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. Author manuscript; available in PMC: 2015 Jun 1.
Published in final edited form as: J Health Psychol. 2013 Aug 8;19(12):1525–1535. doi: 10.1177/1359105313494926

Relationships among Factual and Perceived Knowledge of Harms of Waterpipe Tobacco, Perceived Risk, and Desire to Quit among College Users

Isaac M Lipkus 1, Thomas Eissenberg 2, Rochelle Schwartz-Bloom 1, Alexander V Prokhorov 3, Janet Levy 1
PMCID: PMC4358735  NIHMSID: NIHMS663938  PMID: 23928987

Abstract

Waterpipe tobacco smoking (WTS) is increasing in the U.S among college students. Through a web-based survey, we explored associations among factual and perceived knowledge, perceived risks and worry about harm and addiction, and desire to quit among 316 college WTS users. Overall, factual knowledge of the harm of WTS was poor; factual and perceived knowledge were weakly correlated; both forms of knowledge were related inconsistently to perceived risks and worry, and neither form of knowledge was associated with the desire to quit. Findings provide preliminary insights as to why knowledge gaps may not predict cessation among waterpipe users.

Keywords: health behavior, health psychology, public health psychology, smoking, students

In the U.S., waterpipe tobacco smoking (WTS) among university students has quickly emerged as the second most used tobacco product after cigarettes (8.4% current waterpipe users versus 16.8% current cigarette users (Primack et al., 2013). WTS is a public health concern due to exposures of toxic compounds and related health threats. The amount of smoke inhaled by a single one-hour waterpipe session – sessions typically last 30 to 60 minutes – can equal that produced by 100 or more cigarettes (Maziak, 2008). Smoke inhaled by the waterpipe user contains harmful substances that include heavy metals (arsenic, cobalt, chromium, lead), carcinogenic 4- and 5-membered ring polycyclic aromatic hydrocarbons (Sepetdjian et al., 2008), pulmonary disease-causing volatile aldehydes (Al Rashidi et al., 2008), carbon monoxide (CO) (El-Nachef and Hammond, 2008; Monzer et al., 2008; Shihadeh, 2003), and nicotine (Neergaard et al., 2007). Inhalation of these compounds may be why WTS is related to many of the same tobacco-caused diseases as cigarette smoking, such as cancer, poorer pulmonary function (FEV1), and heart disease (Akl et al., 2010; Cobb et al., 2010; Knishkowy and Amitai, 2005; Maziak et al., 2004a; Raad et al., 2011).

WTS appears addictive. Although long-term data on waterpipe addiction demographics in the U.S. are not available due to its relative novel emergence in this country, the risk of addiction is highlighted by four key dependence indicators (American Psychiatric Association, 1994; Cobb et al., 2011; Maziak et al., 2004b; Maziak et al., 2005). First, delivery of the dependence-producing drug nicotine (Cobb et al., 2011; Shafagoj et al., 2002) indicates potential for waterpipe use to support physical dependence (i.e., cellular adaptation to chronic drug exposure) (Watkins et al., 2000). Second, a hallmark of dependence is failed quit attempts, which occur among waterpipe users (Ward et al., 2005). Third, on surveys some users endorse items indicating that they are “hooked on waterpipe” (Smith-Simone et al., 2008) and by users’ testimonials of being addicted (Hammal et al., 2008). Fourth, abstinent daily waterpipe users report withdrawal symptoms that are suppressed by waterpipe use (Rastam et al., 2011). All told, data from clinical studies, surveys, and interviews converge to support the hypothesis that, at least in some cases, WTS can lead to nicotine addiction.

To date, there is a very poor understanding of what specific details youth know about the harms of WTS. A study by Nuzzo and colleagues (Nuzzo et al., 2012) asked 852 University of Florida students who either were users of waterpipe tobacco or not resistant to using waterpipe (i.e., were susceptible), to indicate whether a single cigarette or a single hookah tobacco session delivered more tar, nicotine, carcinogens, carbon monoxide and heavy metals. A total of 55.8% of the respondents answered all questions incorrectly, with mean number of items answered correctly being one (SD = 1.4). This observation suggests that many college students have a very poor understanding of exposure risks related to waterpipe tobacco use. Further, correct knowledge on any item was not associated significantly with current use or susceptibility to use.

These results raise two issues. First, the user’s perceived knowledge, a metacognition, rather than their factual knowledge, may be more influential with regard to desire to quit and quitting. Someone may have poor factual understanding yet perceive him/herself as highly knowledgeable about the harmful effects of WTS. For example, cigarette smokers have a poor factual understanding of the risks of smoking (Weinstein, 1999; Weinstein et al., 2004), and there is a disconnect between one’s factual understanding of smoking risks and one’s evaluations of that understanding, that is, perceived knowledge (Cummings et al., 2004). Thus, one question we will explore is the extent to which factual and perceived knowledge are related with each other and desire to quit WTS.

Second, the lack of association between knowledge and hookah use (Nuzzo et al., 2012) may reflect a disassociation between factual knowledge influencing important mediators of behavior change, such as perceived risks and worry about the harms of WTS. Based on several theories of health behavior change (e.g., health belief model, Janz and Becker, 1984), perceptions of risk, including the risk of addiction, should translate into a greater desire to quit and cessation. For example, many cigarette smokers report health risks as the main reason for wanting to quit (McCaul et al., 2006). Of import, risk perceptions, negative outcome expectancies, and worry about health are positively related to intention and commitment to quit (Copeland and Brandon, 2000; Dijkstra and Brosschot, 2003; Koblitz et al., 2009; Lipkus and Prokhorov, 2007; Magnan et al., 2009; Manfredi et al., 1998; Strecher et al., 1985; Williams et al., 2011); further, greater health concerns is related to making more quit attempts (Vangeli et al., 2011), and those who quit for health concerns are more likely to succeed than those who try for other reasons (Halpern and Warner, 1993). Consistent with these findings, in a pilot study among college students who smoked waterpipe tobacco, those who perceived themselves at higher risk of harm were more likely to have quit (Lipkus et al., 2011). Overall, if factual and perceived knowledge are weakly related, then both of these constructs may predict perceived risks independently. The key question is which, if any of these constructs, are associated with perceived risks and worries of harm related to WTS.

In sum, based on pooling baseline data from three studies involving college WTS users, we aimed to fill these important gaps in the literature by exploring associations between factual knowledge, perceived knowledge, personal perceptions of risk and worry, and desire to quit. We hypothesized that:

  • H1: Factual knowledge will be low and perceived knowledge will be high (i.e., overall mean score above scale midpoint).

  • H2: Factual and perceived knowledge will be positively correlated.

  • H3: Both greater factual and perceived knowledge will be associated with higher personal ratings of risk and worry of harm and of becoming addicted.

  • H4: Both greater factual and perceived knowledge will be associated with a stronger desire to quit. These associations will be mediated by personal ratings of risk and worry of harm and of becoming addicted.

Methods

Participants

Eligibility for study participation was the same across all three studies. Eligibility included being enrolled in a four-year college or university, aged 18 years or older, having smoked a waterpipe at least once during the last month, having a computer with internet access, and having an email address that is checked daily. Waterpipe smokers were recruited from among a total of seven college and university campuses in central North Carolina via the use of newspaper advertisements, flyers posted around campuses, Craigslist, and campus-wide Listservs.

Overview of Procedures

Procedures for study participation were the same across all three studies. These three studies tested different ways of presenting factual information about the harms of waterpipe use to college waterpipe users, which are reported elsewhere (reference blinded for review). College students responded to advertisements by telephoning the laboratory and then a trained research assistant provided them with an overview of the study and screened them for eligibility (e.g., age, use of waterpipe, enrollment in a college or university). Those who were found eligible and answered “yes” about their interest in participation were then consented verbally on the phone and emailed information about the study website with instructions for how to log on. Upon logging on to the website, participants completed an online baseline survey. We report the main baseline measures below that were consistent across the three studies. These studies, which took place between October 2009 and July 2011, were approved by the university medical center IRB.

Measures

Factual knowledge of dangers of waterpipe

Knowledge of waterpipe dangers was assessed by five questions, four that began with the stem, “When you consider one person completing a single 45-minute waterpipe smoking session and a single 5-minute cigarette smoking session, which.” followed by: 1) “delivers more dependence-producing nicotine to the smoker?”; 2) “delivers more heart disease-causing carbon monoxide to the smoker?”; 3) produces more tar in the smoke?”; and 4) “produces more arsenic and lead in the smoke?.” The fifth question asked, “When you consider the harm associated with tobacco smoking, which of the following has been associated with heart disease?” Response options for each question were waterpipe, cigarette, both waterpipe and cigarette smoking, and neither waterpipe nor cigarette smoking. The correct response to the first four questions was waterpipe, and for the last question both waterpipe and cigarette smoking. A correct score was given a point value of 1, or a zero otherwise. We created a total mean summed score (range 0 to 5).

Note that the questions about exposure to tar, nicotine and carbon monoxide basically replicate the questions posed by Nuzzo and colleagues (2012). Moreover, our question about arsenic and lead in smoke was an attempt to address understanding of heavy metals as posed by Nuzzo and colleagues with specific examples.

Perceived knowledge of dangers of waterpipe use

Participants’ views as to how much they knew about risks related to waterpipe tobacco use were assessed using eight 7-point Likert scales. For example, participants were asked, “How much would you say you know about the risk of waterpipe tobacco smoking? (1=Not much to 7=A lot), “Do you need more information about the risks of waterpipe tobacco smoking to be well-informed?” (1=Definitely no to 7=Definitely yes – reversed scored), and “There is little someone can tell you about the risks of waterpipe tobacco smoking that you do not already know” (1=Strongly disagree to 7=Strongly agree). Items were summed and averaged. A factor analysis revealed only a single factor (eigenvalue of 4.1) with item loadings between .49 and .88. Scale alpha was .86.

Perceived personal risk of harm

Perceived risk was assessed by, “What do you think is your chance of getting a serious health problem in your lifetime from your waterpipe tobacco smoking if you don’t quit?” (1=No chance, 2=Very unlikely, 3=Unlikely, 4=Moderately likely, 5=Likely, 6=Very likely, 7=Certain to happen).

Perceived personal worry of harm

We assessed worry about the physical consequences of waterpipe smoking based on modification of Dijkstra & Brosschot’s 4-item worry scale used for cigarette smoking (Dijkstra and Brosschot, 2003). For example, participants were asked, “How afraid are you of medical problems from waterpipe tobacco smoking?” and, “How much do you worry that your health is being affected by your waterpipe tobacco smoking?” Response anchors ranged from 1=Not at all to 7=Very much. Cronbach’s alphas exceeded .75 across studies. Items were summed and averaged.

Perceived personal risk of addiction

Perceived risk of addiction was assessed by “What do you think is the chance of you becoming addicted to nicotine in tobacco from waterpipe if you continue to smoke?” (1=No chance, 2=Very unlikely, 3=Unlikely, 4=Moderately likely, 5=Likely, 6=Very likely, 7=Certain to happen).

Perceived personal worry for addiction

Perceived worry for addiction was assessed by, “How worried are you about becoming addicted to nicotine in waterpipe if you continue to smoke?” Response anchors were 1=Not at all to 7=Very much.

Desire to quit waterpipe use

Participants’ desire to quit waterpipe use was assessed by, “How strong is your desire to quit waterpipe smoking right now? (1=Not at all to 7=Very).

Statistical methods

Pearson correlations were used to assess relationships among the various constructs (i.e., type of knowledge, risk perception and worry, desire to quit). Differences in means were tested using independent group t-tests or ANOVAs. Multivariate analyses used least squares regression to predict the outcomes of perceived risk and worry as well as desire to quit, controlling for study sample (dummy coded); other specific predictors, which were included in the regression models based on variables found to be statistically significant at the univariate level (e.g., frequency of WTS, cigarette smoking status), are discussed in the relevant sections. Age, race, gender were not related to our outcomes and hence were not included in our statistical models, nor did they differ by sample. The main study outcomes of perceived and factual knowledge, and perceived risk and worry did not differ by study sample, although desire to quit did differ by study sample (F=3.90, p <.03). Whereas mean desire to quit for the first study sample (M=1.7, SD=1.04) and second study sample (M=1.93, SD=1.33) did not differ, mean desire to quit was higher in the most recent study (i.e., sample 3, M=2.21, SD=1.47) than the earliest study (p<.05).

Results

Sample recruitment and characteristics

For Study 1, 177 people were screened, of which 72 were ineligible. The main reasons for ineligibility were not enrolled in college (n=25), enrolled in a college from which we did not obtain IRB approval to recruit (n=19), and not having smoked a waterpipe within the last 30 days (n=25). Of the 108 found eligible, three declined to participate after being informed of study details, four agreed to participate but never provided consent, seven did not complete the baseline survey, and two consented but withdrew prior to completing the baseline, leaving a total of 92 completed baseline surveys. Subsequently, we learned that one participant who completed the baseline survey falsified his/her data; these data were eliminated from the study, leaving a total of 91 completed baseline records. For Study 2, 153 people were screened of which 26 were ineligible. The main reasons for ineligibility were: not enrolled in college (n=2), enrolled in a college from which we did not obtain IRB approval to recruit (n=1), and not having smoked a waterpipe within the last 30 days (n=23). Of the 126 who were eligible, five did not consent (one declined and four agreed to participate but did not consent) and 11 did not complete the baseline. Thus, 112 participants completed the baseline. In Study 3, 131 people were screened, of which nine were found ineligible. One was disqualified for not being enrolled in a college or university, eight were disqualified for not having smoked a hookah within the last 30 days, and one was disqualified by attending a college or university from which we did not obtain IRB approval. Of the 121 eligible, 113 went on to complete the online baseline survey.

Summing across the samples, the mean age was 20.3 years (SD=2.0, range 18 to 32); 65% were men. In terms of race and ethnicity, 66% were Caucasian, 14% Asian/Pacific Islander, 9% African-American, 7% other, and 4% Hispanic. With respect to frequency of use, 67% smoked a waterpipe monthly, 29% smoked weekly, and 4% smoked waterpipe once per day on most days. In terms of tobacco products used, 40% only engaged in waterpipe tobacco use; in addition to waterpipe, 32% used one other tobacco products (e.g., cigarettes, cigar, pipe, chew, snuff) and 18% used two other tobacco products.

Factual and perceived knowledge

Understanding facts of waterpipe use was low, largely supporting our first hypothesis. As shown in Table 1, less than 37% of participants answered correctly any question concerning the amount of toxins a 45-minute waterpipe tobacco session delivers or produces compared to a five-minute cigarette smoking session. Participants did slightly better (45%) stating correctly that both waterpipe and cigarettes are associated with heart disease. The mean number of items answered correctly was 1.55 (SD=1.43). As shown at the bottom of Table 1, 29% missed all questions; only 4% answered correctly all questions.

Table 1.

Response to factual knowledge questions about the harms of waterpipe tobacco use.

Question Response (%)
1. Which delivers more dependence-producing NICOTINE to the smoker?:
 Waterpipe* 35.2
 Cigarette 45.4
 Waterpipe and cigarette are about the same 19.4
 Neither waterpipe nor cigarette delivers nicotine 0.0
2. Which delivers more heart disease-causing CARBON MONOXIDE to the smoker?:
 Waterpipe* 36.5
 Cigarette 44.8
 Waterpipe and cigarette are about the same 16.8
 Neither waterpipe nor cigarette delivers carbon monoxide 1.9
3. Which produces more TAR in the smoke?
 Waterpipe* 22.2
 Cigarette 69.2
 Waterpipe and cigarette are about the same 7.9
 Neither waterpipe nor cigarette smoke contains tar 0.6
4. Which produces more ARSENIC and LEAD in the smoke?:
 Waterpipe* 16.5
 Cigarette 69.5
 Waterpipe and cigarette are about the same 11.1
 Neither waterpipe nor cigarette smoke contains ARSENIC and LEAD 2.9
5. When you consider the harm associated with tobacco smoking, which of the following has been associated with HEART DISEASE?
 Waterpipe 3.8
 Cigarette 48.2
 Both waterpipe and cigarette smoking* 44.8
 Neither waterpipe nor cigarette smoking 3.2
Total items correct (range 0 to 5)
 0 29.4
 1 26.0
 2 21.8
 3 10.1
 4 8.5
 5 4.1
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Notes. Questions 1 through 4 above had the prefix, “When you consider one person completing a single 45-minute waterpipe smoking session and a single 5-minute cigarette smoking session…”

Numbers may not add to 100% due to rounding.

*

Correct response.

The mean score for overall perceived knowledge was 3.89 (SD=1.12, mode=4.0, median=3.87). Thus, our interpretation is that most participants evaluated their knowledge as average. Consistent with the second hypothesis, the correlation between perceived and factual knowledge was low, yet positive (r=.24, p<.0001).

Perceived knowledge varied by frequency of WTS. Individuals who smoked waterpipe daily had greater perceived knowledge than those who smoked waterpipe monthly (M=4.66, SD=0.96 vs. M=3.80, SD=1.18, p<.05), but not significantly more than weekly users (M=3.93, SD=1.27). Factual knowledge did not vary significantly by frequency of WTS (daily smokers M=2.01, SD=1.11, weekly smokers M=1.46, SD=1.36, monthly smokers M=1.55, SD=1.48, p=.34). Further, cigarette smokers (N=139) had greater factual knowledge (M=1.75, SD=1.44) than non-cigarette users (M=1.39, SD=1.40, p<.03).

Relations between forms of knowledge and perceived personal risk and worry of harm and addiction

We predicted that better factual knowledge and greater perceived knowledge would correlate positively with perceived personal risk and worry of harm (M=3.0, SD=1.22 for risk and M=2.51, SD=1.27 for worry) and addiction (M=2.34, SD=1.12 for risk and M=1.98, SD=1.17 for worry). As predicted, greater perceived knowledge was related to seeing oneself at greater risk of harm if they continued to smoke (r=.19, p<.0006) and worry (r=.15, p<.009), but not with risk (r=.07) or worry of becoming addicted (r=.05). Greater factual knowledge was related to greater perceived risk of harm (r=.14, p<.04) but not worry (r=.11, p<.06); it correlated positively with greater perceived risk of addiction (r=.12, p<.04) but not with worry of becoming addicted (r=.06).

Frequency of WTS was related to perceived worry about health only. Daily smokers were more worried about their health (M=3.44, SD=1.44) than weekly or monthly users (M=2.39, SD=1.17, M=2.50, SD=1.28, respectively, p<.05). Further, cigarette smokers perceived themselves as more likely to become addicted than non-cigarette users (M=2.69, SD=1.19 vs. 2.13, SD=0.99, p<.0001).

Three multivariate regression analyses were conducted using predictors found to be significant in the univariate analyses, controlling for study sample. First, perceived risk of harm was predicted from both perceived and factual knowledge. The overall model was not significant (overall model adjusted R2 = .02, p<.07). Second, worry about harm was predicted from perceived knowledge while also controlling for frequency of WTS. Higher perceived knowledge predicted greater worry about harm (beta=.14, p<.02; overall model adjusted R2 = .02, p<.05). Third, perceived risk of addiction was predicted from factual knowledge controlling for cigarette smoking status. Whereas factual knowledge did not predict risk of addiction (beta=.07, p<.09), being a smoker predicted a higher risk of becoming addicted (beta=.52, p<.001; overall model adjusted R2 = .07, p<.001).

Relations between forms of knowledge and desire to quit

We predicted that greater factual and perceived knowledge would correlate positively with desire to quit (M=1.96, SD=1.32). Desire to quit was not related significantly with either perceived knowledge (r=.10, p<.09) or factual knowledge (r=.10, p<.09) – note, taking into account study sample did not change these results. Because neither form of knowledge was related with the desire to quit, mediational analyses taking into account constructs such as perceived risk and worry were not conducted.

Relations between personal ratings of risk and worry and desire to quit

Desire to quit was higher among individuals who perceived themselves at higher risk (r=.30, p<.0001) and worried more about harm (r=.49, p<.0001). Further, desire to quit was higher among participants who perceived themselves at higher risk of addiction (r=.27, p<.0001) and worried more about becoming addicted (r=.45, p<.0001). We ran a multivariate regression model predicting desire to quit from measures of harm and worry, controlling for study sample. Both worry about harms (beta= .35, p<.0001) and worry about becoming addicted (beta= .30, p<.0001) continued to predict desire to quit (overall model adjusted R2 = .30, p<.001).

Discussion

To the best of our knowledge, the present paper provides the first report of associations between factual and perceived knowledge of the harms of WTS and their relationships with ratings of personal risk and worry of harm and addiction as well as desire to quit. Overall, our results show that: 1) factual knowledge of the harm of WTS, especially with respect to toxicant exposure, is poor; 2) factual and perceived knowledge are positively, albeit weakly, correlated; 3) both forms of knowledge are related to perceived risk of harm yet inconsistently related to perceptions of personal risk and worry over becoming addicted; and 4) neither forms of knowledge were related to the desire to quit. In addition, worries about harm and addiction were related most strongly to desire to quit. Overall, findings which show that college waterpipe tobacco users have a poor grasp of the degree of toxicant exposure associated with WTS as compared to cigarette smoking reinforce and generalize the result found by Nuzzo and colleagues (Nuzzo et al., 2012) using data from only one university.

The results shed some light on factors that may influence the desire to quit and ultimately cessation of WTS. Consistent with the affect heuristic and risk as feeling model (Slovic et al., 2002; Loewenstein et al., 2001), perceived risk and worry were related with the desire to quit, but worry has a stronger and more consistent relationship. If so, this suggests that public health interventions should focus on evoking negative emotions about the harms of WTS. These interventions may include graphical images of harm as well as level of toxic exposures; such strategies have increased thoughts about quitting for other tobacco products, such as cigarettes (e.g., use of graphic warning labels on packages, Hammond, 2011). Of import, the lack of association between factual and perceived knowledge with desire to quit may be due to the weak associations between these forms of knowledge with perceptions of risk and worry. Ultimately, knowledge of the harms of WTS, as found in prospective analyses by Lipkus et al. (2011), may not directly influence this behavior.

At first glance these findings call into question approaches that attempt to increase factual and perceived knowledge as methods to evoke changes in perceptions of risks and worry of harm and addiction. Reaching this conclusion, given the state of the science of what is known to influence cessation of WTS in youth, is in our opinion premature. Presenting general facts about harms does not personalize the risks. While providing information about harms of waterpipe tobacco use does increase factual knowledge (Lipkus et al., 2011), smokers may not necessarily agree that these harms will apply to them. To counter this, it may be worthwhile to provide college smokers with personal feedback in relation to these exposures (e.g., carbon monoxide inhaled, nicotine, carcinogens captured in urine) as well as feedback using other biomarkers (e.g., blood pressure). Their “experiential” learning activities may create teachable moments that can reinforce the application of what they learned from the feedback to influence perceptions of risks and worry, desire to quit, and ultimately cessation.

Another potentially useful strategy to motivate desire to quit and cessation is to help waterpipe users understand how toxicants produce harm. A science education approach (Weiden Consulting, 2000; Holtz and Twombly, 2007) that engages users in interactive and multimedia activities may make information about harms more personally relevant and hence more likely to influence risk perceptions and resulting attitudes toward waterpipe use. In fact, we have shown that a science education approach that includes multimedia helps to increase science literacy in high school students about tobacco use and enhance their perceptions of risk (unpublished observations).

This study has a few limitations. First, our measures of factual knowledge primarily emphasized knowledge of levels of toxicant exposure comparing waterpipe tobacco use and cigarettes rather than capturing more fully health problems associated with waterpipe use. Whether the magnitude of our effects would differ substantially if our assessment of factual knowledge of harms encompassed more domains awaits further testing. Overall, work on psychometrics of measures capturing knowledge about harms of waterpipe tobacco use is clearly needed. Second, some measures of risk and worry were not the same for domains of harm and addiction. For example, we used a four-item measure to assess worry about physical consequences of harm but did not use a comparable four-item worry measure for addiction. The failure to use comparable measures limits making comparisons of effect sizes. Third, our samples may not be representative when compared to the larger population of college waterpipe users.

In sum, these findings present some insights as to why, without some form of intervention, knowledge of the harms of waterpipe use may not necessarily translate into cessation. We suggest that interventionists consider testing the effects of providing biomarker feedback as well as facts about harms using appealing interactive multimedia science education approaches that can help users better understand and appreciate the mechanisms through which WTS can harm them. We also suggest strategies that focus on emotional appeals to curb WTS. Due to the very limited understanding of how educational approaches and emotional appeals influence WTS cessation processes, public health professionals should consider these strategies to curb this behavior.

Acknowledgments

We thank Dr. Brian Primack for his helpful comments on an earlier version of this paper. We thank Karen Hawkins for helping to collect these data.

Funding Source

This research was supported by the National Cancer Institute (NCI) Grant R01 CA114389 and the National Institute on Drug Abuse (NIDA) Grant P30 DA023026. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCI or NIDA.

Footnotes

Declaration of Conflicting Interests

None of the authors have conflicting interests.

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