- Research article
- Open Access
- Open Peer Review
Patterns and correlates of tobacco control behavior among american association of pediatric dentistry members: a cross-sectional national study
- Stuart A Gansky†1,
- Jennifer L Ryan†2,
- James A Ellison†1,
- Umo Isong†1,
- Arthur J Miller†3 and
- Margaret M Walsh†1Email author
© Gansky et al.; licensee BioMed Central Ltd. 2007
- Received: 16 February 2007
- Accepted: 11 October 2007
- Published: 11 October 2007
To determine the tobacco-related knowledge, attitudes, and practice behaviors among US pediatric dentists.
A survey was conducted in 1998 among a national, random sample of 1500 American Academy of Pediatric Dentistry members. Chi-square tests and logistic regression with odds ratios (ORs) and 95% confidence intervals assessed factors related to pediatric dentists' tobacco control behaviors.
Response was 65% for the survey. Only 12% of respondents had prior tobacco prevention/cessation training. Of those untrained, 70% were willing to be trained. Less than two-thirds correctly answered any of four tobacco-related knowledge items. Over one-half agreed pediatric dentists should engage in tobacco control behaviors, but identified patient resistance as a barrier. About 24% of respondents reported always/often asking their adolescent patients about tobacco use; 73% reported always/often advising known tobacco users to quit; and 37% of respondents always/often assisting with stopping tobacco use. Feeling prepared to perform tobacco control behaviors (ORs = 1.9–2.8), a more positive attitude score (4 points) from 11 tobacco-related items (ORs = 1.5–1.8), and a higher statewide tobacco use prevalence significantly predicted performance of tobacco control behaviors.
Findings suggest thatraining programs on tobacco use and dependence treatment in the pediatric dental setting may be needed to promote tobacco control behaviors for adolescent patients.
- Oral Health
- Tobacco Control
- Smokeless Tobacco
- Adolescent Patient
- Pediatric Dentist
Tobacco use, the single most preventable cause of premature disease and death in the United States , almost always begins during adolescence. Every day in the U.S. more than 3000 youth under age 18 try their first cigarette. It is estimated that half of these youths will become regular addicted smokers, and one-third will succumb to smoking related diseases. Overall, 22% of high school students in the US currently smoke cigarettes and 11% of high school males use smokeless tobacco (i.e., oral snuff or chewing tobacco).
The National Cancer Institute (NCI) recommends all health professionals help patients be tobacco-free by applying the following brief clinical intervention known as the "Five A's Approach" :
▪ Ask all patients about tobacco use;
▪ Advise tobacco users to stop using tobacco and non-tobacco users to remain tobacco-free;
▪ Assess willingness of tobacco users to stop in the next month;
▪ Assist all tobacco users to stop based on their willingness to quit;
▪ Arrange appropriate follow-up.
Many pediatric dentists' patients are adolescents. This frequent contact provides an opportunity to provide a brief tobacco prevention or cessation intervention and reinforcement over an extended period of time enhancing an individual's ability to stop tobacco use [4–6]. The purpose of this study was to evaluate the tobacco control knowledge, attitudes, and behaviors of pediatric dentists and to identify predictors of recommended tobacco intervention behaviors. Although this study was conducted in 1998, a current review of the literature revealed that the most recent published national data on pediatric dentists are from 1994. There is an ongoing need to update the literature to provide benchmarks to monitor trends of compliance with tobacco treatment guidelines over time. This paper presents important new information because it not only reports prevalences of tobacco control behaviors, but also characteristics of providers and their settings related to those behaviors.
The University of California San Francisco (UCSF) Institutional Review Board approved this study. To develop and modify the study questionnaire, a convenience-sample discussion group of 7 practicing pediatric dentists was conducted during a 1998 San Francisco Bay Area Pedodontics Study Club meeting. Responses were recorded by the second author (Jennifer L. Ryan) and qualitatively analyzed to inform questionnaire development for pilot testing. Additional questionnaire items were based on a 1994 national survey to assess tobacco control activities among US general dentists. The preliminary questionnaire, cover letter, and pre-paid return envelope were mailed to another convenience sample of 8 other Northern California pediatric dentists to pilot test for clarity, length, and reliability. Results from this pilot test informed final questionnaire development.
The final study questionnaire, cover letter and pre-paid return envelope were mailed in November 1998 to a random sample of 1500 of the 4200 US pediatric dentist members of the American Academy of Pediatric Dentistry (AAPD). All AAPD members were eligible to receive the questionnaire, except retired, student, or foreign members. Two months after the initial mailing, a second questionnaire, modified cover letter, and pre-paid return envelope were mailed to initial survey nonrespondents. Two months later, nonrespondents were randomly sampled (130/551) and telephoned to gather basic demographic information and determine their reasons for not returning the mailed surveys. Consent was implicit in their willingness to complete the telephone interview. Dentists willing to complete a survey were re-mailed the questionnaire. Finally, information on the 1998 state-level tobacco excise tax and the 1997 smoking prevalence for each state were obtained from the US Centers for Disease Control and Prevention website (1999).
The survey defined adolescents as 11–17 years old and tobacco users as smokers (cigarette, pipe, or cigar users) or smokeless tobacco (snuff or chew) users. The questionnaire items assessed demographic factors (age, gender, race/ethnicity) and practice-related demographics (year of dental school graduation, practice type, practice location, weekly work hours). Tobacco-related characteristics of the responding dentist also were assessed, such as tobacco use status, previous tobacco cessation training, willingness to receive training, tobacco control behaviors (identifying/asking, advising, documenting) and perceived barriers to tobacco cessation (11 items using a 3-point Likert scale). Knowledge about tobacco use among adolescents (2 true/false and 2 multiple choice items), attitudes toward tobacco prevention and cessation (9 items using a 5-point Likert scale as per Dolan et al.  plus 2 additional 5-point Likert scale items) and tobacco-related practice characteristics (office tobacco ban policy and staff member responsible for asking about tobacco use) were also assessed.
Data entry used built-in error and logic inconsistency checking (Epi Info Version 6, Centers for Disease Control and Prevention, Atlanta, GA). Data analyses used SAS© statistical software (version 9.1.2, SAS Institute, Cary, NC). Assisting tobacco users to stop tobacco use was determined as any of 7 items (discuss quitting strategies, setting a quit date, providing self-help materials, recommending nicotine gum, recommending nicotine patch, referring to a cessation program, or providing follow-up). Nine attitude items (5 point Likert scores) related to tobacco prevention and cessation were summed after reverse scoring 3 items to obtain the Dolan score. In addition, 2 new attitude items asking about encouraging non-users to remain tobacco free and about the importance of tobacco use were added to the 9-item Dolan score to obtain a new 11-item score, the University of California (UC) attitude score. Cronbach's alpha assessed internal consistency of the 11-item UC scale which could range from -22 to 22. Using the American Dental Association's Survey Center geographic definitions, nine US divisions were combined into 3 larger regions for analysis.
Categorical measures were assessed with chi-square tests to compare demographics and attitudes about tobacco control between respondents and non-respondents; p ≤ 0.05 was considered statistically significant. Stepwise logistic regression models, with odds ratio (OR) and 95% confidence interval (CI) estimation, were fit separately to identify predictors for each of the 3 tobacco control activities (asking adolescent patients about tobacco use, advising known adolescent tobacco users to quit, and assisting known adolescent users with quitting), with entry and stay criteria of alpha = 0.05. The OR>1 is interpreted as the increased odds of the control activity associated with a change of 1 unit of a numeric explanatory variable or with having a characteristic from a dichotomized explanatory variable. An OR with a 95% CI that does not include one is statistically significant (i.e. equivalent to p ≤ 0.05). The following were candidate variables for the logistic regression models: dental school graduation year, geographic location (reference: Atlantic region), state cigarette tax amount (per $0.10 increment), statewide adult smoking prevalence (per 5% increment), health care provider tobacco use, training (previous training and willingness to receive training), intervention self efficacy (feeling very well or well prepared to ask, advise, and assist), gender, office setting (urban or rural; reference: suburban), and the UC attitude scale (for a 4 point increment). In addition, each model was adjusted for 2 barriers associated with non-response: lack of time and lack of tobacco users in the practice (strongly vs. somewhat or not). Collinearlity (i.e. condition number) was also assessed.
Of the 1500 members of the AAPD randomly sampled to receive a survey, 971 returned a survey, for an overall response rate of 65% (952 were returned after the first two mailings plus 19 after the telephone contact). A total of 872 were analyzed after excluding 99 surveys (80 respondent dentists retired or no longer practiced in the US and 19 did not regularly see adolescent patients).
Among the survey's 551 nonrespondents, 130 were randomly chosen to be telephoned. Of these, 14 were ineligible (8 had incorrect or non-working telephone numbers; 6 were no longer AAPD members) and 23 telephone nonrespondents could not be reached (17 unavailable after at least two attempts, 3 relocated and 3 refused). Thus, 93 (i.e. 80% of those eligible) were successfully reached.
Compared to AAPD members returning a survey after telephone contact (phoned respondents), those who did not return a survey (phoned nonrespondents) were significantly more likely to report: lacking time (43% of phoned nonrespondents vs. 16% of phoned respondents), tobacco use was not a problem in their office (10% of phoned nonrespondents vs. 0% of phoned respondents), and lacking interest (23% of phoned nonrespondents vs. 0% of phoned respondents). Nonrespondents and respondents did not differ significantly in thinking tobacco control was an inappropriate topic for pediatric dentists. Phoned nonrespondents and phoned respondents also did not differ significantly in dental school graduation year, age, ethnicity, tobacco use (both current and past), or office tobacco use policy.
Description of study sample
Demographic and Practice Characteristics of Responding Pediatric Dentists
Age (years) (N = 858)
Gender (N = 872)
Ethnic Group (N = 868)
Dental School Graduation Year (N = 862)
Prior to 1975
Type of Practice (N = 440)
Setting of Practice (N = 815)
Location of Practice (N = 865)
Urban (pop. ≥ 300,000)
Suburban (> 2,500 but < 300,000)
Rural (≤ 2,500)
Number of Days Worked per Week (N = 799)
1 – 3
Number of Adolescent † Patients per Day (N = 850)
Tobacco-Related Characteristics of Responding Pediatric Dentists and Their Practices
Current† Tobacco Use‡
Former Tobacco Use‡
Any (none current)
Office Tobacco Policy
No tobacco use by patients & parents (N = 862)
No tobacco use by staff (N = 865)
Responsible for Asking* (N = 867)
Health History form
No one person
Do Not Ask
Prior Training (N = 864)
Training in tobacco use prevention or cessation
Willingness for First Training (N = 750)
Willing to be Trained (among Untrained)
Feel Very Well/Well Prepared to
Ask about tobacco use (N = 853)
Advise users to quit (N = 852)
Assist users with quitting (N = 846)
Tobacco control knowledge, attitudes, and perceived barriers
Pediatric Dentists' Adolescent Tobacco Use Knowledge and Attitudes
Knowledge Items (N = 872)
• One in three US adolescents uses tobacco by age 18†
• 90% of first-time cigarette use occurs before high school graduation‡
• Every day, more than 1000 US adolescents become regular smokers†
• In the last 25 years the number of US adolescents using smokeless Tobacco has tripled ‡
• The pediatric dentist should set a good example by not using tobacco. (N = 859)
• It is important for a pediatric dentist to encourage adolescent non-users to remain tobacco free. (N = 859)
• It is important for a pediatric dentist to ask adolescent patients about tobacco use. (N = 857)
• Most adolescents will not give up tobacco use even if their pediatric dentist tells them to. (N = 854)
• It is a pediatric dentist's responsibility to help patients who wish to stop using tobacco to accomplish this. (N = 861)
• It is a pediatric dentist's responsibility to convince patients who use tobacco to stop. (N = 860)
• Most adolescent tobacco users have a hard time quitting because they are addicted to nicotine. (N = 856)
• Pediatric dentists should be more active than they have been in speaking before lay groups about tobacco use. (N = 857)
• Most adolescent tobacco users can stop if they want to. (N = 851)
• A pediatric dentist's time can be much better spent doing things other than trying to reduce tobacco use in adolescent patients. (N = 851)
• Adolescents have enough problems without adding to them by trying to give up tobacco. (N = 859)
Internal consistency testing of the Dolan scale had a standardized Cronbach's coefficient alpha of 0.53, whereas the UC attitude scale yielded an alpha of 0.67 (moderate internal consistency) – better reliability with the UC scale than that of Dolan et al.
Pediatric Dentists' Barriers to Helping Adolescent Patients Stop Tobacco Use* (N = 838)
Feel patients are resistant to cessation services
Don't know where to send patients for counseling
Don't feel could effectively help patients quit
Don't have materials to hand out
Lack of time
Most adolescent patients do not use tobacco
Did not occur to me to provide these services
Don't know what to say
Lack of adequate reimbursement
Unsuccessful in providing these services in past
Don't feel this is appropriate for a pediatric dentist
Tobacco cessation counseling behaviors
Pediatric Dentists Reported Behaviors Regarding Adolescent Patients' Tobacco Use
Ask All Patients about Use (N = 857)
Advise Users to Quit (N = 856)
Assist Users with Quitting (N = 841)
Factors related to tobacco cessation counseling behaviors
Relationships of Feeling Preparedand Perceived Importance with Reported Tobacco Control Behaviors
Ask (N = 841)
3.1 – 7.9
Advise (N = 839)
2.3 – 4.3
Assist (N = 832)
2.9 – 6.2
Ask (N = 845)
4.8 – 13.7
Advise (N = 844)
2.2 – 4.2
Assist (N = 838)
2.6 – 5.1
Correlates of Tobacco Cessation Behaviors
Lack of Time
Lack of Users
Preparation to Ask
Preparation to Advise
UC Attitude Scale*
Gender – Female
Region: Pacific vs. Atlantic/Central†
State Smoking Prevalence‡
We surveyed members of the AAPD to assess their knowledge, attitudes and behaviors related to tobacco control activities in their dental practices.
Although findings indicate low knowledge levels about general adolescent tobacco use, pediatric dentists held positive attitudes about intervening with their adolescent patients. For example, over half of respondents believed pediatric dentists should encourage, advise, and assist tobacco users to quit using tobacco. In addition, 80% reported that trying to reduce adolescent tobacco use was worth the time. Despite these positive attitudes about intervening with tobacco-using adolescent patients, less than one-quarter of respondents (24%) reported always asking adolescents if they used tobacco. This finding, however, reveals an increase in the behavior of asking patients about tobacco use status compared to the finding of a 1994 survey that reported only 2% of pediatric dentists asked most patients about smoking. The discrepancy might be due to the latter study not differentiating between adolescent and younger patients.
In our study, nearly three-fourths (73%) of respondents reported always or often advising known tobacco users to stop using tobacco, which is consistent with a previously published report on pediatric dentists (80%). These findings fall just short of the US Department of Health and Human Services Healthy People 2010 objective to increase to at least 85% the proportion of dentists who advise cessation.
Only 37%, however, reported always or often offering cessation assistance to known tobacco-using patients, similar to other reports[7, 9], but significantly less than the 85% Healthy People 2010 goal. Perhaps low assisting involvement may have been from feeling unprepared to do so. Interventions are needed to address this void. In fact, over 70% of untrained responding pediatric dentists indicated a desire for training and 55% agreed, "It is a pediatric dentist's responsibility to help patients who wish to stop using tobacco to accomplish this." These findings agree with a 2001 pilot study of 173 pediatric dentists in which 56% felt it was part of pediatric dentists' role to help their adolescent patients stop smoking.
In a 1994 study including 586 pediatric dentists as a subgroup, Dolan and colleagues reported, consistent with our findings, that only 12% of pediatric dentists had prior training in tobacco cessation counseling. However, the 2001 pilot study found the percentage increased to 18%, with a third of trained respondents indicating training in the past year. Comparisons of our 1998 data with the 1994 data  indicated significant increases in positive attitudes and behaviors related to tobacco control among dentists who have a pediatric interest. For example, feeling very well or well prepared to assist users with quitting significantly increased from 12% in 1994 to 17% in our 1998 study (p < 0.001). In addition, asking patients always or often about smoking and smokeless tobacco use significantly increased from 2% for each in 1994 to 8% and 7%, respectively in the current study (p < 0.001). Assisting tobacco users with quitting significantly increased from 9% in the Dolan study to 37% in the current study (both p < 0.001). Comparisons between our study and the 2001 study were not possible due to differences between the two study designs.
Feeling prepared to ask and to advise were significantly predictive of asking, advising, and assisting. Moreover, a moderate association was noted between feeling prepared to ask with asking, and between feeling prepared to advise with assisting. These findings suggest the importance of preparing dentists who see a large number of adolescents on a fairly frequent basis to address tobacco use in their practices. Such training in tobacco cessation could greatly increase the quantity and quality of cessation services to pediatric dental patients.
In addition, the UC attitude score was consistently predictive of all 3 behaviors. This scale could be used to tailor different training program components based on prospective trainee attitude scores since such scores include barriers that could be targeted as educational activities. Female gender was predictive only of asking. Women may have been more likely to ask than men since female health care providers have been reported to be generally more empathetic based on an empathy scale used in a recent study training healthcare providers. Even stratifying by year of graduation to adjust for potential confounding yielded significant gender effects for asking.
Lacking time has consistently been identified as a major barrier to delivering tobacco prevention services[12–14]. Almost half of respondents identified lacking time as a barrier (somewhat of a barrier or a strong barrier). Similarly, nearly half identified feeling most adolescent patients do not use tobacco. One-third of respondents identified lacking adequate reimbursement as a barrier, whereas previous studies reported 39% and 45%[7, 9]. The American Dental Association has a tobacco cessation services reimbursement insurance code, but many individual insurance contracts restrict coverage for tobacco prevention and cessation. Dental health policy makers and insurance providers need to address tobacco cessation benefits for patients in oral healthcare settings.
Importantly, 70% of respondents felt patients would resist cessation services. This perception contradicts the literature indicating that most adolescents who smoke want to quit[15, 16]. In addition, studies report that patients prefer smoking cessation counseling from a health professional over support groups, self-help, and telephone counseling. A survey of 3,088 dental patients in 53 dental practices revealed that 58.5% believed that dental offices should provide tobacco cessation treatment services. There was equal support among tobacco users and nonusers. Moreover, a survey of patients in independent dental practices and HMO clinics revealed that 40–67% of ST users reported interest in receiving cessation from their dentists. Patients not only expected oral health professionals to advise them on smoking related matters, but welcomed such involvement. Educating pediatric dentists to these patient perceptions may help them overcome their perceived "patient resistance" barrier to helping adolescent patients stop tobacco use. Perceived patient resistance was reported in other studies at 56–94% [14, 19].
Respondent dentists in states with higher smoking prevalence were more likely to ask, advise, and assist. Perhaps respondents in these states with high smoking prevalence were more sensitized to the tobacco use problem, and more likely to have received tobacco cessation training, and therefore were more involved in tobacco prevention and cessation activities. In addition, respondents in the Pacific region were less likely to advise about tobacco use compared to those in the Atlantic or Central regions, which may be related to lower state tobacco use prevalence in Pacific region states.
Pediatric dentists can play an important role in preventing initiation or promoting cessation of tobacco use among adolescents to whom they provide care. Adolescents are a unique population. Studies report adolescents consistently rank physical attractiveness, dental concerns, and oral health as greatly important[20, 21]. Such findings are highly relevant to pediatric dental practice. They suggest relating smoking to short-term adverse effects associated with attractiveness and oral health may be more relevant and meaningful to an adolescent smoker than relating smoking to long-term health effects such as cardiovascular or lung diseases. Pediatric dentists are well positioned to identify tobacco-related oral health and hygiene problems in the mouths of adolescents who use tobacco. Incorporating this feedback in a brief tobacco cessation intervention in the pediatric dental care setting may encourage adolescents to try to stop smoking. Several studies have demonstrated brief cessation interventions by dental professionals who identify spit (smokeless) tobacco-related lesions in a client's own mouth and who provide brief cessation counseling are effective in helping patients stop their tobacco use[22–25].
Adolescence is the primary time for cigarette smoking initiation with transition from experimentation to some level of dependence. About 65% to 70% of adolescents will try smoking before completing high school, more than one-third will become daily smokers, and almost one quarter will become nicotine dependent. Most adult smokers began smoking by the age of 18. Since adolescent smoking results in increased adult health problems, initiation and maintenance of smoking during adolescence represent a genuine public health concern. The need for effective interventions to prevent the transition from youthful smoking to adult smoking is clearly indicated.
Compared with adult smokers, adolescent smokers are more likely to be sporadic or non-daily smokers, and to have more variable smoking patterns on days they do smoke. Nevertheless, many adolescent smokers begin to experience nicotine addiction early in their smoking careers and when smoking only sporadically or occasionally[30–33]. Adolescents may have greater vulnerability to nicotine dependence. Animal studies suggest that processes involved in central nervous system maturation may play critical roles in the development of nicotine dependence[35, 36]. Even adolescents who smoke infrequently (e.g., only a few cigarettes a month) have a high probability of becoming regular adult smokers. In a large adolescent sample, Chassin et al.  found that the probability of adult smoking varied by smoking level in adolescence. Findings indicated that adolescents who had smoked more were more likely to be adult smokers, yet 25% of adolescents who had only smoked one or two cigarettes also became adult smokers (defined as smoking in the past week). Given that adolescents are so vulnerable to long term tobacco use, access to them becomes important for early intervention to prevent smoking initiation and to promote smoking cessation. Pediatric dentists are more likely to see teenagers than other health professionals on a regular basis.
A limitation of this study was that it was performed in 1998. Publication of the 2000 Clinical Guideline for the Treatment of Tobacco Use and Dependence may have increased training of dentists in the area of tobacco prevention and cessation in dental schools and residency training programs, and in dental practices through dental continuing education. In addition, dental professional associations have actively advertised and supported the dentist's role in tobacco prevention and cessation. A review of scientific sessions sponsored by the AAPD from 2000 to 2006 and of AAPD articles published during the same time period revealed tobacco cessation programs in 2002 and 8 tobacco-related papers (3 on AAPD policy statements in 2000, 2003, and 2006; 3 on the negative health effects of tobacco use on oral health, 2 in 2003 and 1 in 2004; and 2 literature reviews on evidence-based tobacco interventions, 1 in 2000 and 1 in 2006). While these strategies may have increased tobacco-control knowledge among pediatric and general dentists, they appear not to have changed tobacco-control behavior dramatically in general dentists. In the past 15 years, prevalences of general dentists asking patients about tobacco use have not changed radically: ranging from 24% in 1992 to 33% in 1994 to <60% in 1997 to 26% in 2001 to 28% in 2005. It is likely that changes in the prevalences of tobacco-control behavior among pediatric dentists over time have paralleled those of general dentists. Nevertheless, no national data on pediatric dentists are available since 1994. Furthermore, factors related to tobacco control activities of pediatric dentists previously have not been reported.
Another caveat of this survey was its reliance on self-reports. Respondents may have overestimated their actual performance when reporting their tobacco cessation counseling behavior. Moreover, because the study sample was drawn from the membership of the AAPD, membership bias may be present in the sample. Dentists likely to join the AAPD may be more likely to perform tobacco cessation behaviors than those who are not members. Additionally, AAPD members include dentists who have pediatric dentistry specialty certificates from accredited programs as well as general dentists interested in treating pediatric patients but who are not certified as pediatric dentistry specialists. Another limitation of our study is that our survey did not distinguish between these two groups. We should therefore be cautious about completely accepting these self-reported values. However, these study results still provide useful information for comparison to other self-reports and for developing and targeting educational programs.
The Public Health Service Guidelines for brief clinical interventions recommend all individuals seeking oral healthcare be asked if they use tobacco. Tobacco users should be advised to quit, assessed for willingness to quit, assisted appropriately based on willingness to quit, and follow-up arranged. Pediatric dentists could not only deter experimental smoking among adolescents by discussing the addiction's dangers, but also could provide referral for treatment for highly dependent smokers. Training programs to enhance knowledge and skills related to the treatment of tobacco use and dependence in pediatric dental settings may be needed and evidence indicates that such programs would be well received by pediatric dentists.
Respondents who felt prepared to intervene with patients about their tobacco use were much more likely to do so than those who did not feel prepared. Moreover, respondents with training in tobacco cessation counseling were more likely to assist tobacco users with quitting. These and other findings make a strong case for the need to better prepare dentists who treat pediatric patients to address tobacco use in their practices.
This work is based on a survey conducted by Jennifer L. Ryan, DDS for her Master of Science degree thesis during her UCSF Pediatric Dentistry Residence Program and was made possible in part by a research award from the California Society of Pediatric Dentists. The authors thank the American Academy of Pediatric Dentistry and Dr. John A. Bogert, Executive Director at the time of this survey, for providing the random sample of 1500 pediatric dentists and for donating the mailing labels. The authors also thank Dr. Teresa Dolan for sharing her survey instrument and Ms. Joanna Hill for help with data entry and manuscript preparation. The authors dedicate this manuscript to the memory of Dr Umo Isong with whom we had the honor of working on this project -- she continues to inspire us to work to make the world a better place.
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