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Abstract
Background Following California’s statewide law prohibiting the sale of flavoured tobacco products, some cigarette brands introduced new variants advertised as non-menthol, yet featuring design and text commonly found in menthol cigarette marketing.
Methods Data are from the February–May 2023 wave of the Tobacco Epidemic Evaluation Network (TEEN+) national probability-based survey (aged 13–25 years). Respondents (N=10 217) were shown images of two (of four) ‘new non-menthol’ brand ads or packaging and two comparators (‘classic’ non-menthol and menthol cigarette brands). Respondents reported expected taste of each (no or any minty/menthol taste; ‘don’t know’). Multinomial regression models tested associations between predictors (age, gender identity, race and ethnicity, perceived financial situation, smoking status) and expectation of minty/menthol taste.
Results Younger age was associated with expectations of minty/menthol taste, controlling for covariates. Respondents aged 13–17 years had greater odds of expecting minty/menthol taste than no minty/menthol taste for all tested new non-menthol brands (Camel Crush Oasis adjusted OR (aOR): 1.30, p<0.05; Camel Crisp aOR: 1.47, p<0.001; Kool Non-Menthol Blue aOR: 1.27, p<0.05; Kool Non-Menthol Green aOR: 1.43, p<0.01), compared to respondents aged 21 and older. Respondents aged 18–20 years had greater odds of reporting minty/menthol expectancies than no minty/menthol expectancies for Camel Crush Oasis (aOR: 1.35, p<0.05) and Kool Non-Menthol Green (aOR: 1.29, p<0.05) compared to those aged 21–25 years. Compared to non-Hispanic white respondents, non-Hispanic Asian respondents had greater odds of expecting minty/menthol taste than no minty/menthol taste for Camel Crush Oasis (aOR: 1.89, p<0.01), Kool Non-Menthol Blue (aOR: 1.88, p<0.01) and Kool Non-Menthol Green (aOR: 1.72, p<0.05).
Discussion Younger age was associated with expectations of new non-menthol cigarettes having a minty/menthol taste. Results raise concerns regarding the potential appeal of these products to youth and young adults.
- Packaging and Labelling
- Advertising and Promotion
- Public policy
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Youth perceive green colour schemes to indicate that a cigarette is mentholated, and blue to imply a mild, mellow, smooth and/or menthol flavour. People who are young and/or inexperienced with smoking are more likely to use menthol than non-menthol cigarettes.
WHAT THIS STUDY ADDS
More youth and young adults have inaccurate flavour expectancies for “new non-menthol” brands introduced in California following statewide flavor restrictions, than for classic non-menthol or menthol brands. Based on the ads and/or packaging, new non-menthols were frequently expected to have a menthol taste.
Menthol flavour expectancies of new non-menthol brands were more likely among youth compared to young adults, as well as among Asian non-Hispanic individuals compared to those who are white.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
New non-menthol brand variants in jurisdictions where menthol cigarettes are banned could circumvent the intended effect of public health policy.
Introduction
Menthol is a chemical compound with anaesthetising properties that, when added to cigarettes, produces a minty taste and cooling sensation.1 Menthol reduces the harshness of tobacco smoke and facilitates trial and use.2–4 People who are young and/or inexperienced with smoking are more likely to use menthol than non-menthol cigarettes, and thus, these products prompt concerns regarding their role in youth initiation of tobacco and nicotine use.5 6
California began enforcing a statewide law prohibiting the sale of flavoured tobacco products on 21 December 2022. The law prohibited the sale of menthol cigarettes, which are not subject to federal restrictions on flavoured cigarette sales.7 California is the second US state with such a law, preceded only by Massachusetts, which was effective June 2020.8 Following this, some major menthol cigarette brands introduced new cigarette variants advertised as ‘non-menthol’ in these states.9 However, certain new brand variants were marketed, through various channels including outdoor ads, on brand websites and through direct mail, with messaging suggesting they were designed specifically for people who smoked menthol cigarettes (eg, ‘Your answer to California’s menthol ban’ and ‘Your favorite menthol styles are gone, but we’ve crafted two new non-menthol blends with you in mind.’).9 10
Despite the use of the term ‘non-menthol’ on pack labels and accompanying ads, both packaging and ads feature colour schemes (ie, green, blue), terminology (eg, ‘fresh’, and ‘green’ or ‘blue’) and imagery (eg, water) commonly found in marketing of menthol cigarettes.9 Previous studies have found that youth recognise green cigarette packaging and colour schemes as denoting menthol.11 12 The current study examines whether young people in the USA expect ‘new non-menthol’ brand variants to have a minty or menthol taste based on their packaging and/or advertising, and identify individual characteristics associated with these perceptions.
Methods
Data collection
Data are from Wave 2 of the Tobacco Epidemic Evaluation Network (TEEN+) study, an online survey of a national probability-based cohort of youth and young adults (aged 13–25 years) administered by the CDC Foundation.13 The Wave 2 fielding period spanned February 2023 to May 2023. Survey measures that are specific to new non-menthol brands were added in Wave 2. The national sample of respondents (N=10 217) were shown images of packaging and/or marketing materials for two new non-menthol brands that were being marketed in California as of December 2022: Camel Crisp and Kool Non-Menthol Green (‘A’ and ‘C’) or Camel Crush Oasis and Kool Non-Menthol Blue (‘B’ and ‘D’). They were also shown pack images for two comparator cigarettes: a ‘classic’ non-menthol: Marlboro Gold (‘E’) or Camel Regular (“G”); and a ‘classic’ menthol: Camel Menthol (‘F’) or Newport (‘H’). See figure 1 for the ads and packs included in the study. Each image was shown on a separate screen and the participants advanced to the next screen after responding to the flavour expectancy question for that brand. The images were not paired, but respondent received four images that included at least two ‘new non-menthol’ images, one classic non-menthol image and one classic menthol image. The selection of images (A–H) and order in which the images were presented were randomised by respondent.
Marketing materials and packaging tested among youth and young adults in the USA to measure flavor expectancies of cigarette brand variants.
All survey respondents were asked, Which do you think best describes the taste of this product? Response options were: This product has NO minty/menthol taste; This product has SOME minty/menthol taste; This product has a STRONG minty/menthol taste; do not know. ‘Some’ and ‘strong’ responses were collapsed into an ‘any minty/menthol taste’ for the main analysis.
Statistical analysis
Data were weighted according to national demographic benchmarks for age, race and ethnicity, and sex. Weighted proportions were tabulated to identify perceptions (no minty/menthol taste; some minty/menthol taste; strong minty/menthol taste; don’t know) of each new non-menthol product and classic comparators. To provide additional insight, results were examined when stratified according to age group and smoking status (never vs ever).
For each new non-menthol brand variant and each ‘classic’ menthol or non-menthol brand, multinomial logistic regression was used to assess whether perceptions of any minty/menthol taste (recoded by combining responses for ‘some’ or ‘strong’ taste expectancies) were associated with individual characteristics found to be significant for at least one brand in bivariate χ2 tests of association: age group (13–17; 18–20, 21–25); gender identity (boy or man; girl or woman; non-binary, questioning, or something else); race and ethnicity (white and non-Hispanic; black and non-Hispanic; Asian and non-Hispanic; multiracial and other non-Hispanic; Hispanic); a subjective measure of financial situation (lives comfortably; meets needs with a little left over; just meets needs with nothing left over; does not meet needs)14; and current smoking status (never smoked; ever smoked, but not in the past 30 days; smoked a cigarette at least 1 day in the past 30 days). To understand whether ‘don’t know’ responses inform the study’s conclusions, the multinomial regression models included ‘don’t know’ as an outcome for each brand (ie, ‘no minty/menthol taste’ vs ‘any minty/menthol taste’ and ‘don’t know’).
Results
The weighted demographic characteristics of the sample are presented in table 1. Among the 10 217 youth and young adults in the study sample, 40.9% were ages 13–17 years, slightly less than one-quarter (22.2%) were ages 18–20 years and slightly more than one-third (36.9%) were ages 21–25 years. Slightly less than half (46.8%) of respondents identified as a girl or woman, half (49.7%) as a boy or man, and 3.5% as non-binary, something else or questioning their gender identity. Approximately half (51.8%) of respondents identified as white and non-Hispanic, 13.8% as black or African American and non-Hispanic, 5.5% as Asian and non-Hispanic, and 4.9% as another or multiple races and non-Hispanic. Nearly one-quarter (24.0%) reported being of Hispanic or Latino ethnicity. When providing a subjective measure of their financial situation, 47.6% reported living comfortably, 33.9% reported that their needs were met with a little left over, 15.7% reported just meeting basic expenses with nothing left over and 2.8% reported not meeting basic expenses. Three-quarters (75.3%) of respondents had never smoked a cigarette.
Sociodemographic characteristics of US youth and young adults in Wave 2 of the TEEN+ study, February–May 2023 (N=10 217)
Expectations of minty/menthol taste of each brand variant are summarised in table 2. Respondents were approximately evenly divided according to whether they thought each new non-menthol brand had no minty/menthol taste, any minty/menthol taste or they did not know. For Camel Crisp, 20.8% of respondents expected it would have ‘some’ minty/menthol flavour, while 12.5% expected it to have a strong minty/menthol taste. Slightly less than one-quarter (22.6%) of respondents expected Camel Crush Oasis to have some minty/menthol taste and 17.9% expected it would have a strong minty/menthol taste. Nearly one-quarter (23.3%) of respondents expected Kool Non-Menthol Blue to have some minty/menthol taste, and 16.3% felt it would have a strong minty/menthol flavour. For Kool Non-Menthol Green, 21.0% of respondents expected ‘some’ and 13.6% expected ‘strong’ minty/menthol taste.
US youth and young adults’ flavour expectancies in response to ads for cigarette brand variants, TEEN+ study, February–May 2023
Many respondents correctly expected the ‘classic’ menthol brands (Camel Menthol and Newport) to have a minty/menthol taste (62.9% and 47.1%, respectively). Slightly more than one-quarter (27.3%) of respondents expected Newport to have some minty/menthol taste, an additional 19.8% expected it to have a strong minty/menthol taste, and 14.6% expected it to have no minty/menthol taste. The plurality of respondents (40.8%) expected Camel Menthol to have a strong minty/menthol taste, and an additional 22.1% expected it to have ‘some’ minty/menthol taste. Few (6.3%) expected Camel Menthol to have no minty/menthol taste.
Few respondents expected ‘classic’ non-menthol brands Marlboro Gold and Camel to have any minty/menthol taste; instead, approximately half of sampled respondents correctly expected that these would have none (51.0% and 52.4%, respectively). For all brand variants (new non-menthol, classic menthol, and classic non-menthol), the proportion responding ‘don’t know’ ranged from 29.5% to 38.4%.
Online supplemental table 1 stratified flavour expectancies, including ‘don’t know’ responses, by age group. Similar proportions of respondents aged 13–17 and aged 18–20 years expected any menthol taste for Camel Crisp (32.8% and 34.8%, respectively) and Kool Non-Menthol Green (34.1% and 37.0%), while the youngest respondents (aged 13–17) reported expectations of any menthol taste less frequently for Camel Crush Oasis (34.9% and 44.1%, respectively) and Kool Non-Menthol Blue (37.6% and 43.6%) compared with respondents aged 18–20 years. For all brands included in the study, youth aged 13–17 years reported ‘don’t know’ more frequently than young adults (35.7–47.7%, compared with 25.8–37.3% among 18–20 year olds and 24.1–31.6% of 21–25 year olds).
Supplemental material
Multinomial models of the relationship between individual-level characteristics and respondents’ expectation of minty/menthol taste of new non-menthol brands found significant associations for age, controlling for gender identity, race and ethnicity, perceived financial situation and smoking status (table 3). Compared with respondents aged 21 years and older, respondents aged 13–17 years had greater odds of reporting minty/menthol flavour expectancies than no minty/menthol expectancies for all new non-menthol brand variants: Camel Crush Oasis (adjusted OR (aOR) 1.30, 95% CI 1.03 to 1.63); Kool Non-Menthol Blue (aOR 1.27, 95% CI 1.02 to 1.59); Camel Crisp (aOR 1.47, 95% CI 1.18 to 1.83); and Kool Non-Menthol Green (aOR 1.43, 95% CI 1.15 to 1.79). Respondents aged 18–20 years had greater odds of reporting minty/menthol expectancies than no menthol expectancies for Camel Crush Oasis (aOR 1.35, 95% CI 1.04 to 1.75) and Kool Non-Menthol Blue (aOR 1.27, 95% CI 1.00 to 1.61) compared with those aged 21 and older. In the same models, respondents aged 13–17 years had significantly greater odds of responding that they ‘don’t know’ what they expected the new non-menthol brands to taste like than having no minty/menthol expectancies compared with those aged 21–25 years: Camel Crush Oasis (aOR 1.83, 95% CI 1.43 to 2.33); Kool Non-Menthol Blue (aOR 1.68, 95% CI 1.33 to 2.23); Camel Crisp (aOR 1.60, 95% CI 1.26 to 2.02); Kool Non-Menthol Green (aOR 1.60, 95% CI 1.27 to 2.03).
Multinomial regression models of individual characteristics that predict US youth and young adult expectancies of minty/menthol flavour based on advertising or packaging for ‘new non-menthol’ cigarette brand variants, TEEN+ study, February–May 2023
Less consistent significant effects on expectations of minty/menthol taste were found for most other individual characteristics, controlling for all covariates listed above (table 3). One exception was found among non-Hispanic Asian respondents; this group had significantly greater odds of perceiving minty/menthol taste than no menthol expectancies compared to those who were non-Hispanic white for Camel Crush Oasis (aOR 1.89, 95% CI 1.20 to 2.98), Kool Non-Menthol Blue (aOR 1.88, 95% CI 1.17 to 3.01) and Kool Non-Menthol Green (aOR 1.72, 95% CI 1.10 to 2.70). Black non-Hispanic respondents were significantly more likely to respond that they did not know what each new non-menthol brand would taste like than no menthol expectancies compared with white non-Hispanic respondents (table 3). A similar pattern for the ‘don’t know’ response outcome was observed among Asian non-Hispanic respondents for each brand, and among Hispanic respondents for all brands except Kool Non-Menthol Green.
Smoking status was not a significant predictor of of minty/menthol flavour expectancies for most new non-menthol brands (table 3), with the exception of Camel Crush Oasis where respondents who had ever smoked (aOR 1.87, 95% CI 1.43 to 2.45) or currently smoke (aOR 3.35, 95% CI 2.09 to 5.35) had significantly greater odds of expecting any minty/menthol taste than no minty/menthol taste compared with those who had never smoked. Those who had ever or currently smoked were significantly less likely to indicate that they ‘don’t know’ how they expected Camel Crisp, Kool Non-Menthol Blue or Kool Non-Menthol Green to taste than having no minty/menthol expectancies, compared with respondents who had never smoked (table 3). For most new non-menthol brands, a similar proportion of those with and without smoking experience expected the new non-menthol brands to have some or strong minty/menthol taste for Camel Crisp (47.7% and 47.5%, respectively), Kool Non-Menthol Blue (53.2% and 57.4%, respectively) and Kool Non-Menthol Green (47.7% and 50.0%, respectively) (online supplemental table 2).
Supplemental material
Multinomial models of ‘classic’ brands show that the youngest respondents (aged 13–17 years) have higher odds of inaccurately expecting classic non-menthol brands Marlboro Gold (aOR 1.42, 95% CI 1.04 to 1.93) and Camel (aOR 1.48, 95% CI 1.08 to 2.02) to have a minty/menthol taste than no minty/menthol taste, compared with those aged 21–25 years (table 4). In contrast to the results observed for some new non-menthol brands (table 3), respondents aged 18–20 years did not significantly differ from those aged 21–25 years in their flavour expectancies for any classic brands (table 4). No relationship was found between age and flavour expectancies for the classic menthol brands Camel Menthol or Newport, although respondents aged 13–17 years were significantly more likely to indicate that they did not know what they expected Newport to taste like than expect no menthol taste (OR 1.56, 95% CI 1.17 to 2.07) compared to those aged 21–25 years.
Multinomial regression models of individual characteristics that predict US youth and young adult expectancies of minty/menthol flavour based on advertising or packaging for ‘classic’ menthol and non-menthol cigarette brand variants, TEEN+ study, February–May 2023
Respondents who had ever smoked reported accurate flavour expectancies with greater frequency for all ‘classic’ menthol and non-menthol brands compared with those who had never smoked. In multinomial models, those who had ever or currently smoked were significantly more likely to expect classic menthol brands to have a minty/menthol taste than have no minty/menthol taste compared with those who had never smoked (table 4), and significantly less likely to expect the classic non-menthol brand Camel to have a minty/menthol taste than no minty/menthol taste compared with those who had never smoked. No difference was found in multinomial models for flavour expectancies of the classic non-menthol Marlboro Gold according to smoking status. Those who had ever or currently smoked had significantly lower odds of indicating that they did not know whether each ‘classic’ brand had a minty or menthol taste than no minty/menthol taste compared with those who had never smoked, with the exception of Camel Menthol where no difference in the likelihood of ‘don’t know’ responses was observed according to smoking status (table 4).
Discussion
Results indicate that at least one-third of respondents viewing the ads/packages for new non-menthol brand variants in this study (Camel Crisp, Camel Crush Oasis, Kool Non-Menthol Green or Kool Non-Menthol Blue) expected each to have a minty or menthol taste, despite non-menthol descriptors featured on the packaging and ad copy. Respondents were particularly inclined to feel that Camel Crush Oasis and Kool Non-Menthol Blue would taste like mint or menthol. By contrast, few respondents provided discordant responses for the classic brand variants; only 6–15% incorrectly identified classic menthols (Camel Menthol or Newport) as having no minty or menthol taste, and approximately 10% incorrectly thought classic non-menthols (Marlboro Gold or Camel) would have a minty or menthol taste. At least half of the youth and young adults in the sample were able to correctly identify whether or not each of the classic brand variants would taste like mint or menthol. The proportion of respondents who said they ‘don’t know’ whether the brand variant would have a mint or menthol flavour was relatively similar (ranging from 30% to 38%) for all tested ads and packages—including the classic menthol and classic non-menthol cigarettes.
Consistent with cross-sectional nationally representative surveys in the USA,15 16 most (about three-quarters) of the youth and young adults surveyed in this study had never smoked cigarettes. Nonetheless, the majority of respondents were able to accurately distinguish the expected flavours of classic menthol and classic non-menthol cigarette brand variants. Few reported inaccurate flavour expectancies for classic brand variants, potentially due to the brands’ marketing strategies and established advertising cues, such as pack colour.11 12 Their flavour expectancies of the ‘new non-menthol’ brand variants were notably more mixed.
Younger age was the most consistent and significant factor associated with respondents’ expectations that new non-menthol brand variants would have a minty or menthol taste rather than none, controlling for other demographic factors. In fact, the youth in our sample answered ‘don’t know’ more frequently when asked about flavour expectancies for ‘classic’ non-menthol brands (Marlboro Gold and Camel) and the ‘classic’ menthol brand that lacked a menthol descriptor (Newport) than they did for new non-menthol brands. Respondents aged 18–20 years also expressed significantly greater odds of expecting minty/menthol taste than no minty/menthol taste for two new non-menthol brands compared with those aged 21–25, yet did not differ from older respondents in their flavour expectancies of classic brands.
Previous research has shown that green colour schemes effectively communicate to youth that a cigarette is mentholated, and youth in these studies describe blue as denoting a mild, mellow, smooth and/or menthol flavour.11 12 These sensory characteristics appeal to youth, as they reduce the harshness of cigarette smoke and mask the bitter taste of nicotine that can make early smoking experiences more aversive.17–19 The new non-menthol ads and packaging tested in this study prominently featured green and blue colour schemes. Chemical analyses have detected the presence of a synthetic cooling agent (WS-3) in some new non-menthol brand variants marketed in California—including Camel Crisp, which was among the ads tested in the present study.20 21 Neither WS-3 nor menthol was found in the Kool Non-Menthol or Camel Crush Oasis products sampled from California in previous studies,20 21 but researchers have detected flavour chemicals such as vanillin in Camel Crush Oasis that have the potential to impart a sweet or candy flavour at sufficient levels.20 Although research that tests consumer flavour perceptions after smoking these new brand variants has yet to be published, the advertising and packaging imply youth-appealing sensory characteristics and thus may encourage trial and use of these brands among youth and young adults. State and national tobacco use surveys may consider measuring youth and young adult use of new non-menthol brand variants to determine whether these products are being used in trial and initiation of cigarette smoking among young people, to inform the implementation and enforcement of policies restricting menthol tobacco products. Additional research on product design features that differentiate new non-menthols from classic brand variants is also warranted. Finally, further study is warranted of our finding that non-Hispanic Asian youth and young adults had a greater likelihood of mint/menthol flavour expectancies of new non-menthol brand variants compared with those who are white. Our findings among this group are particularly relevant to California, a state where more than fifteen percent of the population is Asian or Asian-American.22
Limitations
This study is subject to limitations. First, it did not include ads for all of the new non-menthol brand variants introduced onto the market in California following the flavour ban. Other brands introduced in California include Newport EXP and a Newport Non-Menthol in green packaging (a departure from the brand’s classic non-menthol in red packaging); both variants were found to contain WS-3, but not menthol, in laboratory analyses.20 21 Second, there is a possibility that the greater likelihood of youth to expect minty/menthol taste across both new non-menthol and classic non-menthol brands was due to greater susceptibility to survey priming or acquiescence bias at younger ages. Our survey item was designed to mitigate the potential for response bias, including a neutral question prompt (‘Which do you think best describes this product?’) and the inclusion of a ‘don’t know’ response option. Indeed, respondents aged 13–17 years used the ‘don’t know’ option with greater frequency than any other age group. Third, our study did not control for whether respondents had previously tried new non-menthol brand variants, which would inform their flavour expectancies. However, this limitation is unlikely to have influenced the findings for several reasons. Three-quarters of the sample had never smoked cigarettes, and only 6% had smoked in the past 30 days. As a nationally representative sample, most respondents did not live in California or Massachusetts (the only other state with a comprehensive flavour ban); these brand variants are not available nationally and thus most respondents who smoke would not have had access to them. Furthermore, ads promoting the impending ‘new arrivals’ onto the California market appeared within weeks of the survey launch. It is unknown how widely available these brand variants were within the California market at the time of the survey. A third limitation is that our findings do not reflect the perspectives of older adults who may have different expectancies than young people of new non-menthol brands based on their interpretation of the advertising or packaging. Additional research is needed on expectations that people with more extensive smoking histories will have of new non-menthol products based on marketing, and whether the products appeal to those who preferred menthol but are unable to obtain menthol cigarettes due to policy restrictions. Finally, our study did not include a measure of appeal as an outcome for each tested brand, which is an important area of future research so long as such products remain on the market in jurisdictions where menthol tobacco products are restricted.
New non-menthol products are being marketed as a direct response to California’s restrictions on flavoured cigarettes, purportedly offering new, specially formulated alternatives to menthol flavours.9 The introduction of new non-menthol brand variants in jurisdictions where menthol cigarettes are banned represents the latest example of tobacco product development that could circumvent the intended effect of public health policy.23–25 The results of this study suggest that youth and younger adults are more likely than those age 21 years or older to assume these products have minty or menthol taste. These brands may hold more appeal for youth and young adults during smoking trial and experimentation than ‘classic’ non-menthol brands. It is important for evaluations of flavour policies to account for new non-menthol brand variants and their marketing, including their potential to undermine efforts to prevent smoking initiation among young people.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Advarra Institutional Review Board (Pro00064406). Participants gave informed consent to participate in the study before taking part.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors KM and BS conceptualised the study and designed the survey measures. JMK, AS, FRMA and KM developed the analytical plan. JC coordinated data collection and conducted all data analyses. JMK drafted the manuscript. KM serves as the guarantor of the study. All authors contributed edits and provided critical reviews of the manuscript and revisions.
Funding Financial support provided by the Bloomberg Initiative to Reduce Tobacco Use through the CDC Foundation with a grant from Bloomberg Philanthropies.
Disclaimer The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the CDC Foundation.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.