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Experiences with smoking habits and the need for cessation among habitual smokers in Japan: a qualitative study based on semi-structured interviews



Although more than half of the habitual smokers recognize that they want to quit smoking cigarettes, approximately half have failed to quit and experienced distress relapse; therefore, there is an urgent need to focus on these populations. When chronic behavior occurs, it is necessary to view the behavior in the context of the entire life of the person involved, considering the history of the person. In this study, we aimed to describe experiences with smoking from the onset to the present and the need for smoking cessation among habitual smokers in Japan and to explore efforts to address them.


Semi-structured interviews that lasted for 55–90 min were conducted with the cooperation of 16 habitual smokers who smoked cigarettes daily. The content of the interviews included demographic characteristics, experiences with smoking from the onset to the present, whether they have attempted to quit and related experiences, and their thoughts on smoking. Interviews were transcribed verbatim and analyzed qualitatively. The Medical Research Ethics Review Committee of Jikei University approved this study (approval number: 33–384(11008)).


The participants were aged 26–59 years (mean ± SD: 40.8 ± 8.9 years) and included 10 men and 6 women. The participants started smoking between age 13 and 24 years. The highest number of cigarettes smoked in the participants’ lives ranged from 10 to 80 daily, and 12 participants had attempted to quit smoking so far without success. Regarding experiences with smoking from the onset to the present, four themes of “expand one’s world,” “unconscious attachment,” “attempts and failures,” and “losing oneself” were extracted. Regarding the need for smoking cessation, four themes of “empowerment from experts,” “peer interaction,” “social commitment,” and “recovery of confidence” were extracted.


To support smoking cessation from the perspective of habitual smokers, in addition to improvements through the existing approaches, it is important to recover their confidence using ongoing activities in peer groups according to the target background and support from experts incorporating visual assessments of lung function, along with multiple short-term goals. It is also necessary to raise awareness in communities through activities.

Peer Review reports


Smoking is a major risk factor for disability-adjusted life years (DALYs) [1], cancer [2], cardiovascular diseases [3], respiratory and chronic obstructive pulmonary diseases [4], mental health [5], tuberculosis [6], coronavirus disease 2019 (COVID-19) [7], and other diseases. Despite this, there were 1.14 billion smokers worldwide in 2019, with 769 million deaths and 200 million DALYs wasted owing to smoking [8]. The estimated smoking rate has decreased from 32.7% in 2000 to 22.3% in 2020, mainly because of several key measures implemented by the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC), namely, taxation, smoke-free policies, warning labels, bans on advertising, and cession programs [9]. However, the smoking population continues to increase in some countries [10]. Japan is among the top 10 countries with the highest number of smokers. These 10 countries account for approximately two-thirds of the global smoking population; therefore, smoking cessation is an urgent and important task [8].

Effective methods of smoking cessation include pharmacological therapy [11], nicotine replacement therapy [12], and various psychological therapies such as counseling [13, 14] and cognitive behavioral therapy [15, 16]. Combining these pharmacological or nicotine replacement therapies with psychological therapy has been found to be the most effective [17, 18], and many habitual smokers are attempting to quit on their own, one way or another. Particularly, a systematic literature review on changes in smoking behavior associated with COVID-19 confirmed large purchases and consumption of cigarettes owing to the lockdown, while smoking abstinence attempts and motivation have also increased [19], indicating a growing need for smokers to abstain. More than 70% of smokers in Japan intend to quit or reduce their smoking in 2019 [20]; however, another nationwide survey of habitual smokers in 2016 found that the percentage of smokers who attempted to quit during a year was 30%, and of these, half failed to quit smoking [21]. Similarly, there are numerous reports of long-term smoking cessation rates of approximately 50% worldwide [22, 23], depending on the population of trial smokers. The success rate of smoking cessation varies widely by region and social life, and it is essential to make a comprehensive effort for both individual smokers and the entire group. Efforts to enable smokers with diverse backgrounds to abstain from smoking temporarily and continue to abstain from smoking for a long period to prevent relapse are urgent.

In Japan, smoking control measures have been a top priority, according to the WHO-FCTC, and have also been emphasized in the Sustainable Development Goals. However, the laws and regulations corresponding to this convention are not yet in place. Furthermore, Japan is one of the countries worldwide lagging in taking countermeasures against smoking [24] because pressure from the tobacco industry, consideration for smokers, and tax revenues make it difficult to promote a smoke-free policy [25]. Throughout Japan, the Health Promotion Law, a related law, has been revised, but only to strengthen the prevention of passive smoking in some indoor areas [26]. In Tokyo, an advanced ordinance was enacted in time for the 2020 Olympic and Paralympic Games (held in 2021), banning smoking indoors in principle [27]. Japan’s average smoking rate of 16.7% in 2021 remains high among developed countries and is equal to the average smoking rate of The Organization for Economic Cooperation and Development countries in the same year [28]. Furthermore, the smoking rate among Japanese males in their 40s exceeded 36.5% in 2019, and 26.7% of smokers use heated cigarettes regularly, particularly among young and middle-aged people in their 20s–50s in Japan [20]. The risks of heated cigarettes are underestimated among smokers, and issues related to smoking withdrawal are becoming more obscure and complex. Therefore, appropriate methodologies should be considered, especially in studies that focused on behavior and attempt to teach skills to cope with smoking cravings [29].

Smoking is a tobacco addiction and a chronic behavior. When chronic symptoms and behavior occur, it is necessary to consider the behavior in the context of the entire life of the parties involved in the process [30]. In recent qualitative studies, individuals who smoked were asked directly about their smoking behavior, socio-cultural and environmental factors influencing smoking [31], perspectives on smoking habits [32], factors affecting smoking initiation and cessation [33], reasons for failure to quit smoking [34], and experiences of attempts to quit smoking [35]. However, the results of each study were based on the cultural background and living environment of the country or region and are expected to differ between countries or regions. Therefore, to examine smoking cessation support for habitual smokers in Japan, it is necessary to explore the smoking experiences and cessation need of this population.

In this study, we aimed to describe experiences with smoking from the onset to the present and the need for smoking cessation among habitual smokers and to discuss smoking cessation support from the perspective of the individuals involved. The consideration of the care process for continued abstinence from smoking, which is frequently accompanied by relapse, can contribute to the development of primary care science from the perspective of building partnerships with those who treat chronic symptoms and the inclusiveness of the care of those involved. It can also provide a methodology for recovery from chronic behavior and symptoms.



This was a qualitative descriptive study based on semi-structured interviews with current habitual smokers.


Participants were recruited using public offerings by distributing research cooperation flyers, which indicated “It is not necessary to be interested in quitting smoking, tell us about your smoking experience, we respect your experience,” at a community center and business establishments and through snowball sampling methods between March and October 2022. The inclusion criteria were (1) those who consented to the study and cooperated in the interview, (2) current habitual smokers who smoked multiple times daily, and (3) those aged between 20 and 60 years, considering the Law on the Prohibition of Smoking by Persons Under 20 Years of Age and a sharp decline in smoking rate after the age of 60 years, following retirement in Japan.

Data collection

The study was explained to the potential participants who agreed to participate in the study, and their consent was obtained on paper; interviews were conducted using Zoom Video Communications with eye contact on the screen. Interviews lasted between 55 and 90 min. According to Strauss et al. in 1984, a comprehensive understanding of individuals with chronic symptoms and behaviors involves considering not only their physical symptoms but also the trajectory of behavior, psychological aspects such as emotions and values, social aspects such as interactions with family and affiliations, and the person’s needs [30]. Therefore, we proposed two research questions: “What are the experiences of habitual smokers from the onset to the present?” and “What do habitual smokers need to continue abstaining from smoking based on these experiences?” Information on demographic characteristics, such as gender, age, education level, current cohabitants, cohabitant parent(s) until adulthood, cohabitant smoker(s) until adulthood, smoking history, comorbid diseases and symptoms, and other habits, were collected. Smoking experiences included (1) smoking experiences from the onset to the present and (2) thoughts about smoking. Smoking cessation need included (1) smoking cessation attempts, (2) factors that proved helpful and challenges encountered in the attempt to quit smoking (for participants who had not attempted cessation, anticipated factors that might influence their decision to quit, both positively and negatively), and (3) desired initiatives and environmental improvements toward smoking cessation. All interviews were recorded with permission and were transcribed into verbatim data.


Verbatim transcripts of the open-ended interviews were prepared for qualitative analysis. First, the responses to the questions were categorized into chunks of sentences, and codes were created to express them in a straightforward manner from the smallest unit of sentence whose meaning could be understood. Next, the multiple codes were classified according to similarities and differences in meaning. Two researchers performed these tasks. Subsequently, sub-themes were generated from codes, and interpretations between themes and sub-themes arising from the interrelationships between concepts were verified. Data were collected and interpreted until no new sub-themes emerged after considering new interviews, which implied that no more semantic content leading to new sub-themes could be obtained. One additional interview was conducted from the state of no emergence, and the interview was terminated when no new meaning was obtained to guide new sub-themes. We also emphasized in vivo codes/concepts, which were extracted using the expression of the narrative content to take advantage of specific expressions in the data. Finally, in the theme generation phase, we repeated our efforts to condense the meanings contained in the themes to create real expressions for all participants. To ensure the validity of the analysis, member checking was conducted. Subsequently, we attempted to refine the themes through repeated modification.

Ethical considerations

This study was approved by the ethics committee of Jikei University [approved January 2022; no. 33–384(11008)]. Before conducting the interviews, research and ethical considerations were explained to all participants, and written informed consent was obtained.


Demographics and smoking-related characteristics of participants (tables 1 and 2)

Table 1 Demographics and smoking-related characteristics of participants (N = 16)
Table 2 Participant characteristics (N = 16)

Participants were aged between 26 and 59 years (mean ± SD: 40.8 ± 8.9 years), and 10 were men; one participant was a part-time worker, and the rest had full-time jobs. For education level, seven were university graduates, five were college graduates, and four were high school graduates. Four participants were raised by a single parent during their childhood. Furthermore, 14 participants resided with families (mother or father or grandfather) who were smokers. The starting ages of smoking were from 13 to 24 years. Eleven participants started smoking before the age of 20 years when smoking was permitted under Japan’s law.

The highest number of cigarettes smoked in a single day in the participants’ lives ranged from 10 to 80 daily, and a few had recently changed from heated tobacco products to cigarettes. Twelve participants had attempted to quit smoking without success. Eleven participants had comorbid diseases, and some may have had other habits, such as alcohol or caffeine.

Experiences of smoking habits among habitual smokers in Japan (table 3)

Table 3 Experiences of smoking habits among habitual smokers in Japan (N = 16)

Four themes were identified as experiences with smoking from the onset to the present from the semi-structured interviews conducted among the participants. Table 3 is ordered according to themes, sub-themes, and the main narrative by participants representing the themes and sub-themes. The following describes the four themes and the sub-themes with double quotations, with each theme also explained based on what was stated by the participants.

  1. 1)

    Expand one’s world.

Participants developed an “interest in cigarettes” through the brands made famous by Formula One, movies, those smoked by their favorite celebrities, or through those recommended by their friends or part-time jobs. They also experienced “resistance to passive smoking” indirectly through their parents and siblings who smoked at home and the poor passive smoking environment at their part-time jobs. They also experienced “belonging to the peer community” by accepting invitations to spend time and space with their seniors and club mates. In addition, they experienced the “embodiment of oneself” by smoking cigarette brands with high nicotine and tar content or brands they were particular about. Thus, they expand their relationships and worldviews as “expand one’s world.”

  1. 2)

    Unconscious attachment.

When participants started smoking, they experienced a special sense of weight in their lungs and throat caused by the effects of cigarette inhalation and a momentary loss of consciousness due to vasoconstriction, which caused them to “perceive special sensations.” They had also experienced “switching their own mood” to divert their mind from hectic work and constant child-rearing. Gradually, they transcended to the experience of “calm the unrest,” where they implored themselves to pause for a cigarette each time, they completed a task. Thus, they developed the habit of “unconscious attachment,” where they could not let go of the cigarettes.

  1. 3)

    Attempts and failures.

Participants experienced “reflect on one’s own smoking habit,” where they reflected on the physical effects of their smoking and the meaning of smoking. They attempted to reduce the number of cigarettes they smoked and substituted candies, gum, and carbonated drinks for smoking. They visited a smoking cessation clinic to understand the effects of smoking cessation and to “explore smoke reduction and cessation.” However, they experienced “receiving an invitation to smoke” when they were invited by their friends or seniors to smoke, they started smoking again. Thus, they experienced “attempts and failures” when they repeatedly made an effort to quit smoking and relapsed.

  1. 4)

    Losing oneself.

Participants realized that they were spending more on buying cigarettes, taking breaks to smoke cigarettes, leaving earlier in the morning, having shorter lunches, and other time-consuming “outflow of time and money” experience. They also experienced “trust wavers” when their families disapproved of their smoking relapse, and loved ones were severely disappointed when they found out about their relapse. They also experienced a “shrinkage of whereabouts” as more of their friends succeeded in quitting smoking, and they were forced to smoke in secluded areas with silence and alone. Finally, they experienced “doubt about oneself,” where they refused to talk openly with those around them and became suspicious of their inability to stay away from cigarettes. They had experienced “losing oneself” through the above experiences.

Need for smoking cessation among habitual smokers in Japan (table 4)

Table 4 Need for smoking cessation among habitual smokers in Japan (N = 16)

Four themes were extracted as need for smoking cessation from the semi-structured interviews among habitual smokers. Table 4 is ordered according to themes, sub-themes, and the main narrative by participants representing the themes and sub-themes. The following describes the four themes and the sub-themes with double quotations, with each theme also explained based on what was stated by the participants.

  1. 1)

    Empowerment from experts.

“Empowerment from experts” was the need, which included “attitude of trying to understand,” where people who have been physically, mentally, and socially debilitated by smoking for a long time are sympathized with and healed from the difficulties of smoking cessation through consultations and understanding with doctors, nurses, and public health nurses at smoking cessation clinics and health centers. Participants also required “symptom relief” through medication, nicotine replacement therapy, and teaching relaxation techniques to ease nicotine withdrawal symptoms. Furthermore, participants needed “praise for efforts” from experts as they continued to abstain from smoking. They also needed to “visualize accomplishments” by gradually increasing the number of days of smoking cessation to realize that their short-term goals could be achieved gradually and by periodically measuring lung capacity to visually realize the changes in the lungs due to smoking cessation.

  1. 2)

    Peer interaction.

“Peer interaction” was the need which included “express weaknesses” of expressing the anguish of being unable to quit, the failure to quit smoking, and the pain of withdrawal symptoms. In addition, there was a need for “forward together,” a group of people who could meet face to face, even if they did not know each other, and discuss the progress of their multiple individual short-term goals together. They also needed “mutual acceptance” to understand each other’s feelings of guilt, the pain of relapse, and feelings of alienation from the response of those around them.

  1. 3)

    Social commitment.

“Social commitment” was a need with a view to the surrounding communities and country. There was a need for “public understanding” to understand their situation, such as it was not necessarily initiated solely by their intentions, the pain of being unable to quit smoking, withdrawal, the view of others as a source of passive smoking, and the pain of being considered incapable of self-care. There was also a need for a legal ban on smoking and an “ideal environment” where people could not smoke at all, including restrictions on the sale of cigarettes. Finally, there was a need for “political involvement” because of frustration and anger among the smokers that the government has not banned or supported smoking cessation while permitting the selling of cigarettes in stores and reducing the number of smoking areas. They felt that if the government wanted to reduce smoking, no message was being sent to smokers. They complained that they were being criticized as people who paid high taxes and ignored passive smoking.

  1. 4)

    Recovery of confidence.

“Recovery of confidence” was the need which included “realize one’s own efficacy” to increase self-efficacy by abstaining from smoking and building one’s achievements. In addition, there was a need to be “free from bondage,” i.e., to be free from withdrawal symptoms, the guilt of smoking, and the lack of confidence in being a smoker. Moreover, there was the need for “compassion for neighbors,” which meant caring for oneself and one’s family and neighbors.


This study described smokers’ experiences with smoking from the onset to the present and their need to continue abstaining from smoking based on these experiences. Below is a discussion of the characteristics of the study participants and the results.

Regarding study participants, four were raised by single parents during childhood, most of them had a family member who smoked until their adulthood, and more than half of them started smoking in their teens (the legal age to start smoking in Japan is 20 years old). Parental separation and nicotine dependence of parents in childhood are major examples of Adverse Childhood Experiences (ACEs); several studies related to ACEs have reported a correlation between the severity of ACEs and smoking behavior from teenage years [36, 37], particularly among mothers, which was considered high and overlapped with previous studies on ACEs [38]. Unfortunately, 12 participants had attempted but failed to quit smoking, with some making multiple such attempts. Moreover, the results of this study are similar to those of a previous study that found that the younger the age of smoking initiation and the more cigarettes smoked, the more difficult it was to successfully abstain from smoking [39], suggesting the need to strengthen anti-smoke education to ensure that no one is left behind including school-aged and adolescent individuals. Furthermore, in the process of attempting to abstain from smoking, other addictive behaviors, including alcohol, sugar, and caffeine addiction, were also observed, suggesting the difficulty in continuing to independently abstain from smoking. This finding also parallels existing knowledge that smokers are also overlappingly dependent on other substances [40]. The backgrounds of the participants were diverse but consistent with those of previous studies, and it was necessary to consider the contents and venues of the activities based on the participants’ backgrounds.

The experience of the initiation of smoking was triggered not only by the individual’s interest and concern but also by passive smoking when parents smoked at home, exposure to a poor passive smoking environment at a part-time job, and invitations from close friends to join a group. The participants attempted to broaden their worlds, and the initiation of smoking was caused by factors attributable to the environment during their youth. In a qualitative study on smoking initiation among adolescents, the factors of peer pressure, imitation of parents who smoke, and masculine curiosity were reported, and our study reported similar findings [31, 41]. “Unconscious attachment,” “attempts and failures,” and “losing oneself” were repetitive experiences of attempting and failing to abstain from smoking through a process of addict formation where smoking was substituted for something indispensable, an experience that ultimately resulted in the loss of money, time, trust in others, and trust in oneself. Notably, the participants had attempted to abstain from smoking multiple times in the past and experienced the pain of not being free from cigarettes. Therefore, when supporting smokers, it is essential not to isolate them but to engage them thoughtfully in the background of their smoking initiation and the long process that follows.

The need for smoking cessation “empowerment from experts” comprised encouragement to abstain from smoking, praise for attempting and continuing to abstain from smoking, alleviation of withdrawal symptoms through treatment and teaching relaxation methods, and empowerment through visual evaluation of results by quantifying the improvement in lung function and sharing the number of days of continued smoking cessation with multiple short-term goals. Previous studies have also reported the positive effects of psychological support and withdrawal symptom relief through relaxation programs, such as massage and exercise [13], and the endeavor for acceptance and encouragement without criticism [41]. Reports also state that visualizing one’s lung condition and its effects by presenting lung age are effective [42]. Therefore, it is important to provide support and empowerment through multiple means to support those abstaining from smoking. Concerning “peer interaction,” the participants needed a place where they could express their anxieties and frustrations about continuing to abstain from smoking, exchange information, and express their feelings of shame when they repeatedly failed to quit smoking, as well as a place where they could share their experiences with others who have a similar process. This need is similar to the “belonging to the peer community” aspect extracted from the participants’ experience, and it can be inferred that the participants were seeking companionship. Group programs inspired by group dynamics [43] have received attention in previous studies [44] and have been effective, particularly in Asian countries [45]. Therefore, peers may support each other in abstaining from smoking.

The need for neighbors, national, and political commitment was identified in “social commitment.” As shown in the experience of smoking, smokers frequently have considerable suffering in their backgrounds, including the pain of not being able to quit, and this should be understood by the people around them and by society. Previous studies that described the experience of smokers have similarly reported the need for understanding rather than criticism [41]. Japan’s smoking control measures emphasize the prevention of passive smoking [25], while providing inadequate support for smokers. The government should address the health and ethical issues (e.g., tobacco poisoning – “Can we offer poison to people?”) by separating them from concerns about the tobacco industry and tax revenue. Health professionals should also focus on supporting smokers who wish to quit, and adolescent anti-smoking measures should be adopted. The final and overarching need is “recovery of confidence,” which should be addressed concurrently in the same manner as “empowerment from experts,” “peer interactions,” and “social commitment.” In the experience of smoking, the others’ trust in the participant was shaken, resulting in a reduced sense of belonging and, thus, their confidence should be recovered. Smokers suffer more than two or three-fold from their inability to abstain from smoking, and it is essential to promote practices based on research to understand the feelings of smokers and their application of such research. The novelty of this study is that it describes the longitudinal experience of habitual smokers in Japan from the start of smoking to the present. To change a chronic behavior, it is necessary to consider the behavior in the context of the person’s life [30]. Thus, it is significant that we were able to interview and describe the need for smoking cessation based on smoking experiences. These points in the present study differ from those in existing qualitative studies with narratives from smokers [31,32,33,34,35]. Further, this need was identified not only toward professionals but also toward their peers and society. The importance of meeting this need in an integrated manner and regaining self-confidence was also considered.

As suggestions for program development, in addition to the conventional approaches of symptom relief and psychological support [13], it is important to incorporate a visual assessment of lung function along with the multiple short-term goals and to develop ongoing activities (place and content) in peer groups that are appropriate to the target background, and involve smokers in recovering their confidence. Simultaneously, it is necessary to educate adolescents, society at the community level, and political bodies about the situation of smokers to not only focus on anti-smoking measures.

Limitations and future studies

Because this study collected data based on the snowball sampling method and the distribution of flyers at a few establishments, it was assumed that the population was somewhat homogeneous regarding employment status, income, and other factors. It is also possible that some of the applicants who saw the flyer were interested in quitting smoking. Furthermore, participant narratives of smoking initiation may have been subject to recall bias. These may have influenced the results. Because smokers are a diverse population, it is necessary to determine the actual situation in diverse populations quantitatively.


The habitual smokers’ experiences with smoking from the onset to the present include “expanding one’s horizons,” “unconscious attachment,” “attempts and failures,” and “losing oneself.” In contrast, their need for abstinence requires “empowerment from experts,” “peer interactions,” “social commitment,” and “recovery of confidence.” Therefore, to support smoking cessation from the perspective of habitual smokers, in addition to improvements through the existing symptom relief and psychological support approaches, it is important to develop a program that incorporates the visual assessment of lung function, with multiple short-term goals and ongoing peer group activities. This not only helps to continue smoking cessation but also restores the confidence of the smokers. The program should also provide community education that is appropriate for the target audience.

Data availability

The datasets generated and/or analyzed in this study are not publicly available to protect the participants’ personal information and to guarantee that confidentiality was maintained during the informed consent process. Anonymized and de-identified data may be queried with the corresponding authors with reasonable request.



adverse childhood experiences


coronavirus disease 2019


disability-adjusted life years


World Health Organization Framework Convention on Tobacco Control


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The authors would like to express deep appreciation to all who participated in the study. The author would also like to express her deep gratitude to Editage.


This study was supported by a Grant-in-Aid for Young Scientists from the Japan Society for the Promotion of Science (grant no. 19K19737, PI. Kae Shiratani) and a Grant-in-Aid for Scientific Research (C) from the Japan Society for the Promotion of Science (grant no. 23K10301, PI. Kae Shiratani). In addition, an English editing service was used to assist with editing the manuscript.

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KS was the principal investigator and contributed to the conception and design of the study, data collection, data analysis, and writing of the manuscript. JS contributed to ensuring compliance with ethical matters and to data analysis. MM contributed to data analysis and writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Kae Shiratani.

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This study was conducted with the informed consent of all participants and the approval of the Research Ethics Committee of Jikei University (ID# 33–384 (11008)). All methods were performed in accordance with the relevant guidelines and regulations.

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The authors declare no competing interests.

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Shiratani, K., Shimasawa, J. & Mizutani, M. Experiences with smoking habits and the need for cessation among habitual smokers in Japan: a qualitative study based on semi-structured interviews. BMC Prim. Care 25, 1 (2024).

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