• Users Online: 1097
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Browse Articles Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 54

Effect of a smoking cessation program on inpatients in the largest hospital in Southern Iran


1 Student Research Committee, Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
2 Indiana University School of Dentistry, Indianapolis, IN, USA
3 Department of Community Medicine, Medicinal and Natural Products Chemistry Research Center Shiraz University of Medical Sciences, Shiraz, Iran

Date of Submission10-Feb-2017
Date of Acceptance20-Jun-2017
Date of Web Publication06-May-2019

Correspondence Address:
Mehrdad Askarian
Department of Community Medicine, School of Medicine, Shiraz University of Medical Sciences, Karimkhan-e-Zand Avenue, P. O. Box: 71345-1737, Shiraz
Iran
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpvm.IJPVM_57_17

Rights and Permissions
  Abstract 


Background: There is evidence that cessation programs can be effective for hospital inpatients. Hence, the aim of this study was to investigate the effects of such programs and factors that may affect success. Methods: This study was carried out on in-patient users of tobacco in Shiraz Hospital, Iran in 2015. After implementing the inclusion criteria, a study population was selected using a convenience sampling method. Participants were contacted monthly by study personnel concerning certain aspects of their tobacco cessation program. The study lasted 6 months. Data analyses involved survival analysis using Kaplan–Meier analysis, log-rank test, and multivariate Cox regression modeling. Results: The study included 425 in-patient smokers of which 328 (77.2%) were male. Median follow-up time was 96 days (interquartile range: 20–150). Cessation survival rates were 76% at 1 month, 63% at 2 months, and 61% at 3 months. From the 4th month onward rates remained unchanged at 60%. Univariate analyses with variables such as time since last smoking, consumption type, interval between wake-up and consumption, the severity of dependence and interest in smoking cessation were statistically significant as to cessation survival rate (P < 0.05). After adjusting the confounding variables based on multivariable analyses, results indicated that consumption type, the severity of dependence and interest in smoking cessation were the most important predictors of cessation survival rates among in-patient smokers. Conclusions: Findings indicated that application of the cessation program among our group of inpatients appears to have been an effective intervention that produced an extended period of no smoking.

Keywords: Inpatients, smoking cessation, tobacco use


How to cite this article:
Shoorijeh FT, Palenik CJ, Askarian M. Effect of a smoking cessation program on inpatients in the largest hospital in Southern Iran. Int J Prev Med 2019;10:54

How to cite this URL:
Shoorijeh FT, Palenik CJ, Askarian M. Effect of a smoking cessation program on inpatients in the largest hospital in Southern Iran. Int J Prev Med [serial online] 2019 [cited 2019 Nov 15];10:54. Available from: http://www.ijpvmjournal.net/text.asp?2019/10/1/54/257754




  Introduction Top


Today, more than one billion people smoke tobacco making it a prime risk factor for the onset of chronic diseases including cancer, respiratory, and cardiovascular maladies. Tobacco smoking is responsible for approximately seven million deaths annually.[1]

Fatalities and other consequences of tobacco smoking are predicted to increase steadily over the next 30 years.[1],[2],[3] Tobacco smoking causes 16,000 deaths each year in England.[4] It is predicted that the prevalence of tobacco-related fatalities will continue to increase over the next 30 years, resulting in significantly higher medical costs and heavy economic losses in terms of decreased earnings and shorter life spans.[1],[5] Smoking intervention is a proven effective mechanism that through limiting tobacco use decreases incidences of disease and improves the overall quality of life.[5]

There are approximately 10,000,000 smokers in Iran, which results in 60,000 deaths (25% of all deaths) annually.[6] The benefits of tobacco cessation have been demonstrated repeatedly with the best results coming from those under the age of 35.[7] However, cessation even at the age of 70 also will result in preventing premature death.[7]

Because of smoking results in higher rates of hospitalization, Iranian medical facilities have since 1992 actively become involved with cessation programs. This includes establishing tobacco-free environments and formal cessation programs. It is known that such efforts can be successful, especially if the cause of hospitalization is tobacco-related.[2],[5],[8] In a 2001 study, 6-month cessation success was far greater among hospitalized patients who started to quit while being an inpatient (45% success rate) versus that of outpatients (25%).[9] Studies have reported the positive effect of decreasing tobacco use from financial and medical standpoints while the smoker was hospitalized.[2],[5],[8] Study data have resulted in the formation of cessation guidelines and protocols[2],[5] which indicate the need for an initial hospital consultation and pharmacotherapy that must continue after release.[5],[8]

Because of the importance and potential effectiveness of tobacco cessation programs in a hospital environment along with the emphasis of world health organization on the dangers associated with tobacco use, it was decided to implement such a program for the first time in Shiraz Nemazee Hospital. This facility is the largest medical center in Southern Iran. This study was carried out to investigate the effect of a tobacco cessation program and factors that could affect success.


  Methods Top


Study population

This research project reviewed inpatient tobacco smoking inpatients in Shiraz, Fars Province, Iran Approval for the study came from the Vice President of Research and Technology and the Ethics Committee (ec-p-9375-7155) of Shiraz University of Medical Sciences. During 2015, researchers visited all inpatients (2156 total) in several wards (including general and cardiac surgery, coronary care, internal medicine, neurology, and urology) to evaluate them in terms of having inclusion conditions (dependency on tobacco compounds such as cigarette, hubble-bubble, pipes, or chewing tobacco and ascertaining if the patient as willing to participate in a tobacco cessation program). In the end, 425 patients were recruited using a convenience sampling method after obtaining their informed consent.

Study process implementation

After inclusion, researchers reviewed initial patient data collection forms, which included demographic information, cause (s) for hospitalization, ward, contact phone number, companions, disease history among first-degree relatives, and the time elapsed since last smoking and dates of hospitalization. Another form was completed which included types of tobacco materials used, average daily consumption, interval between waking up in the morning and beginning tobacco consumption, the age when beginning to smoke, having a family member or close friend who also smokes, having received advice on cessation and an evaluation of the tendency to quit smoking. Finally, a date for a follow-up phone call or an in-person visit approximately 3 weeks after discharge was determined.

Because none of the participants desired an in-person visit, study researchers were forced to conduct the established protocol (except for medications) by phone (six monthly calls). During the initial contact, researchers informed participants of the study's goals. Implementation plans (methodology) was discussed during subsequent consultations. Patient national ID codes were applied to the study forms using software designed in-house. This meant that the completed forms could be opened and the patient information reviewed and edited, if necessary.

There were two conditions:

If the last tobacco smoking took place before hospitalization

Because smoking is forbidden in hospitalization wards, many of the patients began their cessation process while hospitalized. This means that forms and checklists were completed soon after admission as possible.

Data collected included the types and amount of the tobacco materials used, the average daily consumption, age when regular smoking began, the duration of nonsmoking, methods for and frequency of motivating schemes to help patients continue their cessation process, evaluation of a patient's desire to quit, including the most important reason for recent efforts to quit smoking, current methods of cessation used, including types and amounts of nicotine applications and patient satisfaction with the study. Data were incorporated into a formal checklist. In the next step, the patient readiness (e.g., prethinking, thinking, readying, or maintenance) was assessed. Patients received recommendations and strategies when judged ready for cessation. Researchers tried to present appropriate behavior modification techniques to address postcessation temptations.

If the last tobacco smoking took place <30 days ago (present/current smoker)

Data on the checklist used on present/current smokers included information such as type and amount of used tobacco materials, the average daily tobacco consumption, the age when beginning to smoke, evaluation of the desire to quit, previous cessation history, previous cessation methods, including types and dosage of the drugs employed, the interval since last cessation attempt and if cessation resulted in a minimum 24-h cessation in the past year. The checklist also reported on patient readiness for cessation within the next 30 days, their most important reason for trying to quit, perceived harmful signs of cessation and reason (s) and date for the last cessation's failure.

Based on checklist data patients were classified into two categories-interested and uninterested. In the interested group, the patients were asked to score their desire to quit smoking from 1 (lowest) to 5 (highest). Those with scores of at or near 5 were considered in the “ready to quit group” and were further evaluated as to their patient readiness. Those with scores of around 1 were categorized as to be in the “unready to quit group.” For these people, a cessation program was implemented that involved patient readiness steps, presentation of a motivational report and application of the 5R technique (relevance, risks, rewards, roadblocks, and repetition).

For those in the uninterested and hesitant groups (2–4), additional phone calls were made that included motivational interviews performed by the study researchers.

Description of protocol

Because none of the participants desired an in-person visit, study researchers were forced to conduct the established protocol by phone. After informing goals of the study, implementation plans was described during next consultations. In patients with the last tobacco smoking before hospitalization, basic needed data collected and in the next step, the patient readiness (e.g., prethinking, thinking, readying, or maintenance) was assessed. Patients received recommendations and strategies when judged ready for cessation. Researchers tried to present appropriate behavior modification techniques to address postcessation temptations. In patients with the last tobacco smoking took place <30 days ago, after collecting data as mentioned earlier, using checklist data, patients were classified into two categories – interested and uninterested. In the interested group, the patients who were “ready to quit group” and were further evaluated as to their patient readiness. Another group were labeled as “unready to quit group.” For these people, a cessation program was implemented that involved patient readiness steps, presentation of a motivational report and application of the 5R technique (relevance, risks, rewards, roadblocks, and repetition).

For those in the uninterested and hesitant groups, additional phone calls were made that included motivational interviews performed by the study researchers.

Analysis

All statistical analyses were conducted using the SPSS software package for Windows, Version 22 (SPSS Inc., Chicago, USA) and STATA version 11 (STATA Corporation, College Station, TX, USA). Continuous variables were presented as mean ± standard deviations or median and interquartile range (IQR). Qualitative variables are presented as numbers and percentages.

The Kaplan–Meier method was used to calculate observed survival, while log-rank statistics was used to compare the differences in survival curves. Furthermore, multivariate Cox proportional hazards regression analysis was performed to determine the influence of the programs and factors affecting cessation survival rate. Variables of P < 0.2 provided a basis for the proportional hazard assumptions and were entered into the Cox regression model using a forward likelihood ratio method. All probability tests were two-tailed with a P < 0.05 was considered statistically significant.

In this study, recitative smoking was considered as a countable event and inpatients that died or remained nonsmokers until the end of study were considered as censor. Variable time to event was assessed based on the moment that inpatients entered to study until the moment they started (or did not start) smoking again.


  Results Top


[Table 1] shows that 425 tobacco smoking inpatients, 328 men (77.2%) and 97 women (22.8%) participated. The median duration of follow-up was 96 (IQR = 20–150) days with a range of 1–230 days. The mean age of inpatients, their range of age and their median age were 52.7 ± 16.3, 18–94, and 52 years, respectively. Furthermore, the mean age of when smoking began was 26.4 ± 11.4 years, whereas the lowest and highest starting age were 9 and 82 years. 85.4% of patients had smoked during the last 30 days. Nearly 65.2% of participants smoked cigarettes, whereas 30.4% of smoke hubble-bubble (water pipe). The most widely used method for controlling smoking was complaints from smoker families who observed activity in and away from home. Nearly 90.4% were supported by their family to quit, whereas 88.7% were aware of the dangers associated with tobacco smoking. Demographic information of study participants can be found in [Table 1].
Table 1: The demographic information of inpatient smokers in Nemazee Hospital, 2015

Click here to view


Cessation survival rates were 91% after the 1st week, 84% at 2 weeks, 76% at 1 month, 63% at 2 months, 61% after the 3rd month and approximately 60% from the 4th month to the end of the study [Figure 1]. Comparison of cessation survival within the subgroup variables was studied using univariate conditions, including log-rank tests. Results indicated statistically significant relationships (P < 0.05) existed between cessation survival and select variables including the period since the last tobacco use, consumption type, the interval between wake-up and consumption, the severity of dependence and interest to smoking cessation.
Figure 1: The curve of the cessation function for the tobacco-smoking inpatients using the Kaplan–Meier method inpatient smokers in Nemazee Hospital, 2015

Click here to view


Six-months cessation survival rates for inpatients who had not smoked for at least 30 days before entering the cessation program were greater than those of inpatients whose last smoking event was <30 days previously (P = 0.05). Furthermore, the cessation survival rate for inpatients by consumption type indicated that more than one item smokers were higher than those using only cigarettes or hubble-bubble (P = 0.001). Moreover, patients with mild dependence had a greater cessation survival rate than those with severe dependencies (P = 0.002), whereas patients with a greater interest in stopping were more likely to quit (P = 0.037).

This study used a multivariate Cox regression model to investigate factors affecting on the cessation survival rate among tobacco-smoking inpatients after modifying for confounding factors. Variables with P < 0.2 values or better provided the foundations for proportional hazard assumption (PHreg plots) and entered into the Cox regression model using a forward likelihood ratio method.

The results of multivariate Cox analyses indicated that variables such as consumption type, the severity of dependence and interest in stopping smoking were the most important predictors of cessation survival rate for inpatient smokers. Patients who had no interest in stopping were 1.59 (confidence interval [CI]; 95%; 1.03–2.24) times more likely to use smoke again when compared with those interested a cessation program.

Furthermore, patients severely dependent on smoking were 1.81 (CI 95%; 1.29–2.53) times more likely to use again as compared to mildly dependent patients. Cigarette or hubble-bubble smokers had 4.61 (CI 95%; 1.44–14.71) and 2.36 (CI 95%; 0.67–7.38) times more likely to use again than more one item smokers, respectively [Table 2].
Table 2: The modeling of the factors affecting cessation in the tobacco-smoking inpatients by using Cox regression model inpatient smokers in Nemazee Hospital, 2015

Click here to view



  Discussion Top


Study results indicated that 60% of participants had quit by the end of their cessation course. In a study performed in the city of Yazd reported that a smoking clinic intervention scheme produced only a 16.6% success rate.[10] A study conducted by Hymowitz et al. revealed that 67% of participating cigarette smokers reported attempting a serious cessation effort; however, only 33% were successful by the end of the study.[11]

King et al. investigated tobacco cessation interventions among African–Americans. The desire to smoke and associated signs of depression had decreased during the 1st month of most programs. Cessation levels after the 1st, 2nd, 3rd and 4th weeks were 32%, 56%, 44%, and 34%, respectively and 22% after the 3rd through 6th months.[12] Another study, which was similar to that of King et al. in that is used the same population but different pharmacotherapy techniques plus a motivational interview, cessation values were 36% in the end of 7 weeks and 22% after 6 months.[12] The highest cessation level in the study's population was 49% at 6 weeks using a multi-step intervention method which included strong behavioral consultations, nicotine patches, social support, and mental health consultations employing the assistance of a variety of heath observers.

Another study used alternative methods for nicotine provision, and behavioral consultations reported that patients who had participated completely in a tobacco cessation course were more 50% more successful in quitting than those who had not participated in all coursework. It also has been reported that stronger participant desire to quit, improved surveillance, and more complete interventions will increase cessation. As intervention levels increase, cessation levels will increase by 2–3 times. It should be noted, nonparticipation in training courses may not be considered the only cause of cessation failure because many successful quitters had not participated in all sessions and cessation consultation courses.[10]

In this study, choosing inpatients as participants was likely one of the reasons for higher cessation levels at the 6-month point. Providing participants an opportunity to quit tobacco smoking while as inpatients proved advantageous. Munafò et al. reported that cessation might be easier in locations where cigarette smoking was limited or even prohibited. This study also indicated providing tobacco cessation services within a hospital environment helped those trying to quit and increased the chances of a longer cessation.[13] Park et al. showed that the patients hospitalized for coronary artery disease were more motivated to quit smoking than those hospitalized for other reasons.[14] Intervention among smokers with cardiovascular diseases proved motivated to quit after receiving a phone consultation.

Some of the inpatients that participated in this study were being treated for some type of cardiovascular disease (19.5%). Harms associated with smoking might have had a motivation effect to stop. In this study, 88.9% of participants were aware of the risks associated with tobacco smoking. In the survey done by Park et al.[14] more than 50% of participants declared that their knowledge about the harms of smoking was one of the early reasons for stopping. It appears that additional factors may have to be present to better assure a cessation attempt. Attending physicians may have to pay more attention to patient needs and provide stronger support for cessation. A constant level of encouragement appears required for improving the chances of smoking cessation.[14]

As in this study, Aminian et al. demonstrated significant differences exist between the successful and unsuccessful cessation groups in terms of having or not having smoking-related diseases.[10] Aminian et al. also revealed that those who were successful in cessation often suffered from smoking-related diseases, such as cardiovascular and/or pulmonary diseases (40.5% vs. 23.5%) and that having smoking-related diseases, changing behavior advice, lower nicotine dependence, and produced fewer postcessation complications. A study conducted in Korea followed patients for 96 months after heart surgery and found that 72% had remained tobacco-free.[14]

Studies conducted between 1996 and 2000 produced a set of clinical practice guidelines which emphasized the importance of physician-directed cessation interventions to help reduce tobacco consumption.[5],[6] The mentioned studies as well as the results of this study indicate that if consultations are made by health care personnel, especially physicians, the chances of cessation increased dramatically. However, McMenamin et al. reported that most users do not receive the tobacco cessation interventions from physicians in spite of the fact that almost 70% had visited their physician in the past year. It appears a possible chance for effective cessation intervention may have been lost.[15]

In today's complicated health care environment, greater attention should be paid to the fact that successfully treating dependence on tobacco best lies within the health care system.[14] According to meta-analyses results, US Clinical Practice Guidelines indicated. Short-term (<3 min), long-term (3-10 min) and very long-term (more than 10 min) consultations lead to cessation levels of 13.4% (2.5% higher than the control group–no consultations), 16% (5% higher than the control group), and 22.1% (11% higher than the control group) within a 6-month period, respectively.[5],[16]

Both single- and multivariable analyses of this study indicated that lower levels of tobacco dependence were associated with greater levels of cessation success. These findings meld well with the results of Aminian et al., which reported that successful and unsuccessful groups differed significantly in terms of initial levels of nicotine dependence.[10] Furthermore, in our study, about half of the patients (50.6%) had quit smoking sometime in the past, whereas 49.4% had no history of cessation. Cessation history, however, did not produce meaningful differences in cessation levels. These findings differ from those reported by Vafai et al. in Ilam, Iran.[17] That reported the cessation history significantly affected the chances of future tobacco usage. Differences between this study and Vafai's may be related to the fact that only inpatients were participated our cessation program.[14],[17]

Limitations

This study had limitations, including only inpatients, limited number of participants, older primarily male population, a lack of cooperation by some wards and failure of some participants to attend follow-up clinic sessions, requiring the use of monthly phone consultation calls. Other potentially affecting factors, such as health status, type and length of hospitalization and social and/or religious influences.

Implications of the study

We believe that hospitals should start working on smoking cessation programs as soon as the patient is admitted in the hospital.

A well-established program with the support of community medicine specialist could be very helpful to run this program in hospitals.


  Conclusions Top


Acceptance of tobacco cessation interventions may take time and require significant financial support and trained personnel. One possible way to make rapid advances is to conduct programs among hospital inpatients. The results of this study support the viability of such efforts.

Acknowledgements

We would like to thank the staff of Nemazee Hospital sections for their collaboration in collecting the data. This research was performed by Fateme Tabatabai Shoorijeh in partial fulfillment of the requirements for certification as a specialist in community medicine at Shiraz University of Medical Sciences.

Financial support and sponsorship

This research was supported financially by the Vice-Chancellor for Research at Shiraz University of Medical Sciences (grant numbers of 7155 and Razi festival of 7200).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Tobacco kills more than 7 million people per year and is costing the world economy USD 1.4 trillion annually, May 2017. Available from: http://www.who.int/fctc/mediacentre/press-release/wntd-2017/en/. [Last accessed on 2017 Aug 04].  Back to cited text no. 1
    
2.
Hays JT, Ebbert JO. Bupropion for the treatment of tobacco dependence: Guidelines for balancing risks and benefits. CNS Drugs 2003;17:71-83.  Back to cited text no. 2
    
3.
University of Wisconsin Center for Tobacco Research and Intervention. Treating Tobacco Use and Dependence in Hospitalized Patients: A Practical Guide; 2012. Availabnle from: http://www.ctri.wisc.edu/.  Back to cited text no. 3
    
4.
Twigg L, Moon G, Walker S. The Smoking Epidemic in England. London: Health Development Agency; 2004. Availabnle from: http://www.eprints.port.ac.uk/12146/.  Back to cited text no. 4
    
5.
Clinical Practice Guideline Treating Tobacco Use and Dependence Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008;35:158-76.  Back to cited text no. 5
    
6.
Heydari GR, Sharifi H, Hosseini M, Masjedi MR. The effect of effect of family on cigarette consumption among high school students in Tehran-2003. J Med Counc Iran 2006;24:24-33.  Back to cited text no. 6
    
7.
Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health The Health Benefits of Smoking Cessation: A Report of the Surgeon General; 1990. Available from: https://www.profiles. nlm.nih.gov/ps/access/nnbbct.pdf. [Last accessed on 2017 Aug 04].  Back to cited text no. 7
    
8.
University of Ottawa Heart Institute, 2012. Best Practice for Clinical Smoking Cessation in Canada. The Ottawa Model for Smoking Cessation; 2011-2012. Available from: http://www.ottawamodel.ottawaheart.ca/files/omsc/docs/omsc2011-12report.pdf. [Last accessed on 2017 Sep 04].  Back to cited text no. 8
    
9.
Swartz SH, Cowan TM, Klayman JE, Welton MT, Leonard BA. Use and effectiveness of tobacco telephone counseling and nicotine therapy in Maine. Am J Prev Med 2005;29:288-94.  Back to cited text no. 9
    
10.
Aminian A, Nouri Shadkam M, Ghovea M, Dehghani A, Ghomizadeh A, Lotfi M. The effect of interventions for smoking cessation in clinic Imam for visitors to the clinic. TOLOO-E-BEHDASHT 2007;6:47-58. [Persian].  Back to cited text no. 10
    
11.
Hymowitz N, Cummings KM, Hyland A, Lynn WR, Pechacek TF, Hartwell TD. Predictors of smoking cessation in a cohort of adult smokers followed for five years. Tobacco control 1997;6 Suppl 2:S5.  Back to cited text no. 11
    
12.
King A, Sánchez-Johnsen L, Van Orman S, Cao D, Matthews A. A pilot community-based intensive smoking cessation intervention in African Americans: Feasibility, acceptability and early outcome indicators. J Natl Med Assoc 2008;100:208-17.  Back to cited text no. 12
    
13.
Munafò M, Rigotti N, Lancaster T, Stead L, Murphy M. Interventions for smoking cessation in hospitalised patients: A systematic review. Thorax 2001;56:656-63.  Back to cited text no. 13
    
14.
Park AH, Lee SJ, Oh SJ. The effects of a smoking cessation programme on health-promoting lifestyles and smoking cessation in smokers who had undergone percutaneous coronary intervention. Int J Nurs Pract 2015;21:107-17.  Back to cited text no. 14
    
15.
McMenamin SB, Schauffler HH, Shortell SM, Rundall TG, Gillies RR. Support for smoking cessation interventions in physician organizations: Results from a national study. Med Care 2003;41:1396-406.  Back to cited text no. 15
    
16.
Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008;16;(2):CD000165.  Back to cited text no. 16
    
17.
Vafai B, Shahamfar J, Fadai Hagh A. Causes of tendency to smoking and the effect of psychological counseling, advice, therapy and nicotine gum to quit smoking in Tabriz university-2002. Tehran Univ Med J 2004;62:877-84.  Back to cited text no. 17
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed272    
    Printed32    
    Emailed0    
    PDF Downloaded38    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]