Monday, September 25, 2023
| Characteristic | Current cigarette smokinga | ||||||
|---|---|---|---|---|---|---|---|
| No past-year mental health condition (n = 6,896) | Past-year any mental illnessb (n = 3,983) | Past-year serious mental illness (n = 1,336) | Past-year mild or moderate mental illness (n = 2,647) | Past-year serious psychological distress alone (n = 1,498) | Past-year major depressive disorder alone (n = 303) | Past-year serious psychological distress and major depressive disorder (n = 1,337) | |
| Overall | 13.6 (13.0–14.3) | 22.8 (21.7–23.8) | 27.2 (25.3–29.0) | 21.2 (19.8–22.6) | 24.5 (22.3–26.7) | 17.6 (13.8–21.5) | 25.0 (23.3–26.8) |
| Survey year | |||||||
| 2019 | 14.6 (14.0–15.2) | 25.2 (24.3–26.2) | 30.1 (27.7–32.6) | 23.6 (22.4–24.8) | 27.7 (25.7–29.6) | 18.5 (15.6–21.4) | 27.2 (25.3–29.2) |
| 2020 | 12.7 (11.7–13.7) | 20.3 (18.4–22.1) | 24.3 (20.9–27.7) | 18.9 (16.3–21.4) | 21.3 (17.3–25.3) | 16.7 (9.4–24.0) | 22.9 (20.0–25.9) |
| Age, y | |||||||
| 18–25 | 9.7 (8.9–10.5) | 14.9 (13.8–16.0) | 18.9 (16.6–21.2) | 13.1 (11.8–14.5) | 14.3 (12.4–16.3) | 10.6 (7.6–13.6) | 16.2 (14.1–18.3) |
| 26–34 | 16.5 (15.6–17.4) | 26.1 (24.4–27.9) | 31.6 (27.9–35.4) | 24.1 (22.3–26.0) | 26.7 (23.3–30.1) | 25.1 (15.7–34.6) | 30.2 (26.2–34.1) |
| 35–49 | 17.4 (16.4–18.3) | 27.8 (26.0–29.6) | 34.4 (30.5–38.3) | 25.3 (23.3–27.4) | 31.6 (28.0–35.2) | 21.5 (15.9–27.2) | 32.1 (27.9–36.3) |
| 50–64 | 15.7 (14.4–17.1) | 27.0 (23.4–30.6) | 27.0 (21.6–32.3) | 27.0 (22.3–31.7) | 32.1 (22.3–41.9) | 15.9 (10.1–21.7) | 28.7 (22.2–35.1) |
| ≥65 | 7.7 (6.7–8.8) | 11.6 (8.4–14.7) | — c | 11.8 (8.3–15.4) | 18.1 (8.8–27.4) | — c | 11.8 (4.9–18.6) |
| Sex | |||||||
| Male | 15.8 (15.0–16.6) | 25.5 (23.8–27.1) | 29.1 (26.0–32.1) | 24.3 (22.2–26.3) | 30.1 (26.2–34.0) | 16.4 (12.2–20.6) | 28.0 (25.0–31.0) |
| Female | 11.4 (10.6–12.2) | 21.2 (19.8–22.5) | 26.1 (23.6–28.6) | 19.4 (17.6–21.2) | 20.7 (18.7–22.7) | 18.4 (13.0–23.7) | 23.3 (20.8–25.9) |
| Sexual orientation | |||||||
| Heterosexual | 13.4 (12.7–14.0) | 22.1 (21.0–23.3) | 27.1 (24.9–29.3) | 20.6 (19.1–22.2) | 24.1 (21.8–26.3) | 18.1 (13.9–22.2) | 24.7 (22.8–26.6) |
| Gay/lesbian | 20.7 (16.1–25.2) | 29.2 (23.8–34.6) | 29.3 (19.1–39.5) | 29.2 (21.6–36.7) | 29.4 (20.6–38.2) | — c | 31.3 (21.0–41.7) |
| Bisexual | 22.3 (19.5–25.0) | 25.9 (22.9–28.9) | 28.5 (24.9–32.2) | 23.9 (20.0–27.8) | 26.8 (22.4–31.2) | 17.1 (9.6–24.5) | 25.4 (21.6–29.1) |
| Race/ethnicity | |||||||
| Hispanic | 8.5 (7.6–9.4) | 19.0 (16.0–22.1) | 23.2 (17.8–28.5) | 17.7 (14.1–21.3) | 21.7 (14.7–28.8) | 12.8 (6.1–19.5) | 18.6 (14.2–22.9) |
| Non-Hispanic American Indian, Alaska Native | 26.0 (18.8–33.2) | 53.3 (40.5–66.2) | 59.2 (34.5–83.8) | 50.8 (33.8–67.8) | 71.0 (50.1–92.0) | — c | 40.8 (19.2–62.4) |
| Non-Hispanic Asian | 7.2 (5.1–9.2) | 7.9 (4.5–11.3) | — c | 8.1 (4.2–11.9) | 6.0 (2.8–9.2) | — c | — c |
| Non-Hispanic Black | 16.2 (14.2–18.2) | 21.0 (16.9–25.0) | 17.4 (11.0–23.9) | 22.1 (17.6–26.6) | 24.8 (18.7–30.9) | — c | 15.9 (10.5–21.4) |
| Non-Hispanic multiple races | 23.4 (18.1–28.6) | 29.1 (22.6–35.5) | 32.5 (22.8–42.3) | 27.9 (19.3–36.4) | 22.8 (11.9–33.7) | 23.0 (10.1–35.9) | 26.4 (18.5–34.4) |
| Non-Hispanic Native Hawaiian, Pacific Islander | 13.5 (8.3–18.7) | — c | — c | — c | — c | — c | — c |
| Non-Hispanic White | 14.8 (13.9–15.7) | 24.1 (22.8–25.3) | 29.6 (27.4–31.9) | 22.1 (20.4–23.8) | 26.0 (23.4–28.6) | 18.6 (13.8–23.5) | 28.0 (26.2–29.9) |
| Education | |||||||
| Less than high school diploma | 21.1 (19.2–23.1) | 36.3 (31.2–41.4) | 46.3 (37.0–55.5) | 33.8 (28.2–39.3) | 33.2 (24.8–41.7) | — c | 41.6 (33.6–49.7) |
| High school diploma/GED | 19.0 (17.5–20.4) | 32.3 (29.5–35.2) | 33.0 (28.4–37.7) | 32.0 (28.7–35.4) | 37.7 (33.2–42.3) | 29.8 (20.4–39.3) | 31.5 (26.9–36.1) |
| Some college/associates degree | 14.8 (13.8–15.8) | 23.1 (21.6–24.6) | 26.3 (23.5–29.1) | 21.7 (19.6–23.9) | 22.2 (19.1–25.4) | 16.8 (12.5–21.0) | 24.2 (21.5–27.0) |
| College graduate | 5.6 (5.1–6.2) | 10.5 (9.3–11.7) | 16.9 (14.2–19.5) | 8.7 (7.6–9.9) | 9.6 (7.5–11.8) | 10.1 (6.5–13.8) | 14.7 (12.1–17.4) |
| Disabilityd | |||||||
| Yes | 15.4 (13.5–17.3) | 26.7 (24.9–28.5) | 29.8 (26.8–32.7) | 24.9 (22.5–27.4) | 27.8 (24.5–31.0) | 23.1 (15.6–30.6) | 29.6 (26.5–32.8) |
| No | 13.3 (12.7–13.9) | 19.8 (18.5–21.2) | 23.9 (21.0–26.7) | 18.9 (17.2–20.6) | 22.7 (20.1–25.4) | 13.9 (10.5–17.3) | 19.8 (17.6–21.9) |
| Annual household income | |||||||
| Income at or below federal poverty threshold | 22.5 (20.4–24.7) | 36.7 (33.6–39.7) | 37.6 (32.0–43.2) | 36.2 (32.5–40.0) | 36.8 (31.3–42.3) | 24.8 (14.5–35.1) | 35.9 (31.0–40.9) |
| Income up to 2x federal poverty threshold | 18.5 (16.9–20.1) | 28.1 (25.9–30.4) | 32.4 (28.1–36.7) | 26.6 (23.7–29.4) | 26.9 (22.9–30.8) | 27.8 (15.8–39.9) | 29.6 (26.2–33.1) |
| Income more than 2x federal poverty threshold | 10.9 (10.3–11.5) | 17.0 (15.9–18.1) | 21.4 (19.0–23.8) | 15.6 (14.3–16.9) | 19.4 (16.5–22.3) | 12.9 (9.9–15.9) | 19.5 (17.2–21.9) |
| Marriage status | |||||||
| Married/living with partner | 10.0 (9.2–10.8) | 17.7 (15.9–19.5) | 22.1 (18.6–25.6) | 16.4 (14.5–18.4) | 21.2 (17.1–25.4) | 15.7 (9.9–21.5) | 20.3 (16.9–23.8) |
| Divorced/separated/widowed | 19.6 (17.7–21.6) | 30.2 (27.9–32.6) | 36.7 (32.1–41.3) | 27.8 (24.9–30.7) | 35.8 (29.3–42.3) | 21.1 (14.8–27.4) | 37.9 (32.6–43.3) |
| Never married | 17.1 (16.1–18.1) | 23.4 (22.2–24.6) | 25.9 (23.3–28.4) | 22.4 (20.9–23.9) | 22.4 (20.4–24.4) | 17.5 (12.4–22.6) | 22.5 (20.4–24.7) |
| Health insurancee | |||||||
| Public | 18.5 (16.9–20.1) | 31.6 (29.2–33.9) | 32.7 (28.8–36.6) | 31.1 (27.9–34.2) | 32.7 (28.9–36.4) | 26.5 (15.8–37.1) | 31.7 (27.9–35.5) |
| Private | 10.5 (9.9–11.1) | 15.7 (14.6–16.8) | 19.8 (17.1–22.4) | 14.5 (13.2–15.8) | 17.3 (14.4–20.2) | 13.1 (10.3–15.9) | 17.3 (15.0–19.6) |
| Uninsured | 23.1 (21.2–25.0) | 37.7 (34.4–40.9) | 43.8 (37.3–50.3) | 35.2 (31.5–38.9) | 37.7 (32.9–42.5) | 24.8 (12.7–36.9) | 40.0 (34.6–45.4) |
| Employment status | |||||||
| Full time | 14.4 (13.7–15.2) | 20.5 (19.1–22.0) | 25.6 (23.3–27.9) | 19.0 (17.3–20.6) | 22.0 (19.4–24.7) | 16.0 (11.2–20.9) | 23.7 (21.1–26.2) |
| Part time | 11.6 (10.3–12.9) | 16.4 (14.4–18.4) | 20.0 (15.7–24.3) | 15.1 (12.9–17.2) | 14.6 (10.9–18.3) | 13.8 (8.4–19.3) | 17.9 (14.0–21.8) |
| Unemployed | 23.3 (20.3–26.2) | 35.7 (31.3–40.1) | 36.8 (27.6–46.1) | 35.2 (29.6–40.8) | 35.4 (29.3–41.4) | 29.2 (13.7–44.6) | 32.2 (25.9–38.4) |
| Other/not in labor force | 12.1 (11.1–13.2) | 26.3 (23.6–28.9) | 30.3 (26.6–34.1) | 24.8 (21.4–28.1) | 30.2 (25.2–35.3) | 19.1 (11.1–27.1) | 28.8 (24.9–32.7) |
| Metropolitan statistical areaf | |||||||
| Large metro | 11.6 (10.8–12.4) | 19.3 (18.0–20.7) | 22.9 (20.1–25.8) | 18.2 (16.4–20.0) | 20.7 (17.3–24.0) | 16.7 (10.4–23.1) | 20.4 (17.8–23.1) |
| Small metro | 15.5 (14.5–16.5) | 24.6 (22.7–26.4) | 30.1 (26.9–33.3) | 22.4 (19.8–25.0) | 26.6 (22.8–30.3) | 16.3 (12.3–20.3) | 28.3 (25.3–31.3) |
| Nonmetro/rural | 17.6 (16.2–18.9) | 31.3 (28.3–34.3) | 34.0 (28.4–39.5) | 30.3 (26.7–34.0) | 33.9 (29.2–38.7) | 24.4 (15.6–33.3) | 33.2 (27.8–38.7) |
| Arrested and booked in past 12 months | |||||||
| Yes | 44.1 (38.9–49.2) | 63.0 (56.8–69.2) | 69.9 (60.8–78.9) | 59.3 (51.4–67.2) | 66.2 (53.2–79.2) | 70.2 (43.4–96.9) | 62.1 (52.1–72.1) |
| No | 30.3 (28.8–31.8) | 40.5 (38.2–42.7) | 41.5 (36.1–46.8) | 40.0 (37.2–42.8) | 47.4 (42.0–52.7) | 21.2 (15.7–26.6) | 44.7 (38.5–51.0) |
Table 1. Percentage of Adults Who Currently Smoke Cigarettes, by Mental Health Condition, National Survey on Drug Use and Health, 2019–2020
Abbreviations: GED, General Educational Development.
a Current cigarette smoking was defined as respondents who smoked ≥100 cigarettes in their lifetime and reported smoking part or all of a cigarette in the 30 days preceding interview. Values are weighted percentage (95% CI).
b Past year any mental illness was defined as respondents who reported serious, moderate, or mild mental illness, serious psychological distress, or a major depressive disorder in the past year.
c Estimates suppressed because relative standard error was >30%.
d Disability was defined as respondents reporting any of the following: deaf or difficulty hearing; blind or serious difficulty seeing, even when wearing glasses; serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition; serious difficulty walking or climbing stairs; difficulty dressing or bathing; difficulty doing errands alone such as visiting a doctor’s office or shopping because of a physical, mental, or emotional condition.
e Public and private health insurances are not mutually exclusive; public insurance includes Medicaid, Child Health Improvement Plan, Medicare, Tricare, Champus, Veterans Administration, or some other military insurance.
f Metropolitan statistical areas are based on the 2013 Rural–Urban Continuum Codes (www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx).
| State | AMIb | AMI and smoke cigarettesb,c | No AMI and smoke cigarettesc,d |
|---|---|---|---|
| State median, % | 21.4 | 24.7 | 16.0 |
| Alabama | 20.5 (16.7–25.0) | 35.0 (25.8–45.6) | 19.9 (15.4–25.4) |
| Alaska | 21.1 (17.5–25.3) | 22.5 (15.5–31.6) | 16.4 (13.0–20.4) |
| Arizona | 24.1 (20.7–27.8) | 16.4 (11.2–23.4) | 12.6 (9.2–17.1) |
| Arkansas | 22.3 (18.3–26.9) | 35.3 (26.8–44.8) | 18.3 (14.1–23.3) |
| California | 20.1 (18.6–21.7) | 19.1 (16.0–22.6) | 11.2 (9.6–13.0) |
| Colorado | 23.3 (19.9–27.0) | 20.7 (14.7–28.3) | 12.2 (9.3–15.9) |
| Connecticut | 15.9 (13.1–19.2) | 18.6 (12.7–26.3) | 11.3 (8.0–15.8) |
| Delaware | 20.8 (17.3–24.7) | 24.2 (18.4–31.1) | 17.0 (12.6–22.4) |
| District of Columbia | 23.7 (20.2–27.7) | 19.8 (13.6–27.8) | 18.2 (13.5–24.2) |
| Florida | 16.9 (15.2–18.7) | 23.1 (18.8–28.0) | 15.9 (13.9–18.2) |
| Georgia | 15.7 (13.2–18.5) | 20.0 (14.1–27.6) | 15.3 (12.4–18.8) |
| Hawaii | 17.9 (14.6–21.8) | 22.6 (15.5–31.8) | 15.6 (12.0–20.1) |
| Idaho | 24.9 (21.5–28.6) | 21.1 (15.3–28.3) | 11.8 (8.2–16.7) |
| Illinois | 20.1 (18.0–22.4) | 23.9 (19.1–29.3) | 15.3 (13.2–17.8) |
| Indiana | 20.6 (17.2–24.5) | 35.0 (28.6–42.0) | 20.1 (16.1–24.9) |
| Iowa | 19.7 (16.0–24.0) | 26.4 (19.4–34.9) | 17.7 (13.5–22.8) |
| Kansas | 28.5 (24.3–33.1) | 25.4 (17.9–34.6) | 16.3 (12.3–21.5) |
| Kentucky | 21.6 (18.1–25.6) | 34.2 (26.5–42.9) | 22.3 (18.2–26.9) |
| Louisiana | 21.1 (17.8–24.9) | 42.1 (32.2–52.7) | 20.2 (16.4–24.5) |
| Maine | 22.0 (17.6–27.1) | 23.8 (15.7–34.4) | 15.0 (10.9–20.4) |
| Maryland | 16.6 (14.1–19.5) | 23.4 (17.6–30.3) | 11.5 (8.8–14.8) |
| Massachusetts | 21.4 (17.2–26.3) | 18.6 (10.8–30.2) | 11.7 (9.6–14.2) |
| Michigan | 22.7 (20.3–25.4) | 27.9 (23.7–32.6) | 18.1 (15.5–21.2) |
| Minnesota | 23.6 (20.8–26.7) | 28.4 (21.3–36.8) | 10.5 (8.4–13.2) |
| Mississippi | 22.1 (18.4–26.3) | 32.4 (22.8–43.7) | 22.6 (18.5–27.4) |
| Missouri | 19.8 (17.0–22.9) | 29.6 (23.2–36.9) | 16.4 (13.2–20.1) |
| Montana | 23.0 (18.8–27.9) | 28.6 (21.3–37.1) | 19.1 (16.4–22.1) |
| Nebraska | 23.0 (20.1–26.2) | 30.5 (21.4–41.3) | 12.3 (9.5–15.9) |
| Nevada | 21.2 (17.2–25.9) | 26.7 (19.7–35.1) | 11.9 (8.9–15.9) |
| New Hampshire | 26.3 (22.1–31.0) | 22.0 (15.7–29.9) | 13.8 (10.7–17.6) |
| New Jersey | 17.8 (15.1–20.8) | 17.9 (12.8–24.5) | 12.1 (9.7–15.1) |
| New Mexico | 21.6 (17.6–26.1) | 25.2 (18.6–33.1) | 15.5 (10.8–21.8) |
| New York | 18.7 (17.0–20.6) | 25.6 (21.6–30.0) | 14.0 (12.2–15.9) |
| North Carolina | 18.6 (16.8–20.6) | 27.0 (20.7–34.3) | 17.9 (15.3–20.8) |
| North Dakota | 18.8 (16.2–21.8) | 29.0 (21.2–38.2) | 18.6 (14.6–23.4) |
| Ohio | 24.8 (22.1–27.7) | 34.2 (29.2–39.5) | 19.1 (16.5–22.1) |
| Oklahoma | 29.1 (25.2–33.3) | 28.7 (22.0–36.5) | 21.4 (17.0–26.5) |
| Oregon | 27.5 (23.7–31.7) | 21.5 (15.3–29.3) | 13.8 (10.8–17.4) |
| Pennsylvania | 19.5 (16.9–22.3) | 29.5 (23.1–36.8) | 18.9 (15.5–22.8) |
| Rhode Island | 23.9 (20.2–28.1) | 20.8 (13.3–31.0) | 16.2 (12.1–21.4) |
| South Carolina | 23.3 (19.5–27.5) | 24.7 (18.7–31.9) | 19.9 (16.8–23.5) |
| South Dakota | 18.4 (15.7–21.5) | 28.6 (19.5–39.8) | 19.4 (14.5–25.5) |
| Tennessee | 19.6 (16.2–23.6) | 32.2 (25.3–40.0) | 18.0 (14.1–22.7) |
| Texas | 17.5 (15.7–19.4) | 23.0 (18.9–27.7) | 14.7 (12.9–16.6) |
| Utah | 31.5 (27.8–35.5) | 11.7 (7.9–17.1) | 7.8 (6.1–10.0) |
| Vermont | 22.8 (19.1–26.9) | 27.4 (20.2–36.0) | 10.4 (8.0–13.5) |
| Virginia | 20.4 (17.8–23.4) | 18.9 (13.7–25.5) | 15.2 (12.4–18.4) |
| Washington | 26.1 (22.4–30.1) | 20.1 (15.1–26.3) | 15.4 (12.3–19.0) |
| West Virginia | 28.3 (24.1–32.9) | 31.6 (23.2–41.4) | 20.7 (16.2–26.2) |
| Wisconsin | 21.1 (18.2–24.2) | 22.1 (16.9–28.3) | 16.0 (12.0–20.9) |
| Wyoming | 24.1 (20.3–28.3) | 25.1 (17.7–34.1) | 19.7 (14.7–25.9) |
Table 2. Percentage of Adults Who Currently Smoke Cigarettes, by State and Mental Illness Status, National Survey on Drug Use and Health, 2019–2020a
Abbreviation: AMI, any mental illness.
a Values are weighted percentage (95% CI) unless otherwise indicated.
b Any mental illness was defined as a participant who reported serious, moderate, or mild mental illness, serious psychological distress, and/or major depressive disorder in the past year.
c Current cigarette smoking was defined as those reporting smoking part or all of a cigarette in the past 30 days before interview.
d No serious, moderate, or mild mental illness, serious psychological distress, or major depressive episode reported over the past year.
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Health Sciences Clinical Professor of Family Medicine
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NSDUH is an annual, national household survey of the civilian, noninstitutionalized US population aged 12 years or older. Data are collected through a combination of interviewer-administered questions and computer-assisted self-administered questions [11]. Our analysis was restricted to adults aged 18 years or older. Data were pooled across the 2019 and 2020 survey years to account for small sample sizes in stratified analysis. Participants who did not respond to the mental health questions or provide smoking status (n = 4), mental health condition questions alone (n = 301), or smoking status alone (n = 18) were excluded from analysis. We conducted our analysis from 2021 through 2022.
We based definitions of all mental health conditions on recoded variables in the NSDUH data set. Only those variables found in NSDUH were included in our analysis; therefore, we could not calculate current smoking prevalence for categories in the anxiety domain alone. Detailed NSDUH definitions of mental health disorders are available [11]. Because our focus was on mental health, substance use was not explored separately from mental health [8].
Past-year AMI was defined as having a diagnosable mental, behavioral, or emotional disorder other than developmental or substance use disorder, based on the Diagnostic and Statistical Manual of Mental Disorders–IV[11]. Serious mental illness, defined as a subset of estimates of AMI, was limited to participants with mental, behavioral, or emotional disorders that interfered substantially or limited one or more major life activities (eg, basic daily living skills; instrumental living skills; functioning in social, familial, and vocational context) with a Global Assessment of Functioning (GAF) score of ≤50 [11]. Mild or moderate mental illness was defined as having AMI in the past year and reporting mild to moderate impairment and a GAF score of ≥51 [12]. Serious mental illness and mild or moderate mental illness were included in AMI; however, serious mental illness and mild or moderate mental illness were mutually exclusive categories.
Past-year serious psychological distress was defined as a having a score of 13 or more of 24 on the Kessler Psychological Distress scale (eg, feeling nervous, feeling hopeless, feeling restless, feeling sad or depressed, feeling that everything was an effort, feeling down on yourself) during the month in the past year when they were at their worst emotionally [11].
Past-year major depressive episode — major depressive disorder — was based on having been classified as having had a major depressive episode in one’s lifetime and having experienced a period of depression or loss of interest or pleasure in daily activities lasting 2 weeks or longer in the past 12 months [11].
A person with serious psychological distress or major depressive disorder could be classified in any mental illness category (ie, serious mental illness or mild or moderate mental illness plus AMI). No mental illness reported in the past year included anyone who did not report AMI, serious psychological distress, or major depressive disorder in the past year.
Current smoking was defined as having smoked 100 or more cigarettes in one’s lifetime and smoking at least part or all of a cigarette in the 30 days preceding the interview. We calculated prevalence estimates overall for the past year for current smoking among adults with no AMI, serious psychological distress, or major depressive disorder in the past year; AMI; serious mental illness; mild or moderate mental illness; serious psychological distress alone; major depressive disorder alone; and both serious psychological distress and major depressive disorder. Estimates were further stratified by measures that included survey year, age, sex, sexual orientation, race or ethnicity, education, disability, annual household income, marital status, health insurance, employment status, metropolitan statistical area, and having been arrested and booked in the past year. State-level prevalence of current smoking by AMI status was reported by using 2-year (2019–2020) data from NSDUH’s restricted-use data analysis system (https://rdas.samhsa.gov/#/).
Data were weighted to adjust for survey nonresponse and to provide national and state-level representative estimates. We calculated prevalence estimates and corresponding symmetrical 95% CIs. Extent of disparity (absolute disparity) was calculated by using the absolute difference in the prevalence of smoking by AMI. Estimates with relative standard error greater than 30% were suppressed. SAS-callable SUDAAN software 11.0.3 (RTI International) was used to conduct all analyses.
