Abstract
Objectives. We compared exposure to secondhand smoke (SHS) and attitudes toward smoke-free bar and nightclub policies among patrons of lesbian, gay, bisexual, and transgender (LGBT) and non-LGBT bars and nightclubs.
Methods. We conducted randomized time–location sampling surveys of young adults (aged 21–30 years) in 7 LGBT (n = 1113 patrons) and 12 non-LGBT (n = 1068 patrons) venues in Las Vegas, Nevada, in 2011, as part of a cross-sectional study of a social branding intervention to promote a tobacco-free lifestyle and environment in bars and nightclubs.
Results. Compared with non-LGBT bars and nightclubs, patrons of LGBT venues had 38% higher adjusted odds of having been exposed to SHS in a bar or nightclub in the past 7 days but were no less likely to support smoke-free policies and intended to go out at least as frequently if a smoke-free bar and nightclub law was passed.
Conclusions. The policy environment in LGBT bars and nightclubs appears favorable for the enactment of smoke-free policies, which would protect patrons from SHS and promote a smoke-free social norm.
Secondhand smoke (SHS) exposure increases the risk of cardiovascular disease, respiratory conditions, and cancer.1 Bars and nightclubs are tobacco-friendly environments that the tobacco industry uses as marketing and promotional venues.2–4 In the absence of a smoke-free law that covers bars and nightclubs, these venues can also have particularly high levels of SHS.5,6
Bars and nightclubs have played an important role historically in the lesbian, gay, bisexual, and transgender (LGBT) rights movement, and they serve as a welcoming social venue.7,8 However, compared with non-LGBT venues, LGBT bars and nightclubs may be particularly tobacco friendly, because smoking rates are higher among LGBT than heterosexual individuals.9,10 According to the 2009 to 2010 National Adult Tobacco Use Survey, prevalence of tobacco use was significantly higher among LGBT than heterosexual participants (38.5% vs 25.3%).10 Also, the tobacco industry has targeted LGBT individuals and young adults with bar and nightclub advertisements and promotions.2,11,12 Previous studies with men who have sex with men conducted in Tucson, Arizona; Portland, Oregon; and Los Angeles, California, indicated an association between frequency of LGBT bar attendance and smoking.13,14 Although it is well established that LGBT individuals have high smoking rates,9,15 less is known about exposure to SHS in LGBT bars and nightclubs.
Smoke-free laws, which restrict smoking in certain areas, are an important intervention to reduce or eliminate SHS exposure.5,6,16 Smoke-free policies have been shown to reduce asthma exacerbations and heart attacks17,18 and to contribute to smoking reduction or cessation.19 Smoke-free bar and nightclub environments might contribute to lowering rates of smoking among the LGBT population.
Pizacani et al. examined attitudes about SHS in Oregon and Washington among heterosexual and LGB individuals and found no significant differences by sexual orientation among individuals living in Washington.20 However, among Oregon residents, gay smokers were more likely than heterosexual male smokers to support banning smoking in bars. In addition, lesbian nonsmokers living in Oregon were more likely than heterosexual female nonsmokers to support such a ban. McElroy et al. found that a lower percentage of LGBT than non-LGBT individuals in Missouri supported smoke-free bar policies; however, this difference was not significant after adjustment for other demographic factors.21 Kelly et al. found no difference in support for the New York state smoke-free law between LGBT and heterosexual individuals in New York City nightclubs.22 However, in a nationwide study, King et al. found significantly higher prevalence of support for smoke-free bars, casinos, and clubs among heterosexual than LGBT participants. (49.5% vs 43.0%)23
Nevada has historically lagged behind the nation in enacting smoke-free policies.24 In 2001, Nevada ranked last in percentage of employees covered by a smoke-free policy. Between 1993 and 1999, the percentage of employees covered ranged from 33.3% to 48.7%. By 1999, Nevada was the only state with fewer than half of employees covered by a smoke-free policy.24 In 2006, Nevada passed a state smoke-free law that exempted bars, nightclubs, and gaming areas. This law also removed preemption, allowing local communities to pass stronger smoke-free policies.25 As of January 2013, bars and nightclubs in Nevada were still exempt from the smoke-free law.26
We compared SHS exposure and attitudes toward smoke-free bars and nightclubs among patrons of LGBT and non-LGBT bars and nightclubs in Las Vegas, Nevada, in 2011. We assessed (1) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of past-7-day exposure to SHS in a bar or nightclub, (2) whether frequently going out to LGBT venues was an independent predictor of 7-day exposure to SHS in a bar or nightclub, (3) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of intention to continue to go out as frequently as before if a smoke-free law was enacted, and (4) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of opposition to smoke-free bar and nightclub policies.
METHODS
Our data came from a repeated cross-sectional study of a social branding intervention to promote a tobacco-free lifestyle and environment in bars and nightclubs in Las Vegas.27 We selected venues by randomized time–location sampling of LGBT (n = 7) and non-LGBT (n = 12) bars and nightclubs. Time–location sampling has been used by other public health researchers to recruit a random sample of difficult-to-reach or hidden populations.28 This method involves developing a list of venues frequented by the key population along with likely dates and times and randomly selecting venues, dates, and times to recruit research participants or collect data.29
We conducted an iterative series of key informant interviews with local individuals familiar with the Las Vegas nightclub scene to generate a census of popular young adult bars. We asked key informants (e.g., party promoters, bar owners, writers for local press, bartenders, disc jockeys, and others involved in the nightlife industry) to name all the bars and nightclubs that LGBT and heterosexual young adults most frequently attended, and we conducted additional interviews until saturation was reached (no new bars or nightclubs were named in multiple interviews). We used this census of bars and nightclubs for time–location sampling. The young adult and LGBT patronage was continuously validated when survey teams attended the randomly selected bars and nightclubs for data collection. The manager of each survey team reported whether the randomly selected bar or nightclub was indeed frequented by young adults and whether the patrons appeared to be consistent with the LGBT or non-LGBT reputation. We removed from the list bars that did not conform to their reputation when visited and did not include them in subsequent rounds of randomized venue selection.27 Similarly, we used these methods to determine which non-LGBT bars and nightclubs were most popular among heterosexual young adults. We approached bar owners and offered contracts of $500 to $1000 to allow data collection for the entire study period. One bar refused the contract, and 1 bar declined after the first wave of data collection.
All data collectors completed training in human participant research and the study protocols, including verbal informed consent. We instructed the trainees to follow the randomized data collection schedule and to approach all eligible individuals present in the venue during the data collection time frame. In smaller venues, data collectors approached all bar patrons who appeared to meet the age criterion to screen them for eligibility to complete the survey. In large venues, data collectors followed instructions to systematically approach eligible persons. Participants received information about the study, and we invited those who gave verbal informed consent to fill out a survey. We excluded participants who were visibly intoxicated or who could not verbalize that they were participating in a research study. To limit interactions with highly intoxicated individuals, data collection took place early in the night. Respondents received a $5 incentive for participation in the study. We completed all surveys between February and March 2011, with a 63% response rate. Participants filled out a 77-item paper survey, which included questions on demographics, SHS exposure, and smoke-free law attitudes. We limited our analysis to bar and nightclub patrons aged 21 to 30 years (young adults legally old enough to patronize bars and nightclubs), according to self-reported date of birth.
Dependent Variables
Secondhand smoke exposure.
We asked participants to select from a list “each of the places where you were exposed to other people’s tobacco smoke in the past 7 days,” with one of the listed venues being “at a bar or nightclub.” We coded those who made this selection as exposed to SHS in a bar or nightclub.
Intention to go out at least as frequently if smoking was banned.
We asked participants, “If smoking were banned indoors at bars and nightclubs in Nevada, would you go out to bars and nightclubs more frequently, less frequently or about as often as before?” Respondents answered on a 5-point Likert scale, and we categorized those who reported that they would go out “much more frequently,” “more frequently,” or “about the same” as intending to go out at least as frequently, by contrast to those who responded “less frequently” or “much less frequently.”
Support for smoke-free bar and nightclub policies.
The survey asked, “Currently, smoking is legal in bars and nightclubs in Nevada. Would you say that you are in favor or are against a law to ban smoking indoors at bars and nightclubs in Nevada?” Response categories were “very in favor,” “in favor,” “neither in favor or against,” “against,” “very against,” and “unsure.” We categorized responses of “very in favor” and “in favor” as support for a smoke-free law.
Independent Variables
Bar and nightclub sample.
We classified participants who completed the survey in an LGBT bar or nightclub as part of the LGBT venue sample.
Frequency of attending sexual minority bars and nightclubs.
We asked participants who were sampled from the LGBT venues, “Of the bars/nightclubs you frequently go to, how many of them would be considered gay/lesbian bars/nightclubs or gay/lesbian nights?” We categorized participants who reported that they attended LGBT bars or nights more than half the time as frequently attending LGBT bars or nightclubs.
Demographics.
Covariates were age, gender, race/ethnicity, education, smoking status, and amount of time spent out. We split age into 2 categories according to natural breaks in the data: 21 to 25 years and 26 to 30 years. Two questions assessed race/ethnicity: “Are you of Hispanic, Latino or Spanish origin?” (yes or no), and “What is your race?” (African American, Asian, White, Hawaiian or Pacific Islander, American Indian or Alaskan Native, or other). We collapsed responses to these questions to create the following categories: non-Hispanic White, non-Hispanic African American, non-Hispanic Asian, Hispanic, and other. One question assessed education: “Which statement best describes your current college status?” Response options were “I go to college in the local area,” “I go to college NOT in the local area,” “I have graduated from college,” “I dropped out of college,” and “High school was enough.” We categorized responses to this question as some college or less, currently in college, or college graduate. We categorized individuals who reported having smoked at least 1 cigarette in the past 30 days as current (past month) smokers.
Social activity.
We assessed frequency and lateness of time spent out with 2 questions: “In an average week, on how many nights do you go out to have fun?”(range = 0–7) and “When you go out, how late do you usually stay out until?” (response options were 9:59 pm or earlier, 10:00 pm–10:59 pm, 11:00 pm–11:59 pm, midnight–12:59 am, 1:00 am–1:59 am, 2:00 am–2:59 am, 3:00 am–3:59 am, and 4:00 am or later). We summed responses to these 2 questions and used a logit plot to determine that this variable could be treated as continuous in logistic regression analyses.
We compared the demographic characteristics of participants in both types of venues (LGBT and non-LGBT) by t test or χ2 test as appropriate. We conducted 3 multivariate logistic regressions to predict whether being an LGBT or non-LGBT bar or nightclub patron independently predicted (1) SHS exposure, (2) support for smoke-free laws, and (3) intention to go out at least as frequently if a smoke-free bar and nightclub law passed, with adjustment for age, gender, race/ethnicity, education, and smoking status.
RESULTS
Of the 2667 participants surveyed, 2181 met the age inclusion criterion (21–30 years). Most respondents were aged 21 to 25 years (75.3%), male (58.2%), Hispanic (41.6%), non-LGBT (50.2%), and in college (43.4%). The LGBT venue sample (n = 1113) had significantly more older patrons, men, and LGBT individuals than did the non-LGBT venue sample (n = 1068; Table 1).
TABLE 1—
Sample Characteristics of Patrons of Lesbian, Gay, Bisexual, and Transgender and of General Population Bars and Nightclubs: Las Vegas, NV, 2011
| Characteristic | Total Sample (n = 2181), No. (%) | LGBT Venues (n = 1113), No. (%) | Non-LGBT Venues (n = 1068), No. (%) | P |
| Age, y | < .001 | |||
| 21–25 | 1643 (75.3) | 686 (61.6) | 957 (89.6) | |
| 26–30 | 538 (24.7) | 427 (38.4) | 111 (10.4) | |
| Gender | .001 | |||
| Male | 1265 (58.2) | 684 (61.6) | 581 (54.7) | |
| Female | 908 (41.8) | 426 (38.4) | 482 (45.3) | |
| Race/ethnicity | .071 | |||
| White, non-Hispanic | 693 (31.8) | 339 (30.5) | 354 (33.2) | |
| African American, non-Hispanic | 199 (9.1) | 95 (8.5) | 104 (9.8) | |
| Asian, non-Hispanic | 160 (7.3) | 77 (6.9) | 83 (7.8) | |
| Hispanic | 907 (41.6) | 497 (44.7) | 410 (38.5) | |
| Other, non-Hispanic | 219 (10.1) | 105 (9.4) | 114 (10.7) | |
| Sexual orientation | < .001 | |||
| Non-LGBT | 1089 (50.2) | 236 (21.4) | 853 (80.2) | |
| LGBT | 1080 (49.8) | 869 (78.6) | 211 (19.8) | |
| Education | < .001 | |||
| ≤ some college | 754 (34.7) | 389 (35.0) | 365 (34.4) | |
| In college | 944 (43.4) | 435 (39.1) | 509 (48.0) | |
| College graduate | 476 (21.9) | 289 (26.0) | 187 (17.6) | |
| Tobacco exposure | ||||
| Smoked cigarettes in past 30 d | 928 (45.1) | 507 (47.0) | 421 (43.0) | .07 |
| Exposed to SHS at a bar or nightclub in past 7 d | 1779 (82.1) | 945 (85.6) | 834 (78.5) | < .001 |
| Smoke-free bar preference | .008 | |||
| Oppose | 513 (25.9) | 279 (27.4) | 234 (24.3) | |
| Neutral | 616 (31.1) | 285 (28.0) | 331 (34.4) | |
| Support | 852 (43.0) | 455 (44.7) | 397 (41.3) | |
| If bars were smoke-free, would not patronize less frequently | 1578 (80.6) | 816 (80.6) | 762 (80.6) | .963 |
Note. LGBT = lesbian, gay, bisexual, and transgender; SHS = secondhand smoke.
Overall, exposure to SHS in bars and nightclubs was frequent: 85.6% of patrons of LGBT bars and nightclubs and 78.5% of patrons of non-LGBT venues reported that they had been exposed to SHS in a bar or nightclub in the past 7 days (Table 1). Patrons of LGBT bars and nightclubs had 38% higher odds of reporting past-7-day SHS exposure in a bar or nightclub than patrons of non-LGBT venues (adjusted odds ratio [AOR] = 1.38; 95% confidence interval [CI] = 1.07, 1.77; P = .013; Table 2). We conducted a subgroup analysis of participants recruited in an LGBT bar or nightclub and determined that participants who reported that they frequently attended LGBT bars or nightclubs had nearly twice the odds (AOR = 1.94; 95% CI = 1.33, 2.82; P = .001) of having been exposed to SHS in a bar or nightclub in the past 7 days relative to individuals in the LGBT venue sample who went to LGBT venues half the time or less when they went out (data not shown).
TABLE 2—
Comparison of Patrons of Sexual Minority Bars and Nightclubs With Patrons of General Population Venues on Secondhand Smoke Exposure and Attitudes About Smoke-Free Policies: Las Vegas, NV, 2011
| Variable | Past-7-d Exposure to SHS in a Bar or Nightclub, AOR (95% CI) | Support for a Smoke-Free Law, AOR (95% CI) | Intention to Maintain Frequency,a AOR (95% CI) |
| Bars and nightclubs | |||
| Non-LGBT (Ref) | 1.00 | 1.00 | 1.00 |
| LGBT | 1.38* (1.07, 1.77) | 1.09 (0.90, 1.33) | 1.00 (0.77, 1.30) |
| Age, y | |||
| 21–25 (Ref) | 1.00 | 1.00 | 1.00 |
| 26–30 | 1.16 (0.85, 1.59) | 1.29* (1.03, 1.61) | 0.91 (0.67, 1.24) |
| Education | |||
| ≤ some college (Ref) | 1.00 | 1.00 | 1.00 |
| In college | 0.68** (0.51, 0.90) | 1.10 (0.89, 1.36) | 0.86 (0.65, 1.36) |
| College graduate | 0.96 (0.67, 1.36) | 1.40** (1.09, 1.80) | 1.55* (1.07, 2.23) |
| Race/ethnicity | |||
| White, non-Hispanic (Ref) | 1.00 | 1.00 | 1.00 |
| African American, non-Hispanic | 0.62* (0.40, 0.96) | 0.82 (0.58, 1.16) | 0.92 (0.58, 1.47) |
| Asian, non-Hispanic | 0.72 (0.45, 1.17) | 1.11 (0.77, 1.61) | 1.32 (0.76, 2.27) |
| Hispanic | 0.63** (0.47, 0.84) | 1.03 (0.83, 1.28) | 0.99 (0.74, 1.33) |
| Other, non-Hispanic | 0.68 (0.44, 1.04) | 1.09 (0.79, 1.51) | 0.86 (0.55, 1.32) |
| Gender | |||
| Male (Ref) | 1.00 | 1.00 | 1.00 |
| Female | 1.01 (0.79, 1.28) | 1.26* (1.05, 1.52) | 1.40* (1.08, 1.81) |
| Frequency and lateness of time spent out | 1.06** (1.01, 1.11) | 0.98 (0.94, 1.01) | 1.02 (0.97, 1.07) |
| Current cigarette smoker (past 30 d) | |||
| No (Ref) | 1.00 | 1.00 | 1.00 |
| Yes | 1.08 (0.84, 1.37) | 0.52*** (0.43, 0.62) | 0.15*** (0.11, 0.20) |
Note. AOR = adjusted odds ratio; CI = confidence interval; LGBT = lesbian, gay, bisexual, and transgender; SHS = secondhand smoke.
If a smoke-free law were passed, respondents would go no less frequently to bars and nightclubs.
*P ≤ .05; **P ≤ .01; ***P ≤ .001.
Patrons of LGBT bars and nightclubs did not differ significantly from patrons of non-LGBT bars and nightclubs in reporting that they would go out at least as frequently if bars and nightclubs were made smoke-free (Table 2). Overall, college graduates and women had significantly higher odds than did respondents with less education and men, respectively, of reporting an intention to go out at least as frequently if bars and nightclubs were smoke-free (Table 2). Current smokers had 85% lower odds of reporting an intention to go out at least as frequently, relative to current nonsmokers (AOR = 0.15; 95% CI = 0.11, 0.20; P < .001; Table 2).
Overall, 43.0% of all the bar and nightclub patrons surveyed reported support for a smoke-free bar and nightclub law, and 31.1% expressed neutral feelings toward these policies (Table 1). Among patrons of LGBT bars and nightclubs, 44.7% supported a smoke-free law, and 28.0% were neutral. In non-LGBT venues, 41.3% of patrons supported this law, and 34.4% were neutral (P = .008). However, in multivariate logistic regressions adjusted for demographic factors and smoking behavior, we found no significant differences between patrons of LGBT and non-LGBT bars and nightclubs in support for a smoke-free law or in intention to change their pattern of behavior (going out less frequently) in the presence of a smoke-free law.
DISCUSSION
Our study contributes to the existing body of literature by assessing SHS exposure among LGBT individuals. Although it is well known that LGBT individuals smoke at high rates, little is known about SHS exposure in this population. In addition, we focused on patrons of LGBT bars and nightclubs and conducted a unique analysis comparing individuals who were recruited in LGBT bars and nightclubs and individuals recruited in non-LGBT bars and nightclubs.
In agreement with existing literature, we found that SHS exposure is high in the absence of a law requiring smoke-free bars and nightclubs.5,6 We found that being in an LGBT venue was a significant predictor of SHS exposure. It is possible that LGBT bars and nightclubs have fewer smoke-free policies or that LGBT bars and nightclubs are smokier because more LGBT individuals smoke. People who attended LGBT venues, however, were as likely to support a smoke-free bar and nightclub law as people in non-LGBT venues, and they were as likely as patrons of non-LGBT bars and nightclubs to state that they would go out just as frequently if bars were smoke-free. This finding is similar to some existing literature on LGBT individuals’ attitudes about SHS issues and tobacco control policy, showing that despite higher smoking rates, this population equally supports smoke-free policies.20–22 By contrast, however, a recent nationwide study by King et al. found that more heterosexuals than LGBT individuals supported smoke-free policies.23 Our comparison of support by type of venue (non-LGBT bar vs LGBT bar) may be helpful, because public health interventions (e.g., smoke-free policies) are venue based. Our results are also consistent with and complementary to the body of literature indicating that smoke-free policies are not associated with reduced bar revenue or patronage.30–34
Our results have both practice and policy implications. The high prevalence of SHS exposure in LGBT venues and the overall positive attitude toward a smoke-free law suggest these bar and nightclub patrons would be receptive to tobacco-related interventions. Advocates should work with leaders in the LGBT community to prioritize tobacco issues, including adoption of smoke-free LGBT bar policies. Despite the widely documented high rate of smoking among LGBT individuals, smoking is not commonly emphasized as an important gay health issue.35,36 However, LGBT organizations have demonstrated the ability to oppose the tobacco industry. In 1990, the Washington, DC, chapter of the AIDS Coalition to Unleash Power (ACT-UP) organized a boycott of Philip Morris.37 ACT-UP, founded in 1987, advocated for greater government response against the AIDS epidemic. ACT-UP therefore protested Philip Morris’ support of Senator Jesse Helms (R, NC), who was both for tobacco interests and against many of the concerns of the LGBT community (e.g., he opposed AIDS educational materials). The protesters demanded that Philip Morris stop funding Senator Helms, but the boycott ended after the company pledged millions for AIDS research. This led to a long-standing tie between the LGBT community and the tobacco industry.37 However, the boycott showed that the LGBT community can be mobilized to oppose the tobacco industry.
Our data also suggest that LGBT bars and nightclubs are an important venue in need of tobacco control interventions.11,38 Health advocates have successfully promoted HIV prevention in LGBT bars and venues.39–41 Similarly, LGBT bars may offer an important opportunity to promote tobacco-free lifestyles. An example of a tobacco control intervention for LGBT bar and nightclub patrons is Crush, a social branding intervention implemented by the company Rescue Social Change Group in conjunction with the Southern Nevada Health District’s Tobacco Prevention and Control Program, which targets LGBT individuals in bars and nightclubs in Las Vegas. This intervention uses commercial marketing strategies to create positive associations between a tobacco-free lifestyle and being a socially successful member of the young adult LGBT community in Las Vegas, and Crush requires bars and nightclubs to become smoke-free environments during its social events.27,42
In addition to countermarketing interventions, a particularly important tobacco control policy intervention for the young adult LGBT population would be the passage of a comprehensive smoke-free law in Nevada, which would prohibit smoking in the indoor areas of all workplaces and public places; current Nevada law exempts stand-alone bars.25,43 Our findings indicate that the environment in LGBT bars and nightclubs is favorable for the enactment of smoke-free policies. Smoke-free policies in LGBT venues would reduce both SHS exposure16 and socially cued smoking44 in this vulnerable population, which we found to be disproportionately exposed to SHS. This intervention's likely success is supported by Moore et al.’s finding of particularly strong compliance with California’s smoke-free law in LGBT bars.45
Limitations
Because we used time–location sampling, we relied on multiple key informants to generate a list of bars and nightclubs popular among young adults in Las Vegas. However, it is possible that we did not sample every bar and nightclub popular with this population, which is a limitation of time–location sampling.46 Also, bar owner or patron refusals may have introduced bias into the sample. Participants in the LGBT venue sample were older than those in the non-LGBT sample. However, regression analyses adjusted for age. We relied on self-report of SHS exposure. Future research might compare SHS exposure in LGBT and general venues with objective measures of SHS exposure, such as air quality.
We examined LGBT bar and nightclub patrons in a major city in the western portion of the United States with a unique concentration of casinos; results may not generalize to other cities. A nationwide study might identify differences in other regions, different local economies, smaller cities, or rural areas. Also, our sample had a high percentage of Hispanic individuals, and the LGBT sample was predominantly male (61.6%), which may limit applicability to other groups. We did not ask patrons in non-LGBT bars and nightclubs how frequently they patronized LGBT venues. The high degree of overlap between LGBT orientation and LGBT bar patron composition was a limitation, and future studies are needed to disentangle this confounding by sampling LGBT individuals who do not patronize bars and non-LGBT patrons of LGBT bars and nightclubs in greater numbers. In addition, because Crush occurred simultaneously with our data collection, it is possible that participants were influenced by this campaign.
Conclusions
We documented high rates of exposure to SHS in Las Vegas bars and nightclubs, with 82% of the individuals surveyed reporting exposure at a bar or nightclub in the past 7 days. The majority of these patrons, including those surveyed in LGBT bars and nightclubs, supported or were neutral toward a smoke-free bar law and intended to go at least as frequently if a smoke-free bar law passed. Smoke-free bar and nightclub policies should be enacted to protect patrons from SHS and promote a smoke-free social norm.
Acknowledgments
Majority funding was provided by the Southern Nevada Health District through a Communities Putting Prevention to Work grant from the Centers for Disease Control and Prevention (American Recovery Act). Partial funding was received from the National Cancer Institute (grants R25T CA113710 and U01 CA 154240).
Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Human Participant Protection
This study was approved by the University of California San Francisco committee on human research.
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