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Per CDC's 2019 Behavioral Risk Factor Surveillance System (explained in the article below), West Virginia had the highest rate of smoking in the country, at 23.8 %, followed by Kentucky, Louisiana, Ohio, Mississippi, Alabama, Arkansas, Tennessee, Missouri, Indiana, Oklahoma, and Michigan.

The effects are mostly perpetual because of changes in the structure of the vocal fold

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However, health experts emphasize that all tobacco products carry significant health risks regardless of their appearance, flavor, or marketing approach