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Though the directionality here is yet unclear (i.e., are smokers more likely to develop a mental health condition or the other way around?), studies have shown that the more severe an individuals mental health condition is, the higher the chance they will also smoke

Youre in charge

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It was referenced by Valve in their outtakes for "Meet the Medic", where the Spy's decapitated-but-still-alive-head holds a mouthful of nails in a similar way

Most of the time, smoking is a sign of social standing

Because they already look like smoke