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Developing and evaluating a smoking cessation program combined with an Internet-assisted instruction program for adolescents with smoking.

OBJECTIVE: The purpose of this study was to develop a smoking cessation program combined with an Internet-assisted instruction (IAI) program to help youth smokers quit smoking, and to evaluate the effectiveness of the program in changing youth's attitudes toward smoking, smoking behavior, and self-efficacy for smoking cessation. METHODS: To achieve this goal, a comparative study of 77 senior high students divided into two groups was conducted. One group, designated as the experimental group, accepted a 6-week smoking cessation program plus an IAI program and the other group did not receive any intervention as the comparison group. All participants completed questionnaires before and after the program. RESULTS: The results showed that the strategy of combining the smoking cessation program and an IAI program was highly effective in terms of effects upon the youth's attitude towards smoking, smoking behavior, and self-efficacy. There was a highly positive correlation between the participants' attitude toward smoking and self-efficacy. In contrast, cigarette consumption was in a strongly negative correlation with self-efficacy. CONCLUSION: Most of all participants in the experimental group recognized the effectiveness of the program, and thought the smoking cessation program with an IAI program was helpful and welcomed by youth. This study can serve as reference for future design and implementation of IAI programs for youth smoking cessation.

Adolescent↗

Parental smoking cessation and children's smoking: mediation by antismoking actions.

The present study investigated whether parents' antismoking actions mediated the prospective relationship between parental smoking cessation and children's smoking. Smoking status of parents (predictor) was assessed when their children were in 3rd grade, parental antismoking actions (mediators) were assessed when their children were in 11th grade, and children's smoking status (outcome) was assessed when they were in 12th grade. In 20 Washington state school districts, data were collected from 1,600 children (49% female, 91% White) and from their parents. Results showed that children's odds of daily smoking were reduced by 39% (95% CI = 24%-51%) for those whose parents had quit smoking, compared with those whose parents were current smokers. Asking to sit in nonsmoking sections of public establishments was a significant (p<.01) mediator that explained 64% of the association between parental smoking cessation and children's smoking. However, not allowing smoking in the home and asking others not to smoke around them were not significant mediators (p = .10, and p = .06, respectively). In conclusion, asking to sit in a nonsmoking section of a public establishment substantially mediates the relationship between parental smoking cessation and children's smoking.

Adolescent↗

US adult attitudes and practices regarding smoking restrictions and child exposure to environmental tobacco smoke: changes in the social climate from 2000-2001.

OBJECTIVE: A substantial proportion of homes and automobiles serve as settings for environmental tobacco smoke (ETS) exposure, and many public settings that children frequent are still not smoke-free. Tobacco control efforts are attempting to increase smoking bans. The objective of this study was to describe the knowledge, attitudes, and practices of smokers and nonsmokers regarding smoking bans and child ETS exposure in multiple public and private settings and to report changes from 2000-2001. METHODS: Cross-sectional data from the annual Social Climate Survey of Tobacco Control were analyzed for changes in knowledge, attitudes, and practices regarding tobacco. These data were collected via automated, random-digit-dialing telephone surveys that were conducted in the summers of 2000 and 2001. The samples were weighted by race and gender to be representative of the US population. RESULTS: Response rates for eligible adults actually contacted were 1501 (75%) of 1876 in 2000 and 3002 (84%) of 3566 in 2001. The majority of adults, both smokers and nonsmokers, support smoking bans in a wide variety of places. The percentage of all respondents reporting the presence of smoking bans in several public and private places increased from 2000-2001: the household (69%-74%), in the presence of children (84%-88%), convenience stores (68%-74%), fast-food restaurants (52%-58%), and non-fast-food restaurants (25%-28%). Support for smoking bans also increased in shopping malls (71%-75%), fast-food restaurants (77%-80%), and indoor sporting events (78%-80%). There were no significant changes in support for smoking bans in convenience stores, restaurants, or outdoor parks. Adults' knowledge of the harm caused by tobacco was unchanged, with the vast majority of adults recognizing the dangers of exposure to ETS from parental smoking (95%) and exposure to ETS in cars (77%). CONCLUSIONS: Small improvements in adult attitudes and practices regarding children's ETS exposure occurred from 2000-2001. However, a significant number of adults in the United States still report ignorance of the harmful effects of child ETS exposure, and there was no improvement in reported knowledge in this 1-year period. In contrast, a growing majority of smokers and nonsmokers favor restrictions on smoking in public settings, suggesting that states and communities have public support for broad public smoking restriction policies. There are significant roles that pediatricians can play in preventing children's ETS exposure, through both patient and family education and by moving smoking restriction policies forward on their community's agenda.

Adult↗

Smoking habits of office-based general practitioners and internists in Austria and their smoking cessation efforts.

Tobacco smoking is the major cause of lung disease. This study aimed to determine: 1) the prevalence of tobacco smoking among office-based physicians; 2) their readiness to inquire about their patients' smoking habits and, if need be, to motivate them to stop smoking; 3) whether non-smoking doctors advise their patients more frequently to stop smoking than their smoker colleagues do. A self-designed questionnaire on a post card was sent to 7674 office-based general practitioners (GPs) and internists. 1395 (18.2%) questionnaires were returned. Independent telephone interviews with 91 doctors were also carried out to minimize the bias of self-presentation. Just under 11% of doctors were smokers. About 50% of all doctors who responded described themselves as ex-smokers. 38% of the smokers would accept outside help to stop smoking. About 50% of GPs and 90% of internists inquire about the smoking habits of their patients during history taking. Of these, 85% of GPs and 92% of internists recommend their patients to stop smoking. Doctors who themselves are smokers do so less than their non-smoker colleagues. For this reason, a further reduction in the smoking prevalence among doctors would be of special importance. Inquiry about smoking habits in the initial history taking should be stressed more to identify any smoker who can be subsequently encouraged to stop smoking.

Austria↗

[Smoking habits, attitudes and smoking cessation among sixth-year medical students of Kaunas University of Medicine].

UNLABELLED: The aim of the study was to assess trends of smoking and the relation between smoking behavior of undergraduate medical students and their attitudes towards smoking and treatment of tobacco dependence. METHODS: Data were collected from sixth-year medical students of Kaunas University of Medicine during ten consecutive years. A total of 1518 students completed the anonymous questionnaire; response rate was 83.5%. RESULTS: The daily smoking rate was 19.4% in males and 4.2% in females; 15.9% and 10.4% respectively were irregular smokers, never smoked 41.6% of males and 64% of females. 70% of smokers and 83% of nonsmokers agreed that tobacco smoking is one of the greatest health hazards of modern times; 97.1% of all students considered passive smoking as harmful. More nonsmokers (70%) than smokers (5l%) were aware of addictive nature of tobacco, but there was a little difference in their opinion about support to smokers for quitting: 83.2% of smokers and 87.1% of nonsmokers stated that medical doctors should help smokers to give up smoking and 68% of them thought that doctors had not enough knowledge how to help. Less smokers (55%) than nonsmokers (87%) believed that smoking should be banned in hospitals. CONCLUSIONS: Prevalence of smoking was significantly lower among medical students than in general population. There were no significant changes in smoking prevalence among male medical students during the period of 1995-2004. At the same time smoking prevalence among female medical students increased more than twice. Attitudes of smokers and nonsmokers were significantly different on most items of tobacco, but knowledge of tobacco problem in the undergraduate students was not sufficient. Teaching about tobacco and related issues remains essential in the undergraduate medical course.

Attitude to Health↗

[Smoking behavior and views on the smoking topic in the Styrian population--results of a survey at the Graz autumn convention].

Cigarette smoking has been identified as a major risk factor for cardiovascular diseases apart from hypercholesterolemia and arterial hypertension. Diseases of the respiratory system and several neoplasms as well as complications of pregnancy are considered to be "smoking-related", too. In order to survey the smoking habits and views on smoking in the Styrian population, a questionnaire was issued to 1034 visitors of the Graz Autumn Fair 1992. Pleasure proved to be the main motivation for smoking both in men and in women, habit, addiction, stress and boredom being further motivations. Not only non-smokers, but also smokers were assessed to be aware of smoking being a health hazard. Prohibition of tobacco advertising was accepted most widely as a mean of anti-smoking campaign. About half the non-smokers are exposed to environmental tobacco smoke, at place of work more frequently than at home. Percentage of smokers differs with age and job classes, however, no geographical variations were found. Further anti-smoking measures should be considered. Smoking restrictions at place of work and in public could prevent passive smoking. Ban on advertising seems to be the most effective anti-smoking campaign.

Adolescent↗

No-smoking laws in the United States. An analysis of state and city actions to limit smoking in public places and workplaces.

OBJECTIVE: To assess the prevalence, content, and growth of state and city laws restricting smoking in public places and workplaces in the United States and to identify factors associated with their passage. DESIGN: A mailed survey of city clerks in US cities with a population of 25,000 or greater (N = 980) and review of existing data sources confirmed the status of smoking restrictions in 902 (92%) of the cities in the sample. State laws were identified by contacting each state's Legislative Reference Bureau (100% response). Content of laws was coded using previously developed categories. MAIN OUTCOME MEASURES: Prevalence, comprehensiveness, and cumulative incidence of no-smoking laws in states and in cities with a population of 25,000 or greater. RESULTS: By July 1989, 44 states and 500 (51%) of the cities in our sample had adopted some smoking restriction, but content varied widely. While 42% of cities limited smoking in government buildings, 27% in public places, 24% in restaurants, and 18% in private workplaces, only 17% of cities and 20% of states had comprehensive laws restricting smoking in all four of these sites. The number of city no-smoking laws increased tenfold from 1980 to 1989. City no-smoking laws were independently associated with population size, geography, state tobacco production, and adult smoking prevalence. Laws were more common in larger cities, Western cities, and states with fewer adult smokers. Laws were less common in tobacco-producing states and in the South. CONCLUSIONS: No-smoking laws are more widespread than previously appreciated, especially at the local level, reflecting a rapid pace of city government action in the 1980s. Nonetheless, comprehensive laws, which are most likely to provide meaningful protection from environmental tobacco smoke exposure, remain uncommon and represent a major gap in smoking control policy. Laws are most needed in smaller and non-Western cities and in states that produce tobacco and have a higher proportion of smokers.

Humans↗

Restrictive smoking policies in the workplace: effects on smoking prevalence and cigarette consumption.

BACKGROUND: Thirty-two worksites participating in a randomized trial of worksite health promotion aimed at reducing smoking and obesity were categorized at baseline and 2 years later as having either restrictive or unrestrictive smoking policies. Between the two assessment points, 16 sites received health promotion interventions. RESULTS: At baseline 15 sites had restrictive policies and 17 unrestrictive policies. Smoking restrictions were associated with significantly lower smoking prevalence and higher lifetime quit rates among ever smokers. They also were associated with more recent quit attempts and lower daily cigarette consumption, although these effects were not significant. Between baseline and follow-up, 9 of the 17 worksites that had few smoking restrictions at baseline became restrictive. Although neither baseline smoking policies nor changes in smoking policy predicted change in smoking prevalence or in the frequency of quit attempts, smokers in sites changing from unrestrictive to restrictive policies reported a significant reduction in daily cigarette consumption. CONCLUSIONS: The worksite health promotion program was successful in reducing smoking prevalence in intervention sites compared to controls. However, the existence of restrictive smoking policies neither helped nor hindered these intervention efforts. The present data are believed to support the idea that restrictive smoking policies have beneficial effects on the smoking habits of employees, but that the magnitude of this effect is modest.

Analysis of Variance↗

Effectiveness of the "Smoke-Free Class Competition" in delaying the onset of smoking in adolescence.

BACKGROUND: This paper examines the effectiveness of the "Smoke-Free Class Competition" in delaying the onset of smoking in adolescence. Each participating class must decide if they want to be a "smoke-free class" for the 6-month period from fall to spring. Classes monitor their (non-)smoking behavior and report it to the teacher regularly. Classes in which pupils refrain from smoking for this period of time participate in a prize draw, in which they can win a number of attractive prizes. METHODS: To evaluate the effectiveness of the competition, a sample of 131 participating and nonparticipating classes (number of pupils 2,142; mean age 12.9 years, SD = 0.98) was compared with regard to their smoking behavior. Smoking status was determined by self-assessment on three occasions: (a) prior to the beginning of the competition, (b) 1 month after the competition, and (c) 1 year after the start of the competition. RESULTS: From pretest to posttest smoking increased by 7.5% in the comparison group, while it decreased by 0.2% in the intervention group (OR = 2.19; P < 0.001). In the follow-up measurement, a clear increase in smoking prevalence occurs in all groups; however, the pupils in the intervention condition still have a significant lower increase of smoking (OR = 1.45; P < 0.01). Moreover, with regard to the nonsmokers at baseline, pupils in the comparison group showed significantly higher prevalences in smoking than the intervention group in the postmeasurement, 7.8 versus 13.9% (OR = 1.98; P < 0.001), as well as in the in the follow-up-measurement, 17 versus 21.3% (OR = 1.36; P < 0.05). CONCLUSIONS: The results suggest that the participation in the competition could delay the onset of smoking in adolescence.

Adolescent↗

The implications of simultaneous smoking initiation for inferences about the genetics of smoking behavior from twin data.

We examined early social influences across stages of smoking within the context of a twin study using an environmental exposure specific to smoking: whether twins started smoking at the same time ("simultaneous smoking initiation": SSI). We expected that SSI would be a good index of shared social influences on smoking initiation. Rates of SSI were indeed significantly higher in MZ twins and in twins who shared peers and classes, as well as in male twins. With the exception of regular smoking in females, we found no significant difference in estimates of genetic and environmental parameters between SSI and non-SSI pairs for any of the smoking measures that we examined (DSM-IV and Fagerstrom HSI measures of nicotine dependence; DSM-IV nicotine withdrawal; heavy smoking; and in males, regular smoking). For regular smoking in females, allowing for additional shared environmental influences associated with SSI only modestly reduced our estimates of additive genetic variance (56% vs. 68%). These results indicate the important social influences that may occur for smoking initiation do not appear to seriously bias estimates of genetic effects on later stages of smoking.

Adult↗

Smoking and passive smoking during pregnancy and early infancy: effects on birth weight, lactation period, and cotinine concentrations in mother's milk and infant's urine.

The extent of smoke exposure via mother's milk and passive smoking was investigated in a prospective, longitudinal matched-pair study by comparison between children, whose mothers smoked substantially throughout pregnancy and nursing period and children whose mothers did not smoke. Our preliminary results show that not only infants of smoking mothers but also those of smoking fathers show reduction of birth weight. Smoking mothers weaned their babies earlier than non-smokers. Cotinine concentrations in breast milk depended on the number of cigarettes smoked. The highest urinary excretion of cotinine (as expressed by ng cotinine/mg creatinine ratios) were observed in infants fully breast-fed by smoking mothers. After weaning the values were in the same range as those of formula-fed infants of smoking mothers (exposed to passive smoking only). In the group of non-smokers only small or undetectable amounts of cotinine were found. Thus it is demonstrated that both nursing and--to a lower degree--passive smoking contribute to the exposure of infants to nicotine and its metabolite cotinine.

Birth Weight↗

A randomized controlled trial of the simple advice given by obstetricians in Guangzhou, China, to non-smoking pregnant women to help their husbands quit smoking.

This is a randomized controlled trial to examine the effects of obstetrician's simple advice given to non-smoking pregnant women with the aim to help their husbands to give up smoking. Non-smoking pregnant women who were attending the Guangzhou Women and Children Health Care Centre and whose husbands were smokers were each randomised to an intervention (N = 380) or a control (N = 378) group. The members of the intervention group each received simple advice on encouraging their husbands to give up smoking and an educational booklet at their first antenatal visit, and reminders during subsequent visits, whereas the control group received none, as is the usual practice. Husbands' not smoking for 7 and for 30 days were the main outcomes of the study; other outcomes included husbands' attempts to stop and any decrease in the number of cigarettes smoked. These outcomes were assessed by means of a questionnaire responded to in the last month of pregnancy, which was subjected to 'intention-to-treat' analysis. Results show that more husbands in the intervention group had attempted to stop smoking (30.0% versus 22.2%; p = 0.02), reduced the number of cigarettes smoked (39.7% versus 17.7%; p < 0.0001), and had not smoked any cigarettes for the last 7 days before their wives completed the questionnaire (8.4% versus 4.8%; p = 0.04). The difference between groups in the number of husbands who had abstained from cigarettes for at least 30 days was not significant (6.1% versus 4.2%; p = 0.26). Obstetricians should consider incorporating advice on passive smoking into the antenatal programme for non-smoking pregnant women with smoking husbands.

Chi-Square Distribution↗

Is maternal smoking more determinant than paternal smoking on the respiratory symptoms of young children?

BACKGROUND: It is generally accepted that maternal smoking has more detrimental effects than paternal smoking on the respiratory health of children. The objective of this study was to assess the effects of postnatal exposure due to the smoking behaviour by father and mother in the home, and prenatal exposure from maternal smoking during pregnancy, on the respiratory symptoms in children. METHODS: The parents of 484 children, aged 3-6 years, completed a questionnaire about smoking and respiratory symptoms in children. Bivariate and logistic regression analyses were used to examine the associated factors with respiratory symptoms. RESULTS: The final model of logistic regression analysis showed that prenatal exposure by maternal smoking during pregnancy increased the risk of wheezing with colds (adjusted OR=2.00, 95% CI:1.13-3.55) with respect to those children whose mothers reported no smoking during pregnancy. Postnatal exposure by maternal smoking in the home, in the presence of the child, increased the risk of cough with phlegm (adjusted OR=2.79, 95% CI:1.23-6.30) with respect to those children whose mothers did not smoke in their presence. Paternal smoking was associated with wheezing and cough in the bivariate analysis, but did not remain significant in the multivariate analysis. CONCLUSIONS: Our results underline a greater influence of exposure to maternal smoking (prenatal and postnatal) than postnatal paternal smoking on the development of respiratory symptoms in young children.

Air Pollution, Indoor↗

[Smoking habits, exposure to environmental tobacco smoke, and respiratory symptoms in schoolchildren aged 14-15 years in Terrassa (Barcelona)].

OBJECTIVES: Assessment of the prevalence of smoking habits, environmental tobacco exposure, and asthma-related symptoms in a cross-sectional study in schoolchildren aged 14-15 years in Terrassa (Barcelona). METHODS: A sample of 793 students from 21 schools answered a self-administered questionnaire including information on smoking habits, environmental tobacco exposure and asthma-related symptoms. RESULTS: The prevalence of smoking daily was 16.3% (CI 13. 7-18.9); no difference between sexes were observed, while the proportion of occasional smokers was higher among girls. Age, maternal habit, friend's smoking habit and having older siblings were independently associated to the schoolchildren's smoking habits. Overall, 13% reported a positive history of wheezing and 20.3% of nocturnal cough during the previous year. Smoking daily and passive smoking were positively associated with the prevalence of asthma-related symptoms, but not with previous diagnosis of asthma. CONCLUSIONS: The prevalence of smoking among adolescents seems to have levelled off. There is some trend toward a higher prevalence among girls than among boys. The presence of smoking in the social environment is a strong predictor of the smoking habits among schoolchildren. Both active smoking and environmental exposure to tobacco smoke are associated to increased asthma-related symptoms.

Adolescent↗

Motivational factors related to quitting smoking among prisoners during a smoking ban.

Motivational factors and initial stages of change (precontemplation vs. contemplation) were investigated among incarcerated male smokers forced to quit smoking due to a statewide smoking ban. All smokers completed a baseline questionnaire, which assessed smoking history, nicotine dependence [Fagerstrom Test for Nicotine Dependence (FTND)], nicotine withdrawal [Hughes-Hatsukami Withdrawal Scale (HHWS)], and depression [Center for Epidemiological Studies on Depression (CES-D)]. These measures were given again 4 days (Time 2) and 1 month (Time 3) following the smoking ban. At baseline (n=314), 31.2% of smokers were contemplating quitting within 6 months (contemplators), while the majority of smokers (68.8%) indicated they had not considered quitting (precontemplators). Contemplators at Time 2 reported more success with quitting smoking than precontemplators, although this was no longer significant by Time 3. Logistic regression was used to determine the probability of determining initial stages of change based on demographic and smoking history variables. Smokers in precontemplation scored higher on the FTND, reported less agreement with the smoking policy at baseline, reported more difficulty with their previous quit attempts, and reported increased smoking in anticipation of the smoking ban. The risk of being a precontemplator was over twice as high for smokers who reported increasing the amount they smoked prior to the smoking ban (odds ratio=2.42). Overall, this model correctly classified 70.7% of the smokers. This suggests that initial stages of change plays an important role in eventual quitting even in environments in which smoking has been recently prohibited.

Adolescent↗

Nine-year prospective relationship between parental smoking cessation and children's daily smoking.

AIMS: The first prospective investigation of the extent to which parental smoking cessation predicts their children's daily smoking. DESIGN: Parental smoking status was assessed when children were aged 8/9 years and children's smoking status was assessed at age 17/18 years. SETTING: Twenty Washington State school districts in the control group of the Hutchinson Smoking Prevention Project. PARTICIPANTS AND MEASUREMENTS: Questionnaire data were gathered on 3012 children (49% female and 91% Caucasian) and both of their parents in a cohort with a 95% retention rate. FINDINGS: When both parents quit smoking, children's odds of daily smoking were reduced by 39% (95% CI = 15%,56%) compared to when both parents were current smokers.Furthermore, when both parents never smoked then children's odds of daily smoking were reduced by 71% (95% CI = 62%,78%). CONCLUSIONS: Parental smoking cessation is associated with reduced risk of their children's daily smoking. Parents who quit still place children at substantially higher risk compared to parents who never smoked.

Adolescent↗

Understanding people who smoke and how they change: a foundation for smoking cessation in primary care, part 2.

The purpose of this 2-part article is to develop an understanding of people who smoke and how they change as a foundation for the delivery of smoking cessation interventions in primary care. Central to our approach is the transtheoretical model of change (TMC). The TMC is an evidence-based model of behavior change that has been developed and tested during the past 2 decades by Prochaska and his colleagues in the context of smoking cessation. We use a review of the literature, in-depth interviews of people who successfully quit smoking, and our experience applying the TMC in the context of primary care and a smoking cessation clinic to explore the clinical work of smoking cessation. This is part 2 of the article "Understanding People Who Smoke and How They Change: A Foundation for Smoking Cessation in Primary Care." Part 1 describes the theoretical information known about smoking cessation: why smoking is a powerful behavior, the scientific background of the TMC, and the building-block constructs of the TMC. The first section of part 2 is a review of the Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence, published in 2000. The second chapter of part 2 is a discussion of clinical assessments and strategies for working with smokers grounded in the Public Health Service practice guideline, our understanding of people who smoke, and the TMC. Woven throughout are transcripts of interviews with 4 people in which they describe their experiences smoking and their pathways to cessation.

Adult↗

Gene expression profiling in lung tissues from mice exposed to cigarette smoke, lipopolysaccharide, or smoke plus lipopolysaccharide by inhalation.

The purpose of this study was to investigate whether coexposure to lipopolysacchride (LPS) will heighten the inflammatory response and other pulmonary lesions in mice exposed to cigarette smoke, and thus to evaluate the potential use of this LPS-compromised mouse model as a model for chronic obstructive pulmonary disease (COPD) investigation. AKR/J male mice were exposed to HEPA-filtered air (sham control group), cigarette smoke (smoke group), LPS (LPS group), or smoke plus LPS (smoke-LPS group) by nose-only inhalation. Lungs were collected at the end of the 3-wk exposure and processed for microarray analysis. Clustering and network analysis showed decreased heat-shock response and chaperone activity, increased immune and inflammatory response, and increased mitosis in all three exposed groups. Two networks/function modules were exclusively found in the smoke-LPS group, that is, the downregulated muscle development/muscle contraction process and the upregulated reactive oxygen species production process. Notably, the number of genes and function modules/networks associated with inflammation was reduced in the smoke-LPS group compared to the LPS group. The most upregulated gene in the smoke group, MMP12, is a matrix metalloproteinase that preferentially degrades elastin and has been implicated in COPD development. NOXO1, which was upregulated in all three treatment groups, positively regulates the expression of a subunit of NADPH oxidase (NOX1), a major source of reactive oxygen species, and may play an important role in the pathogenesis of COPD. Serum amyloid A1, which is an acute-phase systemic inflammation marker and can be induced by LPS exposure, was significantly upregulated in the LPS and smoke-LPS groups. MARCO, a scavenger receptor expressed in macrophages that may play a significant role in LPS-induced inflammatory response, was upregulated in the LPS group and the smoke-LPS group, but not in the smoke group. In conclusion, gene expression profiling identified genes and function modules that may be related to COPD pathogenesis and may be useful as biomarkers to monitor COPD progression. In addition, an LPS-compromised mouse model showed potential as a useful tool for studying cigarette smoke-associated COPD.

Administration, Inhalation↗