Abstract
Flavored cigar sales restrictions (FCSRs) may reduce cigar smoking and protect public health. This study examined the correlates of behavior change intents in response to a hypothetical FCSR. Data were from a nationally representative sample of adult flavored cigar smokers (ages ≥21; n=343) collected through an online survey in 2021. Respondents selected their behavior change intents in response to a hypothetical FCSR, including (1) quitting cigars altogether; (2) smoking plain or non-flavored cigars; (3) smoking other flavored tobacco products; (4) smoking cannabis; and (5) other options. Weighted logistic regressions were used to examine the associations of socio-demographic backgrounds, tobacco use history, and tobacco dependence with behavioral change intents. In response to an FCSR, 15.1% of respondents would quit smoking cigars altogether, 41.6% would smoke plain cigars without flavors, 33.4% would substitute flavored cigars with other flavored tobacco products, and 29.2% would substitute flavored cigars with cannabis. Large cigar smokers and blunt smokers were less likely to quit cigars altogether than non-smokers of those products; females and racial/ethnic minorities were more likely to substitute flavored cigars with other flavored tobacco and cannabis products, respectively, than males and non-Hispanic White respondents. Results suggest that FCSRs may reduce cigar smoking among a portion of U.S. flavored cigar smokers while leaving more continuing to smoke plain cigars or transitioning to use other flavored tobacco products or cannabis. Implementing FCSRs should be accompanied by comprehensive flavored tobacco sales restrictions, cessation programs, and educational messages aimed at reducing the use of cigars and other substances.
Keywords: cigars, Tobacco Policy, Flavored tobacco, cigarillos, Large Cigars, Cigar Prevention, health disparities
INTRODUCTION
Cigar smoking, like cigarette smoking, can lead to the development of cancers (e.g., lung, oral, esophageal, and larynx), cardiovascular diseases, and chronic obstructive pulmonary diseases.1 Certain cigar products, such as large cigars and cigarillos, can also contain higher levels of nicotine than cigarettes and contribute to increased nicotine dependence.1 However, unlike cigarette sales, which have seen a large decline in recent decades, cigar product sales have seen a marked increase in the U.S. from 2.47 billion in 2009 to 3.26 billion in 2020.2 Therefore, reducing cigar smoking among the U.S. population has become a critical public health priority.
One prominent reason for increased cigar smoking and sales is the allure of cigar flavors that taste like fruit, candy, or alcohol.3 Between 2008–2015 flavored cigar sales increased by nearly 50%,4 and between 2015–2020, flavored cigar sales in U.S. convenience stores continued to rise.5 In general, flavors in tobacco products may contribute to curiosity and interest in tobacco use and product initiation,6 as well as frequent use7 and difficulty quitting.8 Flavored cigar products may also drive the initiation and frequent use of cigar products9 and are frequently used by Black smokers.10 Consequently, one promising strategy to reduce cigar smoking and its associated health problems is to reduce the availability of flavored cigar products.
Since the early 2010s, many localities in the U.S. enacted restrictions on the sale of flavored non-cigarette products, including cigar products.11,12 In April 2021, the U.S. Food and Drug Administration (FDA) announced its plan to restrict the sale of flavored cigar products to reduce cigar smoking and its associated health disparities.13 Very few studies have assessed the potential impact of flavored cigar sales restrictions (FCSRs) on cigar smoking or their unintended consequences on smokers’ behavior change. Additionally, very few studies have examined the correlates (e.g., demographics, tobacco-using history) of FCSRs’ potential policy outcomes, leaving it unclear how priority groups (e.g., racial/ethnic minority groups) may be affected by FCSRs.
Therefore, this study aimed to explore the correlates of potential behavior change intents in response to a hypothetical FCSR among a nationally representative sample of adult flavored cigar smokers in the U.S. This research can be used to inform local and national FCSR policymaking and predict its potential impact on cigar smokers’ behavior change.
METHODS
Sample and Data Collection Procedures
Data were obtained in 2021 from a nationally representative sample of 1,700 adults (≥21 years; mean age 43.0 years) who were surveyed by YouGov (a survey research company) on current and recent tobacco use. A sampling matching approach with weighting was used to achieve national representation. Informed consent was obtained, and compensations were provided through YouGov. The current analysis was restricted to respondents (n=343; mean age 36.2 years) who reported past-30-day use of flavored cigar products (large cigars, cigarillos, and/or filtered cigars) that taste like menthol, mint, dessert, candy, alcohol, or a beverage. The current analysis did not require review or approval by the National Institutes of Health Institutional Review Board per 45 CFR 46 because it only involved de-identified data and therefore was considered “not human subjects research.”
Measures
Behavior change intents in response to FCSRs.
Respondents were asked, “If the sale of flavored cigar products that taste like fruits, alcohol, candy, menthol/mint, desserts, and beverages are banned, what would you do?” Respondents first saw the response “quit cigars altogether.” The respondents who selected this option were not able to choose additional options. Those who did not select to completely quit were asked to choose one or more of the following options: (1) smoke plain cigars without flavors; (2) substitute flavored cigars with other flavored tobacco products; (3) substitute flavored cigars with cannabis; and (4) others not described above. All behavior change intents were coded as binary variables (Yes=1; No=0).
Socio-demographic backgrounds.
Respondents reported their age, birth, sex, race/ethnicity, annual household income, and highest educational achievement (see Table 1).
Table 1.
Distributions of respondent characteristics overall and by behavior change intent in response to a hypothetical flavored cigar sales restriction among nationally representative adult past-30-day flavored cigar smokers (n=343)
| Total | Would quit cigars altogether | Would smoke plain cigars without flavors | Would substitute flavored cigars with other flavored tobacco products | Would substitute flavored cigars with cannabis | |||||
|---|---|---|---|---|---|---|---|---|---|
| % | % | P-value | % | P-value | % | P-value | % | P-value | |
| Total | 15.1 | 41.6 | 33.4 | 29.2 | |||||
| Age | 0.1675 | 0.0561 | 0.2789 | <0.05 | |||||
| 21–30 | 47.0 | 10.8 | 36.6 | 37.8 | 32.1 | ||||
| 31–40 | 32.0 | 19.8 | 38.9 | 35.2 | 36.6 | ||||
| 41–50 | 11.8 | 10.1 | 70.5 | 18.6 | 13.0 | ||||
| ⩾51 | 9.2 | 26.7 | 38.8 | 23.3 | 9.3 | ||||
| Gender | 0.9443 | 0.4034 | <0.05 | 0.7883 | |||||
| Male | 70.1 | 15.2 | 43.7 | 27.2 | 29.9 | ||||
| Female | 29.9 | 14.8 | 36.5 | 48.0 | 27.6 | ||||
| Race/Ethnicity | 0.6573 | 0.4581 | 0.5595 | <0.05 | |||||
| Non-Hispanic White | 41.9 | 15.5 | 48.6 | 37.9 | 10.9 | ||||
| Non-Hispanic Black | 26.3 | 11.7 | 36.6 | 27.3 | 41.4 | ||||
| Hispanic | 21.1 | 14.6 | 34.4 | 28.9 | 49.3 | ||||
| Non-Hispanic other race | 1.7 | 22.7 | 40.2 | 39.7 | 32.3 | ||||
| Household Income | 0.4410 | 0.9001 | 0.9789 | 0.9138 | |||||
| ⩽$24,999 | 43.6 | 13.7 | 40.4 | 34.6 | 27.1 | ||||
| $25,000–$59,999 | 30.0 | 20.4 | 41.4 | 31.7 | 28.7 | ||||
| $60,000–$99,999 | 12.6 | 12.9 | 49.0 | 31.3 | 30.7 | ||||
| ⩾$100,000 | 13.9 | 9.7 | 38.6 | 35.0 | 35.4 | ||||
| Highest Education Level | 0.3679 | 0.5227 | 0.4341 | 0.5527 | |||||
| ⩽High School | 52.9 | 12.6 | 37.3 | 33.0 | 33.0 | ||||
| Some college | 25.7 | 20.7 | 46.3 | 27.6 | 23.6 | ||||
| ≥Bachelor’s degree | 21.4 | 14.3 | 46.3 | 41.4 | 26.6 | ||||
| Past-30-day Large Cigar Smoking | <0.05 | 0.1495 | 0.1807 | 0.1739 | |||||
| No | 73.2 | 17.7 | 38.3 | 30.5 | 26.2 | ||||
| Yes | 26.8 | 7.9 | 50.6 | 41.2 | 37.3 | ||||
| Past-30-day Cigarillo Smoking | 0.0728 | 0.0608 | 0.6107 | 0.9057 | |||||
| No | 40.0 | 20.6 | 32.0 | 31.0 | 29.8 | ||||
| Yes | 60.0 | 11.4 | 47.9 | 35.0 | 28.8 | ||||
| Past-30-day Filtered Cigar Smoking | 0.4416 | 0.2464 | 0.6623 | <0.05 | |||||
| No | 71.7 | 13.8 | 44.5 | 32.4 | 23.5 | ||||
| Yes | 28.3 | 18.2 | 34.2 | 36.0 | 43.6 | ||||
| Past-30-day Blunt Smoking | <0.05 | 0.9992 | 0.2624 | <0.05 | |||||
| No | 28.4 | 25.4 | 41.6 | 26.7 | 11.8 | ||||
| Yes | 71.6 | 10.9 | 41.5 | 36.1 | 36.1 | ||||
| Past-30-day Cigarette Smoking | 0.9865 | 0.1372 | 0.7432 | 0.6746 | |||||
| No | 32.4 | 15.1 | 32.9 | 35.2 | 31.6 | ||||
| Yes | 67.6 | 15.0 | 45.7 | 32.5 | 28.0 | ||||
| Past-30-day E-cigarette Use | 0.5084 | 0.5121 | 0.3856 | 0.9750 | |||||
| No | 38.4 | 13.0 | 45.3 | 29.1 | 29.4 | ||||
| Yes | 61.6 | 16.3 | 39.2 | 36.1 | 29.1 | ||||
| Tobacco Dependence | 0.5478 | 0.2701 | 0.2442 | 0.0646 | |||||
| ⩾60mins | 10.3 | 17.1 | 40.3 | 27.6 | 20.3 | ||||
| 30–59 mins | 22.6 | 12.7 | 27.5 | 39.3 | 47.7 | ||||
| 6–29 mins | 42.4 | 12.3 | 45.1 | 38.7 | 25.5 | ||||
| ⩽5 mins | 24.7 | 21.1 | 48.9 | 21.3 | 22.2 | ||||
Notes:
Bolded text indicates p-value<0.05
Percentages are weighted to be nationally representative
Tobacco use and dependence.
The respondents also reported their past-30-day use (Yes/No) of different tobacco products (large cigars, cigarillos, filtered cigars, blunts, cigarettes, e-cigarettes). Tobacco dependence was assessed based on the question, “think about all the tobacco products you currently use, how soon do you use one of these products after waking?”14 Response options were ⩽5 minutes, 6–29 minutes, 30–59 minutes, and ⩾60 minutes.
Statistical Analysis
All analyses were weighted to be nationally representative, and weighted distributions of correlates (i.e., socio-demographic background, past-30-day tobacco use, and tobacco dependence) were estimated. The weighted percentage of each behavior change intent in response to FCSRs was estimated in the overall sample and by each correlate. Pearson Chi-square tests were used to assess the bivariate associations between each behavior change intent and the correlates. Weighted multivariable logistic regressions were then conducted to examine the associations between correlates and each behavior change intent, controlling for other correlates. Statistical significance was set to 0.05 (2-tailed). Data were analyzed using Stata 16.0 (College Station, TX).
RESULTS
Respondent Characteristics and Behavior Change Intents
Overall, 47.0% of respondents were between 21–30 years old, 70.1% were male, 41.9% were non-Hispanic White, 26.3% were non-Hispanic Black, 21.1% were Hispanic, and 10.7% were non-Hispanic other race (Table 1). In response to a hypothetical FCSR, 15.1% of respondents indicated that they would quit smoking cigars altogether. Additionally, 41.6% reported that they would smoke plain cigars without flavors, 33.4% would substitute flavored cigars with other flavored tobacco products, 29.2% would substitute flavored cigars with cannabis, and 3.1% would pursue other options.
Correlates of Behavior Change Intents in Response to a Hypothetical FCSR
Weighted Chi-square results show that in response to FCSRs, those who smoked large cigars (p<0.05) or blunts (p<0.05) were less likely to report that they would quit smoking cigars altogether compared to those who did not smoke those products. Females were more likely than males (p<0.05) to substitute flavored cigars with other flavored tobacco products. Non-Hispanic Black and Hispanic participants (p<0.05) were more likely than non-Hispanic White participants to substitute flavored cigars with cannabis. Additionally, those who smoked filtered cigars (p<0.05) or blunts (p<0.05) were more likely than those who did not smoke those products to substitute flavored cigars with cannabis.
The weighted multivariable logistic regressions (Table 2) show that in response to FCSRs, those who smoked large cigars (AOR=0.36, 95% CI=0.15, 0.87) or blunts (AOR=0.38, 95% CI=0.14, 0.98) were less likely to quit smoking cigars altogether compared to those who did not currently smoke those products. Participants of ages 31–40 (AOR=4.45, 95% CI=1.50, 13.3) were more likely than participants of ages 21–30 to report their willingness to smoke plain cigars without flavors. Females were more likely than males (AOR=2.72, 95% CI=1.28, 5.77) to substitute flavored cigars with other flavored tobacco products. Those who reported as non-Hispanic Black (AOR=5.52, 95% CI=1.76, 17.23), Hispanic (AOR=9.49, 95% CI=3.11, 29.02), or non-Hispanic other race (AOR=3.20, 95% CI=1.02, 9.97) were more likely than those who reported as non-Hispanic White to substitute flavored cigars with cannabis. Additionally, those who smoked filtered cigars (p<0.05) or blunts (p<0.05) were more likely than those who did not smoke these products to substitute flavored cigars with cannabis. Finally, past-30-day use of cigarettes and e-cigarettes and tobacco dependence did not predict behavior change intents.
Table 2.
Associations between correlates and behavior change intents in response to a hypothetical flavored cigar sales restriction among nationally representative adult past-30-day flavored cigar smokers (n=343)
| Would quit cigars altogether | Would smoke plain cigars without flavors | Would substitute flavored cigars with other flavored tobacco products | Would substitute flavored cigars with cannabis | |||||
|---|---|---|---|---|---|---|---|---|
| AOR | 95% CI | AOR | 95% CI | AOR | 95% CI | AOR | 95% CI | |
| Age | ||||||||
| 21–30 | Reference | Reference | Reference | Reference | ||||
| 31–40 | 2.25 | 0.83, 6.09 | 1.19 | 0.58, 2.66 | 1.00 | 0.46, 2.16 | 1.18 | 0.47, 2.93 |
| 41–50 | 0.75 | 0.17, 3.28 | 4.45 | 1.50, 13.3 | 0.41 | 0.13, 1.32 | 0.56 | 0.12, 2.51 |
| ⩾51 | 1.70 | 0.44, 6.67 | 1.25 | 0.44, 3.53 | 0.65 | 0.18, 2.31 | 0.38 | 0.09, 1.67 |
| Gender | ||||||||
| Male | Reference | Reference | Reference | Reference | ||||
| Female | 0.88 | 0.38, 2.08 | 0.76 | 0.34, 1.67 | 2.72 | 1.28, 5.77 | 0.87 | 0.34, 2.28 |
| Race/Ethnicity | ||||||||
| Non-HispanicWhite | Reference | Reference | Reference | Reference | ||||
| Non-Hispanic Black | 0.73 | 0.25, 2.17 | 0.71 | 0.31, 1.67 | 0.45 | 0.17, 1.19 | 5.52 | 1.76, 17.23 |
| Hispanic | 1.21 | 0.41, 3.53 | 0.59 | 0.26, 1.35 | 0.44 | 0.16, 1.23 | 9.49 | 3.11, 29.02 |
| Non-Hispanic other race | 1.72 | 0.57, 5.18 | 0.81 | 0.32, 2.02 | 0.78 | 0.32, 1.90 | 3.20 | 1.02, 9.97 |
| Household Income | ||||||||
| ⩽$24,999 | Reference | Reference | Reference | Reference | ||||
| $25,000–$59,999 | 1.45 | 0.61, 3.46 | 1.27 | 0.54, 2.96 | 0.63 | 0.25, 1.52 | 0.60 | 0.25, 1.46 |
| $60,000–$99,999 | 0.82 | 0.22, 3.03 | 1.16 | 0.41, 3.27 | 0.49 | 0.17, 1.40 | 1.28 | 0.37, 4.31 |
| ≥$100,000 | 0.42 | 0.10, 1.76 | 1.00 | 0.36, 2.74 | 0.63 | 0.21, 1.91 | 1.16 | 0.36, 3.78 |
| Highest Education Level | ||||||||
| ⩽High School | Reference | Reference | Reference | Reference | ||||
| Some college | 2.00 | 0.89, 4.50 | 1.41 | 0.64, 3.17 | 0.64 | 0.25, 1.59 | 0.81 | 0.30, 2.17 |
| ⩾Bachelor’s degree | 1.14 | 0.37, 3.45 | 1.52 | 0.62, 3.76 | 1.65 | 0.67, 4.09 | 0.79 | 0.28, 2.26 |
| Past-30-day Large Cigar Smoking | ||||||||
| No | Reference | Reference | Reference | Reference | ||||
| Yes | 0.36 | 0.15, 0.87 | 1.75 | 0.76, 4.02 | 1.54 | 0.71, 3.32 | 1.52 | 0.53, 4.39 |
| Past-30-day Cigarillo Smoking | ||||||||
| No | Reference | Reference | Reference | Reference | ||||
| Yes | 0.73 | 0.33, 1.59 | 1.73 | 0.86, 3.45 | 1.03 | 0.50, 2.15 | 1.02 | 0.45, 2.30 |
| Past-30-day Filtered Cigar Smoking | ||||||||
| No | Reference | Reference | Reference | Reference | ||||
| Yes | 1.52 | 0.69, 3.33 | 0.62 | 0.29, 1.33 | 1.17 | 0.55, 2.47 | 2.59 | 1.13, 5.93 |
| Past-30-day Blunt Smoking | ||||||||
| No | Reference | Reference | Reference | Reference | ||||
| Yes | 0.38 | 0.14, 0.98 | 1.49 | 0.71, 3.12 | 1.25 | 0.53, 2.96 | 3.45 | 1.18, 10.13 |
| Past-30-day Cigarette Smoking | ||||||||
| No | Reference | Reference | Reference | Reference | ||||
| Yes | 1.17 | 0.47, 2.97 | 1.43 | 0.66, 3.11 | 1.00 | 0.47, 2.13 | 0.68 | 0.29, 1.56 |
| Past-30-day E-cigarette Use | ||||||||
| No | Reference | Reference | Reference | Reference | ||||
| Yes | 1.44 | 0.58, 3.59 | 0.83 | 0.41, 1.67 | 1.06 | 0.46, 2.44 | 0.69 | 0.31, 1.56 |
| Tobacco Dependence | ||||||||
| ⩾60mins | Reference | Reference | Reference | Reference | ||||
| 30–59 mins | 1.00 | 0.27, 3.71 | 0.52 | 0.18, 1.52 | 1.27 | 0.39, 4.10 | 2.74 | 0.75, 10.0 |
| 6–29 mins | 0.86 | 0.25, 2.87 | 1.34 | 0.54, 3.28 | 1.21 | 0.41, 3.61 | 0.93 | 0.26, 3.27 |
| ⩽5 mins | 1.17 | 0.34, 4.05 | 1.56 | 0.53, 4.62 | 0.45 | 0.12, 1.70 | 1.43 | 0.33, 6.12 |
Notes:
Bolded text indicates p-value<0.05
DISCUSSION
This is one of the first studies to examine the correlates of behavior change intents in response to a hypothetical FCSR among a nationally representative sample of adult current flavored cigar smokers. Results showed that 15.1% of current flavored cigar smokers would completely quit cigars given an FCSR, whereas more cigar smokers (41.6%) might use plain cigars without flavors. The results also demonstrated that about a third of cigar smokers would substitute flavored cigars with other flavored tobacco products or cannabis, indicating noticeable unintended consequences from implementing FCSRs.
This study’s finding that over 15% of adult flavored cigar smokers may completely quit cigar smoking in response to FCSRs is promising, given that this reduction in cigar smoking may prevent cancers and cardiovascular diseases. Our finding that current large cigar smokers and blunt smokers may be less likely to quit cigar smoking in response to FCSRs suggests that their smoking behavior may be less likely to be affected by removing flavors from cigar products. Therefore, researchers are advised to treat various types of cigar products separately when assessing the policy’s impact on behaviors and the sales related to cigar products. Additionally, more research is needed to determine which accompanying public health strategies may help reinforce the intention to quit cigars or improve quit rates given an FCSR. For example, raising cigar prices by increasing taxes, setting minimum prices, or restricting price promotions for cigar products may discourage cigar smokers from continuing to smoke.15 Additionally, designing and disseminating evidence-based cigar smoking cessation programs and therapies may increase the intention and trial of smoking cessation among cigar smokers.16
Since over 40% of U.S. cigar smokers would smoke plain cigars given FCSRs, it is vital that the FDA and local policymakers consider strategies to reduce the appeal and addictiveness of plain or non-flavored cigar products. For example, previous research has shown that “organic” and “natural” descriptors and marketing claims found on cigar packaging, regardless of the cigars’ flavors, may increase consumers’ positive perceptions and reduce harm perceptions of cigar smoking.17,18 Without removing these descriptors and claims, plain cigar products may remain an appealing option for cigar smokers, thereby undermining the potential impact of FCSRs. Our finding that tobacco dependence does not predict behavior change intents signifies that the potential outcome of FCSRs may not differ by this factor.
This study also found that a sizable portion of flavored cigar smokers may be affected by the unintended consequences of FCSRs by switching to other flavored tobacco products or cannabis products. For example, over 40% of filtered cigar smokers and 36% of blunt smokers in the current study may use cannabis products to replace flavored cigars given FCSRs. This finding is consistent with previous research that found restricting the sale of flavored tobacco products, including flavored and menthol cigarettes, may unintentionally lead to the increased usage of cigars and other substances.19,20 Public health practitioners may consider disseminating educational messages that convey the harm and risk of tobacco and cannabis use and encourage smokers to quit using addictive substances altogether. Comprehensive flavor sales restrictions that are applied to all types of tobacco products may also help reduce the unintended consequences of FCSRs. Additionally, the results show that females and racial/ethnic minorities may be disproportionately affected by the unintended consequences of FCSRs, compared to males and non-Hispanic Whites. This suggests that accompanying educational and communication strategies are necessary when implementing FCSRs to prevent alternative forms of harmful substance use among vulnerable groups.
This study has several limitations. First, the potential options of behavior intents in response to FCSRs may not be exhaustive, although very few respondents selected other intents not listed in the survey. Second, this study investigated cigar smokers’ perceived behavior change intents given a hypothetical policy situation; their actual behavior change might be different and influenced by other factors such as policy enforcement and compliance. Third, behavioral intents of quitting cigars altogether and substituting flavored cigars with other products may not be mutually exclusive. Future research should allow participants to choose more than one option.
Overall, our findings suggest that FCSRs may reduce cigar smoking among a portion of U.S. adult flavored cigar smokers while leaving more smokers to use plain cigars without flavors. Moreover, a sizable proportion of flavored cigar smokers may transition to using other flavored tobacco products and cannabis, and certain vulnerable population groups may be more likely to be impacted by the unintended consequences of FCSRs. Results suggest that when implementing local and national FCSRs, other cigar-prevention policies, cigar cessation programs, and substance use prevention messages should accompany those restrictions to increase the interest and trial of quitting cigars and reducing cigar smokers’ transition to using plain cigars and other substances as a replacement for flavored cigars.
Highlights.
This study examines the correlates of behavior change intents given a hypothetical flavored cigar sale restriction.
Given a restriction, 15.1% of respondents would quit smoking cigars altogether, and 41.6% would smoke plain cigars.
33.4% and 29.2% would substitute flavored cigars with other flavored tobacco products or cannabis, respectively.
Large cigar and blunt smokers were less likely to quit cigars altogether than non-smokers of those products.
Females and racial/ethnic minorities were more likely to use other flavored tobacco and cannabis products, respectively.
Funding sources
This work was supported by the Division of Intramural Research, the National Institute on Minority Health and Health Disparities. KC, BJ, KH, and PH are supported by the Division of Intramural Research, the National Institute on Minority Health and Health Disparities. JCS and ME were supported by grant R00CA242589 from the FDA/NCI and Rutgers Cancer Institute of New Jersey Cancer Center Support Grant (P30CA072720). JCS was also supported by Penn/Rutgers TCORS (U54CA229973). Comments and opinions expressed belong to the authors and do not necessarily represent the views of the U.S. Government, National Institutes of Health, National Cancer Institute, National Institute on Minority Health and Health Disparities, or the U.S. Food and Drug Administration.
Footnotes
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Credit Author Statement
Julia Chen-Sankey: Conceptualization, Formal analysis, Methodology, Software, Supervision, Resources, Investigation, Project administration, Writing- Original draft preparation.
Maryam Elhabashy: Visualization, Writing- Reviewing and Editing.
Aniruddh Ajith: Methodology, Visualization, Writing- Reviewing and Editing.
Bambi Jewett: Methodology, Visualization, Writing- Reviewing and Editing.
Kiana Hacker: Methodology, Visualization, Writing- Reviewing and Editing.
Lilianna Phan: Methodology, Visualization, Writing- Reviewing and Editing.
Kelvin Choi: Methodology, Software, Resources, Data curation, Investigation, Funding acquisition, Project administration, Writing- Reviewing and Editing.
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests
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