Abstract
Purpose
To examine cigarette use and the tobacco-related environment among adolescents living in metropolitan and non-metropolitan areas.
Methods
Data from adolescents ages 14–17 that completed the 2012 Florida Youth Tobacco Survey were analyzed (n=40,746). This includes a representative sample of middle and high school students throughout the state.
Results
Non-metropolitan adolescents were more likely than metropolitan adolescents to report lifetime smoking, past 30-day smoking, daily smoking, initiating smoking at younger ages, having smoked a greater number of cigarettes in their lifetime and in the past 30 days, friend acceptance of adult smoking, a parent offering them a cigarette, living with a smoker, and that smoking was allowed in their home. Non-metropolitan adolescents were also more likely to have seen tobacco ads the last time they visited convenience marts, gas stations, grocery stores, and big box stores, and flavored tobacco products or ads for them. These differences persisted after controlling for demographics.
Conclusions
The present results suggest vast differences in smoking behavior among non-metropolitan and metropolitan adolescents and that targeting social and environmental factors may be beneficial for reducing tobacco disparities among non-metropolitan adolescents.
Keywords: adolescents, cigarette, health disparities, rural, tobacco
Individuals living in non-metropolitan (non-metro) areas suffer disproportionately from tobacco use1–4 and tobacco-related illness compared to individuals living in metropolitan (metro) areas.5 National and state-level surveys consistently show that adolescent1–3,6–8 and adult9 tobacco use is higher in non-metropolitan areas than in metropolitan areas. Smoking rates among adolescents are of particular concern, since the majority of smokers begin smoking prior to age 18.10 Nationally, in 2013, the Monitoring the Future (MTF) study showed that past 30-day cigarette smoking was higher in non-metropolitan areas compared to metropolitan areas among 8th (8.0% vs 2.5%), 10th (13.0% vs 5.8%), and 12th graders (20.9% vs 14.5%).11
Few empirical studies have investigated how patterns of cigarette use differ among metropolitan and non-metropolitan adolescents. Only one study reported that the mean age of initial smokeless tobacco use was over a year earlier in rural adolescents, compared to urban adolescents.12 No studies have examined how age of initiation of cigarette smoking varies among metro and non-metro youth. One study, however, found that 14% of rural adolescents report heavy (eg, daily) smoking compared to 10% of urban high school students.2 Understanding differences in patterns of cigarette consumption among non-metro and metro adolescents is essential for tailoring tobacco-related interventions to address tobacco-related disparities in smoking among rural populations.
Few studies to date have examined how the tobacco-related context differs for metro and non-metro adolescents. Previous research suggests that a wide variety of factors, at multiple levels, influence cigarette smoking. For example, research shows that individual (eg, gender and age11), family (eg, disapproval of use, attitudes, and behavior13–15), peer (eg, disapproval of use, attitudes, and behavior16), and community characteristics (eg, rates of use and availability)17 play an important role in smoking behavior, particularly among adolescents. Utilizing a social-ecological framework, Connell and associates examined factors associated with patterns of substance use, including tobacco, among a large sample of non-metropolitan high school students. The authors found that peer substance use had the largest effect on substance use among this sample. The authors also found that family and community characteristics were consistently related to patterns of use including parental disapproval and availability of substances.18 One limitation of this study, however, is that the authors did not examine factors associated with tobacco use specifically.
The present study addresses several important gaps in the literature about smoking disparities in rural communities. First, differences in cigarette use among metro and non-metro adolescents are examined across a range of indices, including age of initiation and detailed cigarette consumption measures. Second, the current study utilizes an ecological framework to examine how a range of smoking-specific factors at the individual, peer, family, and community levels vary among metro and non-metro adolescents. Utilizing an ecological framework provides a broader understanding of factors that contribute to disparities in cigarette smoking among non-metro adolescents.
Methods
Overview of the Florida Youth Tobacco Survey
The Florida Youth Tobacco Survey (FYTS) is a school-based survey administered annually by the Florida Department of Health. The sample includes middle and high school students across the state, using a 2-stage cluster probability design. First, a random sample of public middle and high schools is selected. Second, a random sample of classrooms is selected from each school, and all students in the selected classrooms are invited to participate in the survey. In the odd years, the survey is administered in 43 counties across the state (with a much smaller sample size) and the data are only weighted to the state population that represents those who took the survey (middle/high school). In even years, data are collected in all 67 counties across the state and the data are weighted to both the state and county population that represents those who took the survey (middle/high school). All counties required parental consent (65 counties used passive and 2 counties used active consent procedures). The present study focuses on the 2012 data, in which the data are weighted to the county population.
The 2012 FYTS was administered in the spring of 2012 to 75,428 total students within 746 public schools, of which 38,989 attended middle school and 36,439 attended high schools. The overall survey response rate for middle schools was 77%, and the overall survey response rate for high schools was 73%. Data were collected from 66 of the 67 counties in Florida, with one county abstaining (Osceola County) and another removed due to unrepresentative sampling (Hardee County).19 Participants between 14 and 17 years of age at the time of survey were included in the present study (n=40,746). The majority of youth included were in high school (grades 9–12; 82.2%), or at the end of middle school (8th grade; 14.9%). The study is a secondary data analysis on de-identified data and was therefore exempted from Institutional Review Board approval.
Geographic Classification
Geographical location was defined according the 2003 Rural-Urban Continuum Codes (RUCC) developed by the United States Department of Agriculture.20 The codes are assigned to counties based on the population size of the Metropolitan Statistical Area (MSA), ranging from 1 to 9 (1=counties in metro areas of 1 million population or more, 2=counties in metro areas of 250,000 to 1 million population, 3=counties in metro areas of fewer than 250,000 population, 4=urban population of 20,000 or more, adjacent to a metro area, 5=urban population of 20,000 or more, not adjacent to a metro area, 6=urban population of 2,500 to 19,999, adjacent to a metro area, 7=urban population of 2,500 to 19,999, not adjacent to a metro area, 8=completely rural or less than 2,500 urban population, adjacent to a metro area, 9=completely rural or less than 2,500 metropolitan population, not adjacent to a metro area). A dichotomous variable was created, consistent with the Department of Agriculture’s RUCC metro versus non-metro delineation, in which codes 1 to 3 were coded as “metropolitan” and codes 4 to 9 were coded as “non-metropolitan.” Of the 66 counties included, 31 counties were classified as non-metropolitan.
Demographic Characteristics
Demographic characteristics include gender, age, ethnicity, and race. Participants indicated their age at the time of the survey. Participants were asked to indicate if they were Hispanic/Latino (yes/no), and the best category that described them (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, other). Responses were recoded into Hispanic, non-Hispanic White, non-Hispanic Black, and other (including non-Hispanic Asian, American Indian, Alaska Native, Native Hawaiian or Other Pacific Islander).
Cigarette Use
Participants indicated if they had ever tried cigarette smoking, even a puff or 2. Age of initiation for cigarette smoking was determined through the response to the survey question: “How old were you when you smoked cigarettes for the first time?” Response options ranged from “8 or younger” to “17 years of age or older.” Due to the distribution of the variable, a 3-level variable was created: age 8–11, age 12–14, and age 15–17. Participants indicated if they ever smoked daily (at least 1 cigarette a day for 30 days), how many days in the past 30 days they smoked (0 days, 1–2 days, 3–5 days, 6–9 days, 10–19 days, 20–29 days, and 30 days), and how many cigarettes they smoked per day on the days they smoked (0, less than 1, 2–5, 6–10, 11–20, and more than 20). Due to less variability among the higher number of cigarettes smoked per day, the last 2 categories (11–20 and more than 20) were combined for analysis. Participants also indicated how many cigarettes they have smoked in their lifetime (0; 1–2 puffs, not a whole cigarette; 1 cigarette; 2–20 cigarettes; 21–99 cigarettes; 100+ cigarettes). The following categories were combined into ≤ 1 cigarette: 1–2 puffs, not a whole cigarette, and 1 cigarette. Finally, participants indicated if the cigarettes they smoked were usually menthol (yes/no).
Tobacco Environment
Friend and Family Characteristics
In this category, participants indicated if they thought their friends viewed adult cigarette smoking as acceptable (yes/no), their own exposure to smoking, and any parental factors related to smoking. Exposure to smoking includes the number of days in a room with a smoker during the past 7 days (0, 1–2, 3–4, 5+), who they were around when they were around someone smoking (participants chose one of the following options: parent, relative, friend, co-worker, someone they didn’t know), whether someone smoked in the home (besides the respondent; yes/no), and whether smoking was allowed in the home (yes/no). Parental-related factors included whether their parent had ever offered them a cigarette (yes/no) and whether a parent or guardian had talked to them about the danger of tobacco use during the past 12 months (yes/no).
School and Community Characteristics
Participants were asked 5 questions about school including whether they were taught about tobacco use in any of their classes at school this year (yes/no); if the school has a rule that no one can smoke on school property (yes/no); if during the past 12 months they had seen students smoking on school property (yes/no); if during the past 12 months they had seen teachers, staff, or other adults smoking on school property (yes/no); and if the school has resources for students who want to quit (yes/no).
Participants were also asked about smoking in their community, including whether adult cigarette smoking is acceptable among people in their community (yes/no), if they saw tobacco ads the last time they visited a convenience store, gas station, pharmacy/drug store, grocery store, and big box store (yes/no), and if they had ever seen flavored tobacco or ads for them (yes/no).
Data Analytic Strategy
To accommodate the complex sampling procedures utilized in the FYTS, data were analyzed using survey procedures in SAS 9.4 (SAS Institute Inc., Cary, North Carolina). Due to the few students who reported “not sure” for each item, these responses were omitted. Weighted chi-square analyses were used to examine differences in the demographic composition of the metropolitan and non-metropolitan adolescents in the sample. Logistic and multinomial logistic regression analyses were used for analysis to assess differences between the metropolitan and non-metropolitan adolescents on smoking behaviors and tobacco-related environmental factors. Age, gender, and race/ethnicity were included in the logistic regression analyses as covariates and all analyses were weighted to account for the complex survey design. Separate models were examined for each dependent variable. Due to the large sample size, and the number of comparisons in the present study, the alpha level was adjusted from the traditional .05 to .01.
Results
Demographic Characteristics
The metro and non-metro adolescents were similar in age and gender (see Table 1). Racial and ethnic differences were found among the metro and non-metro samples. The metro adolescents sample was more diverse, including a higher percentage of non-Hispanic black and Hispanic adolescents compared to the non-metro adolescent sample, which had a higher percentage of non-Hispanic white adolescents.
Table 1.
Weighted Demographic Characteristics of the Study Sample by Geographic Location.
| Metropolitan | Non-Metropolitan | ||||
|---|---|---|---|---|---|
|
| |||||
| Characteristic | Weighted N |
M (SD) or % |
Weighted N |
M (SD) or % |
Chi-square |
| Age | .44 | ||||
| 14 | 190118 | 25.0 | 12690 | 26.3 | |
| 15 | 197892 | 26.1 | 12551 | 26.0 | |
| 16 | 192724 | 25.4 | 11941 | 24.8 | |
| 17 | 178398 | 23.5 | 11052 | 22.9 | |
| Gender | 1.79 | ||||
| Male | 374891 | 50.7 | 24555 | 52.3 | |
| Female | 363950 | 49.3 | 22432 | 47.7 | |
| Race/Ethnicity | 117.1 | ||||
| Non-Hispanic White | 327643 | 43.4 | 29830 | 62.2 | |
| Non-Hispanic Black | 173418 | 23.0 | 8324 | 17.4 | |
| Hispanic | 210814 | 27.9 | 7879 | 16.4 | |
| Other | 42843 | 5.7 | 1916 | 4.0 | |
| Total | |||||
P values are based on chi-square tests.
Bold=significant at P < .01
Cigarette Use
Compared to metro adolescents, non-metro adolescents were more likely to have reported trying cigarettes in their lifetime, initiating smoking at a younger age (at both age 8–11 and age 12–14, compared to the older age group), having smoked daily, and having smoked in the past 30 days (see Table 2). Non-metro adolescents also reported higher levels of cigarette consumption in the past 30 days, and smoking more cigarettes in their lifetime. No differences were found in use of menthol cigarettes between metro and non-metro adolescents.
Table 2.
Cigarette Use by Geographic Location.a
| Characteristic | Metro | Non-Metro | AOR (99% CI) (Non-metro vs Metro) |
|---|---|---|---|
| Ever Tried Cigarette Smoking | |||
| Yes | 27.3 | 38.7 | 1.64 (1.48–1.81) |
| No | 72.7 | 61.3 | Ref |
| Age of Initiation | |||
| Age 8–11 | 25.4 | 31.0 | 1.59 (1.20–2.09) |
| Age 12–14 | 47.6 | 48.1 | 1.26 (0.98–1.62) |
| Age 15–17 | 27.0 | 20.9 | Ref |
| Ever Smoked Daily | |||
| Yes | 5.1 | 8.4 | 1.54 (1.26–1.87) |
| No | 94.9 | 91.6 | Ref |
| Smoked in Past 30 Days | |||
| Yes | 9.3 | 14.6 | 1.55 (1.33–1.80) |
| No | 90.7 | 85.4 | Ref |
| Cigarettes Smoked in Lifetime | |||
| None | 72.8 | 61.4 | Ref |
| ≤ 1 Cigarette | 12.8 | 16.5 | 1.57 (1.39–1.77) |
| 2 to 20 Cigarettes | 7.5 | 10.8 | 1.62 (1.40–1.87) |
| 21 to 99 Cigarettes | 3.0 | 4.4 | 1.59 (1.31–1.94) |
| 100+ Cigarettes | 3.9 | 6.8 | 1.91 (1.51–2.41) |
| Cigarettes Smoked Per Day in Past 30 Days | |||
| 0 Cigarettes | 90.4 | 84.9 | Ref |
| ≤ 1 Cigarette Per Day | 4.3 | 6.4 | 1.51 (1.25–1.82) |
| 2–5 Cigarettes Per Day | 3.3 | 5.7 | 1.60 (1.27–2.01) |
| 6–10 Cigarettes Per Day | .9 | 1.7 | 1.86 (1.35–2.55) |
| 11+ Cigarettes Per Day | 1.0 | 1.3 | 1.40 (0.95–2.07) |
| Cigarettes Usually Menthol | |||
| Yes | 51.4 | 48.8 | .88 (0.72–1.08) |
| No | 48.6 | 51.2 | Ref |
Adjusted for age, gender, and race/ethnicity
Bold=significant at P < .01
Smoking Environment:Friends and Family
Non-metro adolescents, compared to metro adolescents, were more likely to report that adult smoking was acceptable among their friends and being in a room with a smoker 3 or more days during the past 7 days (Table 3). When around someone smoking, non-metro adolescents were more likely to report it was someone they knew, including a parent or relative, compared to metro adolescents. Adolescents in non-metro areas were more likely to report that someone in the home smoked (besides themselves), that smoking was allowed in the home, and that a parent had offered them a cigarette. Fewer reported that a parent had talked to them about the danger of tobacco, compared to metro adolescents.
Table 3.
Friend and Family Characteristics by Geographic Location.a
| Characteristic | Metro | Non-Metro | AOR (99% CI) (Non-Metro vs Metro) |
|---|---|---|---|
| Adult smoking acceptable among friends | |||
| Yes | 46.2 | 50.0 | 1.16 (1.04–1.29) |
| No | 53.8 | 50.0 | Ref |
| During past 7 days, days in room with smoker | |||
| 0 days | 58.4 | 50.3 | Ref |
| 1–2 days | 18.0 | 16.9 | 1.03 (0.93–1.13) |
| 3–4 days | 8.1 | 9.4 | 1.27 (1.11–1.46) |
| 5+ days | 15.5 | 23.3 | 1.56 (1.36–1.80) |
| When around someone smoking, who was it? | |||
| Not around anyone who smoked | 63.0 | 54.5 | Ref |
| Parent | 12.6 | 19.3 | 1.58 (1.37–1.81) |
| Relative | 7.7 | 11.1 | 1.63 (1.38–1.92) |
| Friend | 8.4 | 8.7 | 1.16 (0.99–1.36) |
| Co-worker | .8 | 1.0 | 1.42 (0.97–2.07) |
| Someone I don’t know | 7.5 | 5.5 | .83 (0.71–0.99) |
| Anyone in home smoke (besides respondent)? | |||
| Yes | 29.8 | 39.8 | 1.44 (1.28–1.62) |
| No | 70.2 | 60.2 | Ref |
| Parents ever offered cigarette | |||
| Yes | 3.3 | 5.2 | 1.63 (1.27–2.08) |
| No | 96.7 | 94.8 | Ref |
| Parent/Guardian talked about danger of tobacco | |||
| Yes | 53.3 | 51.6 | Ref |
| No | 46.7 | 48.4 | 1.06 (0.99–1.15) |
| Smoking allowed inside home | |||
| Yes | 9.2 | 15.7 | 1.71 (1.49–1.95) |
| No | 90.8 | 84.3 | Ref |
Adjusted for age, gender, and race/ethnicity
Bold=significant at P < .01
Smoking Environment: School and Community
Participants who lived in non-metro areas were more likely to report having been taught about tobacco use during this school year and that the school has resources for students who want to quit smoking compared to metro adolescents (Table 4). Non-metro adolescents were less likely to report seeing students smoking on school property. Metro and non-metro adolescents’ reports of no smoking rules at school and seeing teachers/adults smoking on school property were similar.
Table 4.
School and Community Characteristics by Geographic Location.a
| Characteristic | Metro | Non-Metro | AOR (99% CI) (Non-Metro vs Metro) |
|---|---|---|---|
| School Characteristics | |||
| During this school year taught about tobacco use | |||
| Yes | 36.9 | 42.2 | 1.24 (1.02–1.51) |
| No | 63.1 | 57.8 | Ref |
| No smoking rule at school | |||
| Yes | 92.0 | 91.4 | Ref |
| No | 8.0 | 8.6 | 1.29 (0.92–1.81) |
| Seen students smoking on school property | |||
| Yes | 47.2 | 39.7 | .72 (0.59–0.86) |
| No | 52.8 | 60.3 | Ref |
| Seen teachers/adults smoking on school property | |||
| Yes | 20.2 | 20.7 | 1.03 (0.87–1.22) |
| No | 79.8 | 79.3 | Ref |
| School has resources for students who want to quit | |||
| Yes | 14.8 | 24.9 | 1.83 (1.35–2.49) |
| No | 85.2 | 75.1 | Ref |
| Community Characteristics | |||
| Adult smoking acceptable among community | |||
| Yes | 57.6 | 59.5 | 1.08 (0.98–1.19) |
| No | 42.4 | 40.5 | Ref |
| See tobacco ads when last visited: | |||
| Convenience store (yes) | 65.9 | 74.5 | 1.37 (1.23–1.54) |
| Gas station (yes) | 75.3 | 80.9 | 1.27 (1.13–1.44) |
| Pharmacy/drug store (yes) | 44.4 | 41.0 | .86 (0.77–0.95) |
| Grocery store (yes) | 38.7 | 48.3 | 1.43 (1.31–1.55) |
| Big box store such as Walmart or K-mart (yes) | 36.5 | 48.2 | 1.56 (1.38–1.76) |
| Ever seen flavored tobacco or ads for them | |||
| Yes | 45.7 | 55.0 | 1.37 (1.23–1.52) |
| No | 54.3 | 45.0 | Ref |
Adjusted for age, gender, and race/ethnicity
Non-metro adolescents were more likely to report seeing tobacco ads the last time they visited various locations in the community including a convenience store, gas station, grocery store, and big box store such as Walmart or K-Mart. Non-metro adolescents, however, were less likely to see tobacco advertisements the last time they visited a pharmacy or drug store compared to metro adolescents. Non-metro adolescents were also more likely to report seeing flavored tobacco or ads for it compared to metro adolescents.
Conclusions
The main goal of the present study was to assess differences in cigarette smoking behavior and the tobacco-related environment among adolescents who live in metro and non-metro areas. Consistent with previous studies, adolescents from non-metro areas were more likely to report having tried smoking cigarettes in their lifetime and smoking in the past 30 days.11 The present findings, however, expand this research in 2 important ways. First, our findings show that adolescents from non-metro areas tried smoking at earlier ages (as young as 8–11 years of age) than their non-metro counterparts. Delaying experimentation with cigarette smoking has been shown to be critical for reducing the likelihood of addiction and increasing the likelihood of quitting.21–23 Thus, more interventions need to be implemented in non-metro areas to prevent experimentation with and initiation of cigarette smoking. Second, the present findings suggest that adolescents from non-metro areas are smoking heavier as adolescents than adolescents from metro areas. Adolescents in non-metro areas were more likely to report smoking daily, having smoked more cigarettes in their lifetime, and smoking a greater number of cigarettes per day than adolescents in metro areas. Previous research suggests that approximately half of cigarette smokers will transition to daily smoking by age 18.24 These data suggest that a greater proportion of non-metro adolescents may transition to daily smoking at an earlier age than metro adolescents. Prevention efforts throughout adolescence, along with programs designed to help students quit, may be essential for addressing tobacco use in non-metro areas. Importantly, the present study found that non-metro adolescents were more likely to report that the school had resources for students who wanted to quit. However, this was reported by less than one-quarter of all non-metro adolescents. Evaluating the effects of in-school resources for quitting may be an avenue for future research.
Another primary contribution of the present study was to examine how the tobacco-related environment, at multiple levels including friends, family, school, and community, may differ for metro and non-metro adolescents. With regard to family and friends, differences were found between metro and non-metro adolescents on all the factors examined including social norms (eg, friends’ approval of adult smoking and parents offering them a cigarette) and exposure to smoking (eg, smoking allowed in the home, days in room with a smoker, and others smoking in the home). Due to the cross-sectional nature of this study, it is unclear if these factors led to differences observed in cigarette smoking in the present study. However, these factors have been shown to be important contributors to adolescent smoking in previous studies.25,26 The differences found in the present study indicate that focusing or including parents and adults in non-metro communities in tobacco-related interventions may be important. Encouraging non-metro parents to adopt a home smoking ban may be particularly beneficial. Future studies including longitudinal data are needed to examine how differences in the tobacco-related environment with regard to friends and family lead to differences in smoking behavior among metro and non-metro adolescents.
Finally, we found that important differences existed in the marketing of tobacco among metro and non-metro adolescents, in which non-metro adolescents were more likely to report seeing tobacco ads in common locations such as convenience stores, gas stations, grocery stores, and big box stores. It is possible that the differences observed can be attributed to differences in the types and number of outlets in metro and non-metro areas. While these results should be interpreted with caution, previous research suggests that exposure to tobacco advertising and promotions foster positive attitudes toward smoking and increases the likelihood of initiation among adolescents.27 It is possible that tobacco companies target non-metro counties with their point-of-sale advertising. It is also possible that because there may be fewer retail stores in the non-metro areas, the same amount of point-of-sale advertising becomes more visible. Nonetheless, point-of-sale advertising has been linked to adolescent tobacco use, and a recent review suggests that point-of-sale advertising may contribute to disparities in tobacco use.28
It is notable that adolescents from non-metro areas were less likely to see tobacco ads in drug stores or pharmacies. This may be because rural areas are more likely to have smaller independently owned pharmacies and drug stores that primarily sell health care needs and not tobacco.
The present study has several limitations. First, it includes only adolescents from Florida. The results may not generalize to adolescents in other states in the United States. County-level data, however, are not available in many national datasets such as the National Youth Tobacco Survey. Second, a dichotomous measure of residential status was used: 1) metropolitan and 2) non-metropolitan and rural combined. While this dichotomy is commonly used in health research, it is possible that there is variability in the non-metropolitan and rural category that was not captured in the present study. Third, the present study is cross-sectional and thus, causality cannot be established. Fourth, this study was limited to the questions included on the Florida Youth Tobacco Survey. Not all questions that might be important for understanding differences in tobacco use and the environment were included in the survey. Finally, the Florida Youth Tobacco Survey is a school-based survey and the results may not generalize to adolescents not in school. Finally, the present study includes only youth who were in school. It is well known that rates of smoking are higher among youth who are not in school. Thus, the prevalence estimates of smoking presented in the current study may underestimate the true prevalence of smoking among each group. It is unclear, based on current research, whether this underestimate would be similar or different for metro and non-metro adolescents. Despite these limitations, the present study includes a large, diverse, representative sample from a large state in the US. This study provides a more in-depth examination (versus previous studies) of how both tobacco use and the tobacco-related environment differ among adolescents living in metro and non-metro areas. Future research should examine how differences in the tobacco environment are associated with observed differences in cigarette use.
Acknowledgments
Funding: Dr. Bernat’s effort was supported with a grant from the National Cancer Institute (R03 CA168411; D. Bernat, Principal Investigator). Dr. Choi’s effort was funded by the Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health.
Footnotes
Disclosures: The authors report no conflicts of interest relevant to this article and no financial disclosures.
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