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Buszkiewicz JH, Cook S, Oh H, Mukerjee R, Hirschtick JL, Fleischer NL. A Longitudinal Analysis of Flavored Cigar Use and Cigar Smoking Cessation Among US Adults. Nicotine Tob Res 2024; 26:816-825. [PMID: 38141259 PMCID: PMC11190056 DOI: 10.1093/ntr/ntad256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Flavorings in cigars increase their appeal, mask the harsh taste of tobacco, and may hinder successful cigar smoking cessation; however, limited evidence has examined whether flavors are associated with short- or long-term cigar smoking cessation. AIMS AND METHODS Using restricted data from the Population Assessment of Tobacco and Health Study Waves 1-5, we examined whether flavored cigar use was associated with 30-day-plus and 1-year-plus cigar smoking cessation among US adults. Multivariable discrete-time survival models were fit to a nationally representative sample of US adult (18+) respondents who had a current, established cigar use, smoked five or more days in the past 30 days, and did not exclusively smoke traditional premium cigars at baseline. Models adjusted for age, sex, race and ethnicity, income, cigar and cigarette smoking intensity, and blunt use. RESULTS At baseline, 44.6% of respondents (n = 674) were 18-34 years old, 75.0% were male, 56.7% were non-Hispanic White, 78.9% had household incomes of <$50,000, and 56.2% smoked flavored cigars. In fully adjusted models, flavored cigar use was associated with a lower risk of 30-day-plus (HR = 0.76, 95% CI = 0.60, 0.97) but not 1-year-plus cigar smoking cessation (HR = 0.81, 95% = 0.62, 1.05). CONCLUSIONS We found that flavored cigar use was associated with a lower risk of short-term but not long-term cigar smoking cessation. More work is needed to understand the dynamics of cigar smoking transitions, including initiation, cessation, and relapse, particularly in larger cohorts and among those who exclusively use cigars or dual-use cigars and cigarettes. IMPLICATIONS As local and some state jurisdictions continue to adopt partial or complete bans of flavored cigar products and the United States Food and Drug Administration considers a national ban of all characterizing flavors in cigars, there is a need for more longitudinal work examining the associations between flavorings in cigars and short and long-term cigar-smoking behaviors, including but not limited to initiation, cessation, intensity of use, and relapse, particularly in diverse cohorts.
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Affiliation(s)
- James H Buszkiewicz
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Steven Cook
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Hayoung Oh
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Richa Mukerjee
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
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Osborn C, Pike Moore S, Koopman Gonzalez S, Quisenberry A, Klein E, Trapl E. Come for the Tobacco, Stay for the Flavor: Flavored Cigarillo-Use Trajectories Among Young Adult Sexual Gender Minority Women. Nicotine Tob Res 2024; 26:S112-S120. [PMID: 38817030 PMCID: PMC11140217 DOI: 10.1093/ntr/ntad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 07/14/2023] [Accepted: 09/01/2023] [Indexed: 06/01/2024]
Abstract
INTRODUCTION The purpose of this research was to identify how young adult sexual gender minority (SGM) women who use cigarillos may respond to cigar flavor restrictions. AIMS AND METHODS Young adults aged 21-28 years in the United States who currently use cigarillos were recruited between October 2020 and April 2021 to participate in an online survey. Due to high prevalence of cigarillo use among individuals who identify as sexual and/or gender minority (SGM) women, their (n = 192) flavored tobacco-use behaviors and anticipated responses to cigarillo flavor restrictions were compared to cisgender heterosexual (CisHet) women (n = 110). Logistic regression was used to model cigarillo cessation and product-switching behaviors (flavored and unflavored). RESULTS SGM women were significantly less likely to report the use of flavor at the initiation of cigarillo use (61.7% vs. 86.1%) but were no different in current flavor use compared to CisHet women, with more than 80% of all women using any flavor. SGM women were 2.36 times as likely to say they would discontinue using cigarillos if flavors were unavailable. Among those who would continue using cigarillos, SGM women were 4.53 times as likely to endorse switching to an unflavored tobacco product but had the same likelihood of saying they would switch to flavored product compared to CisHet women. CONCLUSIONS Flavor restriction policies may not reduce the initiation of cigarillos among SGM women and may elicit differential cigarillo use and tobacco product substitution by SGM identity. Flavor restriction policies should be coupled with targeted cessation resources to address potential remaining disparities. IMPLICATIONS SGM US women have a unique cigarillo-use trajectory. These women are more likely to initiate cigarillos without flavor and then later integrate it into their behavior. National cigar flavor restrictions are expected to have a greater impact decreasing cigarillo initiation among CisHet women and decreasing current cigarillo use among SGM women. However, for those who would continue using unflavored cigarillos, SGM women may remain at risk for nicotine dependence due to increased product substitution. SGM women should be prioritized for cessation resources to reduce tobacco-use disparities leading up to and following the implementation of cigar flavor restrictions.
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Affiliation(s)
- Catherine Osborn
- Department of Population and Quantitative Health Sciences, Prevention Research Center for Healthy Neighborhoods at Case Western Reserve University, Cleveland, OH, USA
| | - Stephanie Pike Moore
- Department of Population and Quantitative Health Sciences, Prevention Research Center for Healthy Neighborhoods at Case Western Reserve University, Cleveland, OH, USA
| | - Sarah Koopman Gonzalez
- Department of Population and Quantitative Health Sciences, Prevention Research Center for Healthy Neighborhoods at Case Western Reserve University, Cleveland, OH, USA
| | - Amanda Quisenberry
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Elizabeth Klein
- Division of Health Behavior & Health Promotion, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Erika Trapl
- Department of Population and Quantitative Health Sciences, Prevention Research Center for Healthy Neighborhoods at Case Western Reserve University, Cleveland, OH, USA
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Xu K, Lee T, Reyes-Guzman CM, Davis Lynn BC, Kofie JN, Rostron BL, Chang CM, Chang JT. Use patterns of flavored non-cigarette tobacco products among US adults, 2010-2019. Prev Med 2024; 180:107870. [PMID: 38272271 PMCID: PMC10923177 DOI: 10.1016/j.ypmed.2024.107870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/03/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Flavored non-cigarette tobacco product (NCTP) use is common among US adult tobacco users. To update the estimates of use patterns of flavored NCTPs, this study assessed current NCTP use among adults by flavor use and flavor categories from 2010 to 2019. METHODS We analyzed data from the 2010-2019 Tobacco Use Supplement to the Current Population Survey to estimate the weighted proportion of adult NCTP users by flavor use across survey waves. Flavor use was defined as past 30-day use of any menthol/mint or fruit/other flavors. We used the 2018-2019 data to examine the differences in demographic characteristics and tobacco use patterns among users of menthol/mint or fruit/other flavors compared to exclusive users of tobacco flavor, by product type. RESULTS Compared to 2014-2015, electronic nicotine delivery system (ENDS) users were more likely (79.0% vs. 66.6%, p < 0.001) to report flavor use in 2018-2019, whereas cigar (26.9% vs. 31.2%, p = 0.030) and pipe (56.3% vs. 65.5%, p = 0.015) smokers were less likely to report flavor use in 2018-2019. In 2018-2019, the most prevalent flavor categories were exclusive use of tobacco flavor among cigar (73.1%) and smokeless tobacco (48.3%) users, and use of fruit/other flavors among ENDS (64.9%) and pipe (48.4%) users. Flavored users were more likely to be young adults aged 18-24 years (cigars, ENDS, smokeless tobacco) and Non-Hispanic Black or Hispanic persons (cigars, ENDS, pipes) compared to tobacco-flavored users. CONCLUSIONS Flavored product use increased among adult ENDS users but decreased among cigar and pipe smokers. These findings could inform tobacco regulatory efforts concerning flavored NCTPs.
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Affiliation(s)
- Kerui Xu
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA.
| | - Terrence Lee
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Carolyn M Reyes-Guzman
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Brittny C Davis Lynn
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Justina N Kofie
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Brian L Rostron
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Cindy M Chang
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Joanne T Chang
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
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Diaz MC, Yoon SN, Donovan E, Akbar M, Schillo BA. The Effect of State and Local Flavored Cigar Sales Restrictions, on Retail Sales of Large Cigars, Cigarillos, and Little Cigars in Massachusetts, California, Illinois, and New York. Nicotine Tob Res 2024; 26:169-176. [PMID: 37453140 DOI: 10.1093/ntr/ntad121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/10/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION In 2009, the Family Smoking Prevention and Tobacco Control Act prohibited flavored cigarettes but allowed for flavored cigars. Since, there has been a 34% increase in youth cigar use and widened racial disparities. State and local jurisdictions have increasingly enacted flavored tobacco product sales restrictions. As more jurisdictions consider implementing flavor restrictions, it is important to understand their effect on tobacco markets that have high flavor proliferation, including the cigar market. AIMS AND METHODS This study uses data from Truth Initiative's flavor policy database and NielsenIQ retailer scanners for California, Illinois, Massachusetts, and New York. We use a three-way fixed-effect model to assess the impact of the percentage of the population covered by a flavored cigar sales restriction on per capita unit sales of cigars. RESULTS We find that population coverage by cigar sales restrictions was significantly associated with decreases in per capita cigar sales. More specifically, a 25% increase in the percentage of the population covered by a flavored cigar sales restriction was associated with a decrease in per capita all cigar sales of 15%-19%, 4%-10% for large cigars, 17%-21% for cigarillos, and 2%-41% for little cigars. CONCLUSION Flavored cigar sales restrictions are an effective policy to reduce per capita cigar sales. The Food and Drug Administration (FDA)'s proposed product standards would increase population covered by a flavored cigar sales restriction to 100%, leading to potential significant reductions in cigar sales, especially little cigar, and cigarillo sales. This may also substantially reduce youth cigar use and racial disparities in cigar use. IMPLICATIONS In April 2022, the U.S. FDA published a proposed rule to prohibit characterizing flavors in all cigars and menthol cigarettes. Besides this proposed rule, there has been little federal action to date to reduce sales of flavored cigars. However, as of March 31, 2022, Massachusetts and 333 localities across 10 states have enacted policies that restrict the sale of flavored cigars and other tobacco products. We find that population coverage by cigar sales restrictions is significantly associated with decreases in per capita cigar sales.
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Affiliation(s)
- Megan C Diaz
- Schroeder Institute, Truth Initiative, Washington, DC, USA
| | | | - Emily Donovan
- Schroeder Institute, Truth Initiative, Washington, DC, USA
| | - Maham Akbar
- Public Policy, Truth Initiative, Washington, DC, USA
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Ashley DL, Zhu W, Watson CH, Bravo R, Ngac PK, Valentin-Blasini L, Pickworth WB, Kurti AN, Cunningham C, Blount BC. Mouth Level Intake of Nicotine from Three Brands of Little Filtered Cigars with Widely Differing Product Characteristics Among Adult Consumers. Chem Res Toxicol 2023; 36:43-52. [PMID: 36598842 DOI: 10.1021/acs.chemrestox.2c00261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Little filtered cigars are tobacco products with many cigarette-like characteristics. However, despite cigars falling under the U.S. Food and Drug Administration regulatory authority, characterizing flavors, which are still allowed in little filtered cigars, and filter design may influence how people use the products and the resulting exposure to harmful and potentially harmful constituents. We estimated nicotine mouth level intake (MLI) from analyses of little cigar filter butt solanesol levels, brand characteristics, carbon monoxide boost, and puff volume in 48 dual cigarette/cigar users during two repeat bouts of ad lib smoking of three little filtered cigar brands. Mean nicotine MLI for the three brands was significantly different with Swisher Sweets (0.1% ventilation) Cherry at 1.20 mg nicotine, Cheyenne Menthol (1.5%) at 0.63 mg, and Santa Fe unflavored (49%) at 0.94 mg. The association between nicotine MLI and puff volume was the same between Cheyenne Menthol and Santa Fe unflavored. However, these were different from Swisher Sweets Cherry. At least five main factors─flavor, ventilation, filter design, nicotine delivery related to tar, and user puff volume─may directly or indirectly impact MLI and its association with other measures. We found that users of little filtered cigars that have different filter ventilation and flavor draw dissimilar amounts of nicotine from the product, which may be accompanied by differences in exposure to other harmful smoke constituents.
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Affiliation(s)
- David L Ashley
- Department of Population Health Sciences, School of Public Health, Georgia State University, Atlanta, Georgia 30303, United States
| | - Wanzhe Zhu
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, United States Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Clifford H Watson
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, United States Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Roberto Bravo
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, United States Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Phuong K Ngac
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, United States Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Liza Valentin-Blasini
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, United States Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Wallace B Pickworth
- Battelle Public Health Research Center, Baltimore, Maryland 21209, United States
| | - Allison N Kurti
- Center for Tobacco Products, United States Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Colin Cunningham
- Center for Tobacco Products, United States Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Benjamin C Blount
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, United States Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
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Rogers T, Brown EM, Siegel-Reamer L, Rahman B, Feld AL, Patel M, Vallone D, Schillo BA. A Comprehensive Qualitative Review of Studies Evaluating the Impact of Local US Laws Restricting the Sale of Flavored and Menthol Tobacco Products. Nicotine Tob Res 2021; 24:433-443. [PMID: 34525207 PMCID: PMC8887583 DOI: 10.1093/ntr/ntab188] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/14/2021] [Indexed: 12/21/2022]
Abstract
Objectives To assess the quality of evidence on the effectiveness of local US laws restricting the sale of flavored tobacco products. Methods We conducted a systematic search and qualitative scoping review of English-language papers published through May 2020 that evaluated flavored tobacco sales policies implemented by US jurisdictions during 2010–2019. We constructed a conceptual model for flavored and menthol tobacco sales restriction outcomes, assigned GRADE quality of evidence ratings to policy outcomes evaluated through the included studies, and summarized factors that might explain weak or inconsistent findings. Results We found moderate to high quality of evidence associating policy implementation with reduced availability, marketing, and sales of policy-restricted products, and decreased youth and adult tobacco use of these products; however, policy exclusions and exemptions, implementation challenges, tobacco industry actions (e.g., marketing of concept-named flavored products; exploiting policy exemptions for certain store types), and consumer responses (e.g., cross-border or illicit purchasing) might undermine or mitigate intended policy effects. Conclusions Flavored and menthol tobacco product sales restrictions implemented and evaluated in US jurisdictions appear to have achieved some of their intended outcomes; however, deficiencies in study designs, methods, and metrics could contribute to equivocal findings on quality of evidence associating policy implementation and outcomes. Gaps in the evidence are beginning to be filled with research using more rigorous study designs, improved measurement and analytic methods, and longer-term follow-up. Implications In the absence of comprehensive federal action, US jurisdictions have the obligation to restrict flavored and menthol product sales to protect vulnerable populations from tobacco-related harms. The considerable expenditure of financial resources, political will, and time dedicated to policy adoption and implementation argue for evaluation studies designed to maximize the quality of evidence. This review offers generalizable insights into evaluation findings that can inform efforts to enhance tobacco control policy implementation and impact in the US and globally.
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Affiliation(s)
- Todd Rogers
- Center for Health Analytics, Media, and Policy, RTI International, Research Triangle Park, NC USA
| | - Elizabeth M Brown
- Center for Health Analytics, Media, and Policy, RTI International, Research Triangle Park, NC USA
| | - Leah Siegel-Reamer
- Center for Health Analytics, Media, and Policy, RTI International, Research Triangle Park, NC USA
| | - Basmah Rahman
- Truth Initiative Schroeder Institute, Washington, DC USA
| | - Ashley L Feld
- Center for Health Analytics, Media, and Policy, RTI International, Research Triangle Park, NC USA
| | - Minal Patel
- Truth Initiative Schroeder Institute, Washington, DC USA
| | - Donna Vallone
- Truth Initiative Schroeder Institute, Washington, DC USA
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Crosby L, Yucesoy B, Leggett C, Tu Z, Belinsky SA, McDonald J, Leng S, Wu G, Irshad H, Valerio LG, Rosenfeldt H. Smoke Chemistry, In Vitro Cytotoxicity, and Genotoxicity Demonstrates Enhanced Toxicity of Cigarillos Compared With Cigarettes. Toxicol Sci 2021; 180:122-135. [PMID: 33021639 DOI: 10.1093/toxsci/kfaa155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Abstract
There has been limited toxicity testing of cigarillos, including comparison to cigarettes. This study compared the smoke chemistry and the cytotoxic and genotoxic potential of 10 conventional cigarettes and 10 cigarillos based on the greatest market share. Whole smoke and total particulate matter (TPM) were generated using the Canadian Intense and International Organization for Standardization puffing protocols. Tobacco-specific nitrosamines, carbonyls, and polycyclic aromatic hydrocarbons were measured using gas chromatography-mass spectrometry. TPM smoke extracts were used for the in vitro assays. Cytotoxicity was assessed in human bronchial epithelial continuously cultured cell line cells using the neutral red uptake assay. Genotoxic potential was assessed using the micronucleus (human lung adenocarcinoma continuously cultured cell line cells), Ames, and thymidine kinase assays. TPM from all cigarillos tested was more cytotoxic than cigarettes. Micronucleus formation was significantly greater for cigarillos compared with cigarettes at the highest dose of TPM, with or without rat liver S9 fraction. In the Ames test +S9, both tobacco products exhibited significant dose-dependent increases in mutation frequency, indicating metabolic activation is required for genotoxicity. In the thymidine kinase assay +S9, cigarillos showed a significantly enhanced mutation frequency although both tobacco products were positive. The levels of all measured polycyclic aromatic hydrocarbons, tobacco-specific nitrosamines, and carbonyls (except acrolein) were significantly greater in cigarillos than cigarettes. The Canadian Intense puffing protocol demonstrated increased smoke constituent levels compared with International Organization for Standardization. Even though the gas vapor phase was not tested, the results of this study showed that under the tested conditions the investigated cigarillos showed greater toxicity than comparator cigarettes. This study found that there is significantly greater toxicity in the tested U.S. marketed cigarillos than cigarettes for tobacco constituent levels, cytotoxicity, and genotoxicity. These findings are important for understanding the human health toxicity from the use of cigarillos relative to cigarettes and for building upon knowledge regarding harm from cigarillos to inform risk mitigation strategies.
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Affiliation(s)
- Lynn Crosby
- Center for Tobacco Products, Office of Science, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
| | - Berran Yucesoy
- Center for Tobacco Products, Office of Science, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
| | - Carmine Leggett
- Center for Tobacco Products, Office of Science, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
| | - Zheng Tu
- Center for Tobacco Products, Office of Science, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
| | - Steven A Belinsky
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico, 87108
| | - Jake McDonald
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico, 87108
| | - Shuguang Leng
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico, 87108
| | - Guodong Wu
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico, 87108
| | - Hammad Irshad
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico, 87108
| | - Luis G Valerio
- Center for Tobacco Products, Office of Science, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
| | - Hans Rosenfeldt
- Center for Tobacco Products, Office of Science, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
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