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From 1990 to 2021, high-income North America, Western Europe, and Australasia had the fastest declines in ASMR and ASDR, while North Africa and Middle East, South-East Asia, Andean Latin America, South Asia, Western Sub-Saharan Africa, Oceania, Eastern Sub-Saharan Africa, and Central Sub-Saharan Africa were stable

That said, the size of these effects is uncertain

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The marketing and appealing packaging has also raised questions about what these products will do to youth nicotine use and smoking rates