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E-cigarettes may be eroding this intention not to smoke, or introducing the kids to nicotine

[17] Estimates put Chinese counterfeit production as high as 400 billion cigarettes per year to meet international demand.[18] Because of the enormous volume of product that ships into US ports from China, it may be easier and lower cost to smuggle Chinese cigarettes into California markets through US ports than to try to capitalize on tax arbitrage by transporting products across the continental US

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Physicians in particular may resort to tobacco as a coping mechanism to deal with the day-to-day stress that is associated with long work hours and difficult patient interactions