments (N = 261) responding to popular media articles on smoking bans in inpatient psychiatry between 2013 and 2014 and conducted an inductive and exploratory qualitative content analysis. Results: Verifying previous studies documenting the prevalence of negative commenting, of the comments explicitly supporting or refuting psychiatry smoking bans, there were over twice as many con comments (n = 44) than pro (n = 18). Many commenters argued for access to outdoor smoking areas and warned of patient agitation and risk posed to care workers. Identified content themes included psychiatric medication and negative side effects, broken mental health systems and institutions, denigration of the health risks of tobacco in the context of mental illness, typical pro-smoking arguments about “smokers’ rights” and alternatives (including e-cigarettes), addiction, and stigma. Conclusions: The current findings provide a platform to begin to understand how people talk about mental health issues and smoking. Our analysis also raised complex issues concerning forces that impact U.S. patients with serious mental illness but over which they have little control, including medication, the U.S. health system, stigma, perceptions that life with chronic serious mental illness is not worth living, and psychological and physical pain of coping with mental illness. In consideration of identified barriers raised in opposition to smoking bans in inpatient psychiatry, efforts should emphasize patient stakeholder involvement; patient, visitor, and staff protection from smoke exposure; the effectiveness of nicotine replacement for managing withdrawal; and the lack of evidence that cigarettes are therapeutic.     

Current and Emerging Pharmacotherapies for Cessation of Tobacco Smoking

Tobacco use disorder is a chronic illness. With its high comorbidity rate, it is a major cause of years of life lost or years lived with disability; however, it is also considered the most preventable cause of death in developed countries. Since the development of nicotine replacement therapy (NRT) in 1978, treatment options have continued to evolve and expand. Despite this, currently available treatments remain insufficient, with less than 25% of smokers remaining abstinent 1 year after treatment. In this article, we review existing and emerging smoking cessation pharmacotherapies, with a special emphasis on the most promising agents that are currently being investigated. A search of the Cochrane Database of Systematic Reviews and the PubMed, Ovid, and ClinicalTrials.gov databases (August 2 to September 1, 2017) was undertaken for articles on smoking cessation pharmacotherapies, applying no language restrictions. More than 40 pharmacotherapies were reviewed including conventional pharmacotherapies—NRT, bupropion, and varenicline (all approved by the U.S. Food and Drug Administration as first‐line treatment of smoking cessation)—and novel therapies: cytisine, N‐acetylcysteine, cycloserine, memantine, baclofen, topiramate, galantamine, and bromocriptine. Studies of combination NRT and varenicline showed the greatest smoking cessation rates. Clonidine and nortriptyline are second‐line treatments used when first‐line treatments fail or are contraindicated, or by patient preference. Some novel therapies, especially acetylcholinesterase inhibitors, cytisine, and N‐acetylcysteine, display promising results. Because the results of randomized clinical trials were reported using varied end points and outcome measures, direct comparisons between different pharmacotherapies cannot easily be evaluated. Additional high‐quality randomized double‐blind placebo‐controlled trials with long‐term follow‐up, using validated sustained abstinence measures, are needed to find more effective smoking cessation aids.     

Development and Validation of a Smoking Expectancies Measure for Adolescents Seeking to Quit Smoking

Background: A more comprehensive understanding of factors that affect smoking cessation outcomes among adolescents may help enhance treatment interventions. One promising but underexplored factor that may influence cessation success is teens’ specific expectancies or beliefs about smoking outcomes. The present study evaluated the validity and reliability of a new measure of expectancies and its association with cessation outcomes among 762 adolescent smokers participating in studies of the American Lung Association's Not On Tobacco cessation program. Methods: Self-report questionnaires were collected prior to and following participation in a smoking cessation program. Self-reported cigarette use was verified with expired-air carbon monoxide. A multistep exploratory and confirmatory factor analysis and reliability and validity analyses were performed. Results: Four theoretically related yet empirically independent factors were identified by the Smoking Expectancies Questionnaire (SEQ): (1) Positive Reinforcement, (2) Negative Reinforcement—Emotional Regulation, (3) Negative Reinforcement—Addiction and Withdrawal, and (4) Negative Outcomes/Risk. These factors could be subsumed by a single SEQ factor that reflected an overall concept of smoking expectancies relevant for adolescent smoking cessation. An overall SEQ Function score reflecting the balance between positive and negative expectancies predicted both preintervention cigarettes per day and cessation outcomes. Conclusions: A single, overall SEQ Function score may prove useful for understanding the associations among individual, social, and contextual factors in predicting treatment outcomes. Additionally, study findings may assist with modifying smoking expectancies among cessation program participants, thereby enhancing treatment outcomes with diverse youth smoking populations.     

Smoking Susceptibility and Attitudes Toward Smoking Among Chinese and Vietnamese American Adolescents

Abstract

In California, 641 Chinese and 629 Vietnamese age 12–17 participated in a longitudinal telephone study from 1999 to 2001. Four attitude scales were constructed: acceptance of smokers, addictive nature of smoking, psychosocial reasons to smoke, and gender roles and smoking. Vietnamese American adolescents had more pro-smoking attitudes than Chinese American adolescents. Male gender, having friends who smoked, and baseline smoking were associated with smoking susceptibility at follow-up. Those factors, U.S. birthplace, and the acceptance and psychosocial scales were associated with smoking. Smoking prevention efforts targeting Chinese and Vietnamese American adolescents should focus on gender, birthplace, peer smoking, and attitudes.     

Demographic Moderators of the Relationship Between Adverse Childhood Experiences and Cigarette Smoking

Background: Research suggests that there is a dose–response relationship between Adverse Childhood Experiences (ACEs) and cigarette smoking, such that as ACE score increases, so do the odds of smoking behavior, but little is known about what factors moderate this relationship. Objectives: The goal of this study was to examine demographic characteristics as potential moderators of relationship between ACE score and cigarette smoking. Methods: A secondary data analysis was conducted using the 2013 California Behavioral Risk Factor Surveillance System data. The sample included 2,604?U.S. adults (54.8% female; Age: M?=?53.3, SD?=?8.10). We used multinomial logistic regression to test sex, race, income, and education as moderators of the relationship between ACE score and smoking. Results: ACEs were not significantly associated with smoking behavior. No interactions between ACE score and sex, race, education, or income significantly predicted smoking outcomes. Sex, race, education, and income were significantly and independently associated with smoking outcomes. Men, individuals with lower income and education, and certain ethnic/racial groups reported greater odds of smoking. Conclusions/Importance: Results suggest that there may not be a relationship between ACEs and smoking later in life. Additionally, the relationship between ACEs and smoking in adulthood may not depend on basic demographic features. Knowing which populations are more vulnerable to smoking can help clinicians better assess and tailor interventions to meet the needs of their patients by using culturally sensitive interventions and obtaining resources to help improve treatment access, motivation, and success.     

Relationships Between Drinking Motives and Smoking Expectancies Among Daily Smokers Who Are Also Problem Drinkers

Objective: There is a high co-occurrence of problem drinking and regular cigarette smoking, and cognitive processes (e.g., motivation to use, expectations about the consequences of use) related to each are positively associated with one another. We explored drinking motives in relation to cognitive-based smoking processes among smokers with problematic drinking. We expected that drinking coping motives would be associated with smoking consequences related to negative reinforcement and negative personal outcomes and inflexibility of smoking behavior; observed effects for coping motives would be unique from shared variance with other motives and incrementally evident beyond the variance accounted for by tobacco-related health problems, smoking rate, negative affectivity, cannabis use, and gender.

Methods: The sample included 195 individuals recruited into a larger study of smoking cessation treatments (i.e., they were interested in quitting), who were heavy drinkers and smoked daily. Participants were primarily male (n = 122, 63%), fairly young (M_age = 30.3 years; SD = 12.46), and predominantly White/Caucasian (n = 175, 80%). Roughly 57% (n = 111) had at least one comorbid Axis I disorder, the most common being social anxiety (n = 21, 11%) and generalized anxiety disorder (n = 12, 6%).

Results: Coping drinking motives predicted negative smoking consequences, negative reinforcement, and smoking inflexibility. Enhancement drinking motives marginally predicted positive reinforcement. Conformity drinking motives predicted smoking consequences related to appetite/weight control. Social drinking motives predicted negative reinforcement and barriers to cessation and marginally predicted positive reinforcement.

Conclusions: Theoretical models and clinical activities focused on smoking cessation among problem drinkers may benefit from considering the role of drinking motives, particularly coping-oriented motives, to better understanding cognitive-based smoking processes.     

Emotional Intelligence,Hardiness, and Smoking: Protective Factors Among Adolescents

ABSTRACT

Smoking is the biggest threat to public health, and it remains a serious cause of death in the world. It even causes acute and chronic diseases in passive smokers. Remarkably, the age of the onset of cigarette smoking is decreasing. Therefore, it is essential to increase our knowledge concerning the attitudes among adolescents toward cigarette smoking. The present study sought to examine the association among hardiness, emotional intelligence, and attitude toward cigarette smoking in adolescents. The participants comprised of 550 high school students (ages 16 to 19 years, M = 17.1, SD = .93) from Tehran. They completed the Personal Views Survey, Assessing Emotions Scale, and Attitudes Towards Smoking Scale. The structural equation modeling estimated that adolescents with a high ability for hardiness and emotional intelligence were more likely to report negative attitude toward cigarette smoking. The findings showed that hardiness and emotional intelligence were protective factors against smoking in adolescents. Therefore, these findings reinforce the importance of hardiness training and emotional intelligence training in preventing cigarette smoking in adolescents.     

A Systematic Review of Loneliness and Smoking: Small Effects,Big Implications

Background: Research supports an association between smoking and negative affect. Loneliness is a negative affective state experienced when a person perceives themselves as socially isolated and is associated with poor health behaviors and increased morbidity and early mortality. Objectives: In this article, we systematically review the literature on loneliness and smoking and suggest potential theoretical and methodological implications. Methods: PubMed and PsycINFO were systematically searched for articles that assessed the statistical association between loneliness and smoking. Articles that met study inclusion criteria were reviewed. Results: Twenty-five studies met inclusion criteria. Ten studies were conducted with nationally representative samples. Twelve studies assessed loneliness using a version of the UCLA Loneliness Scale and nine used a one-item measure of loneliness. Seventeen studies assessed smoking with a binary smoking status variable. Fourteen of the studies were conducted with adults and 11 with adolescents. Half of the reviewed studies reported a statistically significant association between loneliness and smoking. Of the studies with significant results, all but one study found that higher loneliness scores were associated with being a smoker. Conclusions/Importance: Loneliness and smoking are likely associated, however, half of the studies reviewed did not report significant associations. Studies conducted with larger sample sizes, such as those that used nationally representative samples, were more likely to have statistically significant findings. Future studies should focus on using large, longitudinal cohorts, using measures that capture different aspects of loneliness and smoking, and exploring mediators and moderators of the association between loneliness and smoking.     

Structural Models of Gender,Alcohol Consumption,and Health

Background.?Gender differences exist in patterns of alcohol consumption and in the health and social effects of alcohol use, but little is known about gender differences in how alcohol use is affected by mental and physical health conditions. Methods.?We used structural equation modeling techniques to examine gender differences in the relationships among alcohol consumption, physical and mental health, functional status, and social and demographic characteristics. Data were obtained from a random sample of the adult membership of a health maintenance organization in the U.S. Pacific Northwest. Simultaneous models evaluated gender differences in predictors of drinking vs. nondrinking status and, among drinkers, amount of alcohol consumed. Results.?Physical health was twice as strong a predictor of drinker/nondrinker status among women compared with men, but among drinkers, there were no gender differences in predictors of amount of alcohol consumed. Mental health predicted drinking status and alcohol consumption among drinkers, but these relationships did not differ by gender. Overall, sociodemographic characteristics and physical health were stronger predictors of alcohol use among women than among men. Conclusions.?Women may be more amenable than men to alcohol-related preventive messages that target physical health concerns. Treating mental health conditions may be an important method for reducing alcohol consumption.     

A Longitudinal Analysis of Stressful Life Events,Smoking Behaviors,and Gender Differences in a Multicultural Sample of Adolescents

Many studies have addressed the associations between stressful life events and adolescent smoking. Few studies, however, have examined gender differences, specifically with multicultural samples. This longitudinal study examines the relationship between 6 stress subscales and smoking behaviors 716 multicultural U.S. adolescents living in the greater Los Angeles area in 2000–2001. At baseline the ethnic break-down of the sample was 63% Latino and 26% Asian/PI and 70% were 11 years of age. Negative personal events were associated with lifetime smoking and negative school events were associated with intentions to smoke. Stratification of the sample by gender indicated that gender confounded the relationship between negative personal stress and lifetime smoking and negative school stress, positive personal stress and intentions to smoke. Two significant interactions were found. Findings indicate there are differential effects of stressful events between genders which may lead to smoking experimentation or intentions to smoke. Implications and limitations are discussed.     

Tobacco Smoking and Suicidal Ideation in School-Aged Children 12–15 Years Old: Impact of Cultural Differences

ABSTRACT

This cross-sectional study examined the association between tobacco smoking and suicidal ideation in school-aged children from 9 countries in Africa, the Americas, and the Western Pacific region. Data were collected through the Global school-based Student Health Survey, a collaborative surveillance project between the World Health Organization, the United Nations, UNICEF, UNESCO, UNAIDS, and the U.S. Centers for Disease Control and Prevention. Suicidal ideation, tobacco smoking, and drug and alcohol use were included in loglinear models to analyze higher order interactions among suicidality and regional and country differences separately for boys and girls. School-aged children who reported suicidal ideation had a higher risk of smoking tobacco even after controlling for drug and alcohol misuse. Furthermore, analyses indicated higher order interactions between suicidal ideation and countries belonging to different regions with different exposure to tobacco smoking among school-aged children. Future studies analyzing the mechanism and sequencing of the relationship among suicidal ideation and tobacco smoking should explore cultural factors.     

Chronic Smoking,Trait Anxiety,and the Physiological Response to Stress

Background and Objectives: Both chronic smoking and trait anxiety have been associated with dysregulations in psychobiological stress response systems. However, these factors have not been studied in conjunction. We expected trait anxiety and smoking status to attenuate stress reactivity. Furthermore, we expected an allostatic load effect resulting in particularly attenuated stress reactivity in high-anxious smokers. In addition, high-anxious smokers were expected to exhibit increased urges to smoke in response to stress. Methods: 115 smokers and 37 nonsmokers, aged 18–64 years, completed a laboratory session including mental stressors such as evaluated public speaking and mental arithmetic. Trait anxiety was assessed using Spielberger's State–Trait Anxiety Inventory. Cardiovascular autonomic indices, salivary cortisol, and the desire to smoke were measured at baseline, during stressors, and at recovery. Results: Regression analyses showed that smokers exhibited attenuated cardiovascular stress responses in comparison to nonsmokers. Higher trait anxiety predicted attenuated systolic blood pressure responses to stress. No interaction effect of smoking status and trait anxiety was found in stress response measures. Higher trait anxiety predicted an increased desire to smoke in response to stress among smokers. Conclusion: Results indicate that both smoking status and trait anxiety are associated with blunted sympatho-adrenal cardiovascular stress reactivity. Elevated urges to smoke in response to stress found among smokers with high trait anxiety suggest an important role of anxiety in smoking propensity and relapse.     

Does Resilience Moderate the Relationship Between Stress and Smoking Status?

Background: There is a growing evidence that resilience to stress can promote nonsmoking. However, few studies have undertaken quantitative research to investigate whether resilience, generated by internal and external factors, moderates the impact of stress on the likelihood of smoking. Objective: This study aims to help fill this knowledge gap in relation to smokers and ex-smokers, and those people who have never smoked. Methods: A large online cross-sectional survey was administered in Australia (2015–2016) to collect data on demographic variables, levels of internal and external resilience, and stress from current and past smokers (n?=?400) and those who have never-smoked (n?=?921). Logistic regressions were employed to test our hypotheses. Results: Most participants were female (82%) and ranged between 18 and 77?years. Higher levels of reported perceived stress and stress-related variables did significantly predict smoking. The combined impact of internal and external resilience factors predicted never-smoking and lessened the relationship between perceived stress and stress-related variables, and the likelihood of smoking. Conclusion: These results are important because they suggest that the social environment should be developed to augment social support and internal properties such as developing “a strong sense of purpose in life” to encourage people not to commence smoking, rather than focus on smoking cessation.