International Journal of Inflammation

International Journal of Inflammation / 2015 / Article

Research Article | Open Access

Volume 2015 |Article ID 439396 |

Sami Aldaham, Janet A. Foote, H.-H. Sherry Chow, Iman A. Hakim, "Smoking Status Effect on Inflammatory Markers in a Randomized Trial of Current and Former Heavy Smokers", International Journal of Inflammation, vol. 2015, Article ID 439396, 6 pages, 2015.

Smoking Status Effect on Inflammatory Markers in a Randomized Trial of Current and Former Heavy Smokers

Academic Editor: Andrew S. Day
Received30 Jan 2015
Revised03 Aug 2015
Accepted06 Aug 2015
Published23 Aug 2015


Background. The level of systemic inflammation as measured by circulating levels of C-reactive protein (CRP) and interleukin-6 (IL-6) is linked to an increased risk for cardiovascular diseases (CVD) and cancer. Methods. We recruited 154 current and former smokers between 40 and 80 years of age with 25 or more pack-years of smoking history to study the relationship between inflammatory markers (CRP and IL-6) and smoking status. Results. Our results show that male smokers had significantly higher levels of serum IL-6 compared to male former smokers. We did not find any gender specific differences for smoking and CRP levels but the IL-6 levels were slightly lower in females compared to males. Additionally, our results show that CRP is significantly associated with IL-6 regardless of smoking status. Modelling indicates that the significant predictors of CRP levels were biomarkers of the metabolic syndrome while the significant predictors of IL-6 levels were age and plasma triglycerides among former smokers and the numbers of smoked packs of cigarettes per year among smokers. Conclusions. In conclusion, our study showed that CRP levels were not associated with markers of smoking intensity. However, IL-6 levels were significantly associated with smoking especially among current smokers.

1. Introduction

Inflammation is associated with a number of chronic conditions, such as cardiovascular disease and cancer. Reducing inflammation may help prevent or treat these conditions. C-reactive protein (CRP) and interleukin-6 (IL-6) are well-studied proinflammatory cytokines [1, 2]. Inflammation is part of our immune reaction and leads to the release of C-reactive protein (CRP) into the bloodstream [3, 4] and IL-6 is a major factor driving the chronic elevation of CRP [5]. Elevated levels of IL-6 are predictive of future adverse health events in both healthy and clinical populations, even after controlling for both lifestyle and other clinical risk factors [69].

Smoking is the major risk factor for lung cancer, the most common cancer worldwide. Cigarette smoking has been associated with increases in CRP and previous investigations have demonstrated that increased CRP levels are a secondary effect of cigarette smoking and reflect tissue injury [10, 11]. The potential significance of IL-6 and CRP has been suggested in the growth and progression of many malignancies [1214]. Many large-scale epidemiological studies among apparently healthy men and women have found CRP to be an independent and strong predictor of future cardiovascular risk [1517].

There is great interest in studying the relationship between inflammatory markers and smoking in an attempt to provide explanations for smoking-mediated morbidity and mortality. The current study is unique with the inclusion and comparison of verified former smokers with a similar smoking history (pack-years and years of smoking) to the current smokers. The profile of inflammation markers is expected to differ following smoking cessation. Therefore, we are reporting here the associations of CRP and IL-6 with smoking status among community-dwelling men and women.

2. Methods

Current smokers (CS) and former smokers (FS) between 40 and 80 years of age with 25 pack-years or more of smoking history were recruited to a randomized, double-blind, and placebo controlled chemoprevention trial of green tea and black tea. The study protocol received approval by the University of Arizona Institutional Review Board. Once informed consent had been obtained, each participant completed a set of smoking, dietary, and health assessment questionnaires and was evaluated for health and respiratory history. A blood sample was collected for a comprehensive metabolic panel. Two additional fasting morning blood samples were collected from which plasma, serum, buffy coat, and erythrocytes were isolated and stored at −80°C prior to the sample analysis. Body mass index (BMI) for each participant was calculated as weight divided by height2 (kg/m2).

2.1. Human C-Reactive Protein (CRP) Immunoassay and Interleukin-6 (IL-6) Immunoassay in Serum

Aliquots were thawed immediately prior to the analysis. Each immunoassay was completed using a commercially available kit from Quantikine (R & D Systems, Minneapolis, MN, USA). Briefly, specified quantities of the specimen or standard are added to microplates with cells precoated with the CRP antibody or the IL-6 antibody, depending on the assay. The antibodies bind the CRP or IL-6 present in the samples and standards. Any unbound substances are washed away and a monoclonal antibody specific for CRP or a polyclonal antibody specific for IL-6 is added. Again, unbound substances are washed away, substrate solution is added, the plate is incubated, and amplifier solution is added. Color develops in proportion to the amount of CRP or IL-6 present in the well and after stopping the color development in the prescribed time, the wells are measured spectrophotometrically for CRP or IL-6 quantification. Both CRP and IL-6 analyses were completed in duplicate for 154 participants. All data entry and values were checked by additional laboratory personnel for quality control.

2.2. Statistical Analysis

Means and standard errors were calculated for descriptive statistics. Because of value skewness, CRP and IL-6 values were log-transformed. Pearson correlations were calculated to describe the unadjusted relationships between the smoking parameters, inflammatory markers, and other relevant variables. Multivariable linear regression models were created to identify independent predictors of log (CRP) and log (IL-6), using variables that had significant correlations () with these inflammatory markers. A basic model was created for each inflammatory marker that included age, sex, BMI, caloric intake, triglycerides, high-density lipoprotein cholesterol, years of smoking, and cigarette pack-years (cigarettes smoked daily 20 cigarettes per pack × years of smoking).

3. Results

3.1. Population Characteristics

One hundred and fifty-four current and former smokers (83 women and 71 men) with a mean age of 60.3 ± 0.7 years (mean ± SE) were included in the study. Characteristics of the study population by gender and smoking status are presented in Table 1. There were no significant differences between males and females except in reported pack-years among current smokers. Male smokers reported significantly greater pack-years of smoking compared to females (). While the cumulative exposure smoking index of pack-years was not significantly different between current and former smokers among males or females, former smokers reported significantly fewer years of smoking compared to current smokers in both genders ().


mean ± SE

mean ± SE
(males versus females)

Age (years) 60.8 ± 1.059.9 ± 1.00.54
 Former smokers62.4 ± 1.560.9 ± 1.40.45
 Current smokers59.5 ± 1.359.2 ± 1.40.89
   value (former versus current)0.140.40
Pack-year45.6 ± 2.640.7 ± 1.90.12
 Former smokers41.1 ± 3.444.6 ± 3.50.49
 Current smokers49.2 ± 3.737.7 ± 1.90.004
   value (former versus current)0.120.07
Years of smoking34.4 ± 1.132.6 ± 1.20.28
 Former smokers29.5 ± 1.527.6 ± 1.60.39
 Current smokers38.4 ± 1.336.4 ± 1.50.33
   value (former versus current)<0.0010.001

2 test.
3.2. Inflammation Biomarkers

The differences in the levels of the biomarkers of inflammation and blood lipids between smokers and former smokers are presented in Table 2 for both men and women separately. Male current smokers had significantly higher levels of serum IL-6 compared to male former smokers. Women (smokers and former smokers) had significantly higher levels of HDL compared to men.

= 71  
mean ± SE
= 83  
mean ± SE
p value
(males versus females)

Serum C-reactive protein7.4 ± 0.137.4 ± 0.110.66
 Former smokers7.2 ± 0.207.3 ± 0.160.58
 Current smokers7.6 ± 0.177.4 ± 0.160.27
   value (former versus current)0.100.87
Serum interleukin-60.67 ± 0.100.43 ± 0.100.09
 Former smokers0.44 ± 0.140.33 ± 0.130.57
 Current smokers0.86 ± 0.130.50 ± 0.140.08
   value (former versus current)0.040.40
Total cholesterol (mg/dL)193.2 ± 5.1206.2 ± 4.00.04
 Former smokers189.5 ± 6.7204.6 ± 5.50.08
 Current smokers196.1 ± 7.6207.3 ± 5.70.23
   value (former versus current)0.520.74
High density lipoproteins (mg/dL)47.0 ± 1.561.5 ± 1.6<0.001
 Former smokers47.1 ± 2.359.0 ± 2.70.002
 Current smokers47.0 ± 1.963.4 ± 1.9<0.001
   value (former versus current)0.990.17
Low density lipoproteins (mg/dL) 114.0 ± 4.2119.7 ± 3.60.30
 Former smokers111.8 ± 5.3118.9 ± 4.60.32
 Current smokers116.8 ± 1.9120.4 ± 5.30.67
   value (former versus current)0.990.83
Total triglycerides (mg/dL) 175.0 ± 18.5139.5 ± 7.10.06
 Former smokers165.4 ± 18.6142.5 ± 11.20.28
 Current smokers182.9 ± 30.3137.3 ± 9.20.12
   value (former versus current)0.640.71

Log transformed data for C-reactive protein and interleukin-6.

Given the fact that there were no significant differences by gender, the correlations among CRP, IL-6, smoking intensity parameters, and other variables are presented by smoking status in Table 3. Log (CRP) and log (IL-6) were significantly correlated regardless of smoking status (). Log (CRP) was not associated with any marker of smoking intensity. Among former smokers, log (CRP) was significantly associated with BMI (, ) and low HDL levels (, ). Among smokers, log (IL-6) was significantly associated with age (, ), years of smoking (, ), pack/years (, ), plasma triglycerides (, ), and low HDL levels (, ). The log (CRP) was only associated with age (, ).


Interleukin-6 (pg/mL)
 Former smoker0.3870.0001.000
 Current smoker 0.5890.0001.000
Age (years)
 Former smoker0.1610.1400.1980.067
 Current smoker0.2700.0260.4460.000
Years of smoking
 Former smoker0.0810.4610.2020.062
 Current smoker0.0170.8890.2420.047
 Former smoker0.1360.2120.3130.003
 Current smoker0.0280.8230.2560.033
Caloric intake/day
 Former smoker0.2060.0650.0140.904
 Current smoker0.0920.4740.0540.677
Total fat intake (g/day)
 Former smoker0.1730.1260.0070.951
 Current smoker0.0900.4880.1240.338
Total cholesterol (mg/dL)
 Former smoker0.0240.8250.0240.829
 Current smoker0.1340.2750.0860.484
HDL-C (mg/dL)
 Former smoker−0.2730.011−0.2070.056
 Current smoker−0.1310.287−0.2900.017
LDL-C (mg/dL)
 Former smoker0.0280.7990.0720.517
 Current smoker0.1820.1410.0610.623
Total triglycerides (mg/dL)
 Former smoker0.1680.1230.1340.220
 Current smoker0.1960.1100.2680.028
BMI (kg/m2)
 Former smoker0.2870.0070.1290.236
 Current smoker0.2030.1000.1300.299

CRP: C-reactive protein; HDL-C = high density lipoproteins; LDL-C: low density lipoproteins; BMI: body mass index.
Log transformed data for CRP (ng/mL) and IL-6 (pg/mL).
Significant correlation.
3.3. Models of CRP and IL-6 by Smoking Status

The multivariate predictors of inflammatory markers by smoking status are presented in Table 4. The best multivariable model for log (CRP) among former smokers included triglycerides () and the interaction between CRP and IL-6 () and the best multivariable model for log (CRP) among current smokers included HDL (), BMI (), and the interaction between CRP and IL-6 (). The best multivariable model for log (IL-6) among former smokers included triglycerides (), age (), and the interaction between CRP and IL-6 () and the best multivariable model for log (IL-6) among current smokers included pack/year () and the interaction between CRP and IL-6 ().

SubjectsExplanatory variableAdjusted

CRP (mg/L)
 Former smokersTotal triglycerides0.4960.009 0.455
CRP IL-6<0.0010.000
 SmokersHDL-C (mg/dL)−0.0170.010 0.369
BMI (kg/m2)0.0280.052
CRP IL-6<0.0010.000
IL-6 (pg/mL)
 Former smokersTotal triglycerides0.4420.002 0.547
CRP IL-6<0.0010.000
 SmokersPack/year0.0120.005 0.436
CRP IL-6<0.0010.000

CRP: C-reactive protein; IL-6: interleukin 6; HDL-C: high density lipoprotein; BMI: body mass index, and CRP IL-6: interaction between CRP and IL-6.
Variables included in the model are gender, age, BMI, total triglycerides, HDL-C, years of smoking, pack/year, caloric intake/day, and interaction between CRP and IL-6.

4. Discussion

In the current study among participants with more than 30 pack-years of smoking exposure, we did not find any significant difference in CRP levels between smokers and former smokers. However, the serum levels of IL-6 were significantly higher among male smokers compared to former smokers (). Exposure to cigarette smoke increases oxidative stress which may lead to vascular inflammation. Because of the possible link between smoking and the initiation of inflammatory pathways, a large number of studies in which serum CRP concentrations have been measured in parallel to smoking status have been published in recent years [24, 10, 16]. However, some of these studies provided conflicting results [18]. The complexity of cytokine-mediated inflammation is described in a study showing that although smoking status was associated with a significant elevation in IL-6 levels, the increase in CRP levels observed in smokers was not statistically significant [19]. Another study indicated that mean CRP levels were significantly lower in never-smokers () compared to current smokers [20]. One study conducted in people of Japanese ethnicity did not find any significant relationship between serum CRP levels and the number of cigarettes smoked per day [4].

The MONICA study from Germany examined gender specific differences for smoking and CRP levels, finding that serum CRP concentrations were significantly higher in male regular smokers than male never-smokers but no significant differences were observed in women [21]. In our study we did not find any gender specific differences for smoking and CRP levels but the IL-6 levels were slightly lower in females compared to males. Also, women had significantly higher levels of HDL compared to men. In addition, our results showed that among smokers, CRP was associated with age while IL-6 was significantly associated with age, smoking variables as measured by years of smoking and number of pack-years, and dyslipidemia as measured by low HDL and high triglycerides levels.

There is strong evidence that IL-6 serum concentration increases with age [22, 23] and it is associated with an increased risk of cardiovascular disease (CVD) mortality, independent of CRP level [24]. Our data showed that the significant predictors of IL-6 levels among former smokers were age and plasma triglycerides. Among smokers, the smoking intensity as measured by the number of smoked packs of cigarettes across the number of years smoked was the main predictor of IL-6 high levels.

Smoking cessation lowers risk for lung and other cancer types along with reducing the risk of coronary heart disease, stroke, and peripheral vascular disease [25]. Inflammation is a key pathological component in these disease processes. Yet in this study among heavy smokers (mean of almost 43 packs per year for 33 years), CRP levels did not differ between former and current smokers. Additionally, former smoker IL-6 levels were significantly lower than the level among current smokers only among the males. These results suggest that CRP levels and IL-6 levels may not be the primary modulators of health improvements following cessation. Alternatively, intense smoking (high frequency over multiple decades) may have more longstanding effects on some types of inflammation. Our CRP results are consistent with results of Asthana et al. among smokers with a similar three-decade history of smoking but with half the pack-years [26].

Numerous studies have now confirmed that CRP levels are elevated in patients with the metabolic syndrome. CRP levels were shown to be strongly associated with BMI, low HDL, triglycerides, and levels of the proinflammatory cytokine, IL-6 [6, 27, 28]. Our results that showed that CRP levels were significantly influenced by HDL, triglycerides, and IL-6 levels support a potential relationship between CRP levels and the metabolic syndrome.

In conclusion, our data supports previous studies that showed that serum CRP is associated with biomarkers of the metabolic syndrome but not with smoking. However, serum IL-6 levels are mainly affected not only by the metabolic syndrome but also by age and smoking status.


(i)We conducted a cross-sectional study on a sample of 154 current and former smokers.(ii)We investigated the relationship between inflammatory biomarkers and smoking status.(iii)CRP levels were significantly associated with IL-6 levels regardless of smoking status.(iv)The significant predictors of CRP levels were biomarkers of the metabolic syndrome.(v)IL-6 levels were significantly associated with smoking especially among current smokers.

Conflict of Interests

The authors declare no conflict of interests.


This work was partially supported by a grant (DOD PR 023104) from the Department of Defense.


  1. M. Y. Abeywardena, W. R. Leifert, K. E. Warnes, J. N. Varghese, and R. J. Head, “Cardiovascular biology of interleukin-6,” Current Pharmaceutical Design, vol. 15, no. 15, pp. 1809–1821, 2009. View at: Publisher Site | Google Scholar
  2. V. Pasceri, J. T. Willerson, and E. T. H. Yeh, “Direct proinflammatory effect of C-reactive protein on human endothelial cells,” Circulation, vol. 102, no. 18, pp. 2165–2168, 2000. View at: Publisher Site | Google Scholar
  3. B. G. Nordestgaard and J. Zacho, “Lipids, atherosclerosis and CVD risk: is CRP an innocent bystander?” Nutrition, Metabolism and Cardiovascular Diseases, vol. 19, no. 8, pp. 521–524, 2009. View at: Publisher Site | Google Scholar
  4. M. Ohsawa, A. Okayama, M. Nakamura et al., “CRP levels are elevated in smokers but unrelated to the number of cigarettes and are decreased by long-term smoking cessation in male smokers,” Preventive Medicine, vol. 41, no. 2, pp. 651–656, 2005. View at: Publisher Site | Google Scholar
  5. R. Roubenoff, T. B. Harris, L. W. Abad, P. W. E. Wilson, G. E. Dallal, and C. A. Dinarello, “Monocyte cytokine production in an elderly population: effect of age and inflammation,” Journals of Gerontology—Series A Biological Sciences and Medical Sciences, vol. 53, no. 1, pp. M20–M26, 1998. View at: Google Scholar
  6. S. Cheng, A. Lyass, J. M. Massaro, G. T. O'Connor, J. F. Keaney Jr., and R. S. Vasan, “Exhaled carbon monoxide and risk of metabolic syndrome and cardiovascular disease in the community,” Circulation, vol. 122, no. 15, pp. 1470–1477, 2010. View at: Publisher Site | Google Scholar
  7. W. B. Ershler and E. T. Keller, “Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty,” Annual Review of Medicine, vol. 51, pp. 245–270, 2000. View at: Publisher Site | Google Scholar
  8. J. A. Nettleton, L. M. Steffen, E. J. Mayer-Davis et al., “Dietary patterns are associated with biochemical markers of inflammation and endothelial activation in the Multi-Ethnic Study of Atherosclerosis (MESA),” American Journal of Clinical Nutrition, vol. 83, no. 6, pp. 1369–1379, 2006. View at: Google Scholar
  9. P. M. Ridker, N. Rifai, M. J. Stampfer, and C. H. Hennekens, “Plasma concentration of interleukin-6 and the risk of future myocardial infarction among apparently healthy men,” Circulation, vol. 101, no. 15, pp. 1767–1772, 2000. View at: Publisher Site | Google Scholar
  10. J. Danesh, R. Collins, P. Appleby, and R. Peto, “Association of fibrinogen, C-reactive protein, albumin, or leukocyte count with coronary heart disease: meta-analyses of prospective studies,” Journal of the American Medical Association, vol. 279, no. 18, pp. 1477–1482, 1998. View at: Publisher Site | Google Scholar
  11. M. Miller, M. Zhan, and S. Havas, “High attributable risk of elevated C-reactive protein level to conventional coronary heart disease risk factors: the third National Health and Nutrition Examination Survey,” Archives of Internal Medicine, vol. 165, no. 18, pp. 2063–2068, 2005. View at: Publisher Site | Google Scholar
  12. M. Groblewska, B. Mroczko, U. Wereszczyńska-Siemia̧tkowska et al., “Serum interleukin 6 (IL-6) and C-reactive protein (CRP) levels in colorectal adenoma and cancer patients,” Clinical Chemistry and Laboratory Medicine, vol. 46, no. 10, pp. 1423–1428, 2008. View at: Publisher Site | Google Scholar
  13. M. Hara, Y. Matsuzaki, T. Shimuzu et al., “Preoperative serum C-reactive protein level in non-small cell lung cancer,” Anticancer Research, vol. 27, no. 4, pp. 3001–3004, 2008. View at: Google Scholar
  14. D.-K. Kim, S. Y. Oh, H.-C. Kwon et al., “Clinical significances of preoperative serum interleukin-6 and C-reactive protein level in operable gastric cancer,” BMC Cancer, vol. 9, article 155, 2009. View at: Publisher Site | Google Scholar
  15. J. Danesh, P. Whincup, M. Walker et al., “Low grade inflammation and coronary heart disease: prospective study and updated meta-analyses,” British Medical Journal, vol. 321, no. 7255, pp. 199–204, 2000. View at: Publisher Site | Google Scholar
  16. M. A. Mendall, D. P. Strachan, B. K. Butland et al., “C-reactive protein: relation to total mortality, cardiovascular mortality and cardiovascular risk factors in men,” European Heart Journal, vol. 21, no. 19, pp. 1584–1590, 2000. View at: Publisher Site | Google Scholar
  17. M. Roivainen, M. Viik-Kajander, T. Palosuo et al., “Infections, inflammation, and the risk of coronary heart disease,” Circulation, vol. 101, no. 3, pp. 252–257, 2000. View at: Publisher Site | Google Scholar
  18. D. G. Yanbaeva, M. A. Dentener, E. C. Creutzberg, G. Wesseling, and E. F. M. Wouters, “Systemic effects of smoking,” Chest, vol. 131, no. 5, pp. 1557–1566, 2007. View at: Publisher Site | Google Scholar
  19. J. Helmersson, A. Larsson, B. Vessby, and S. Basu, “Active smoking and a history of smoking are associated with enhanced prostaglandin F2α, interleukin-6 and F2-isoprostane formation in elderly men,” Atherosclerosis, vol. 181, no. 1, pp. 201–207, 2005. View at: Publisher Site | Google Scholar
  20. S. G. Wannamethee, G. D. O. Lowe, A. G. Shaper, A. Rumley, L. Lennon, and P. H. Whincup, “Associations between cigarette smoking, pipe/cigar smoking, and smoking cessation, and haemostatic and inflammatory markers for cardiovascular disease,” European Heart Journal, vol. 26, no. 17, pp. 1765–1773, 2005. View at: Publisher Site | Google Scholar
  21. M. Fröhlich, M. Sund, H. Löwel, A. Imhof, A. Hoffmeister, and W. Koenig, “Independent association of various smoking characteristics with markers of systemic inflammation in men: results from a representative sample of the general population (MONICA Augsburg survey 1994/95),” European Heart Journal, vol. 24, no. 14, pp. 1365–1372, 2003. View at: Publisher Site | Google Scholar
  22. L. Ferrucci, A. Corsi, F. Lauretani et al., “The origins of age-related proinflammatory state,” Blood, vol. 105, no. 6, pp. 2294–2299, 2005. View at: Publisher Site | Google Scholar
  23. T. B. Harris, L. Ferrucci, R. P. Tracy et al., “Associations of elevated interleukin-6 and C-reactive protein levels with mortality in the elderly,” American Journal of Medicine, vol. 106, no. 5, pp. 506–512, 1999. View at: Publisher Site | Google Scholar
  24. J. K. Lee, R. Bettencourt, D. Brenner, T.-A. Le, E. Barrett-Connor, and R. Loomba, “Association between serum interleukin-6 concentrations and mortality in older adults: the Rancho Bernardo Study,” PLoS ONE, vol. 7, no. 4, Article ID e34218, 2012. View at: Publisher Site | Google Scholar
  25. US Department of Health and Human Services, How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Ga, USA, 2010.
  26. A. Asthana, H. M. Johnson, M. E. Piper, M. C. Fiore, T. B. Baker, and J. H. Stein, “Effects of smoking intensity and cessation on inflammatory markers in a large cohort of active smokers,” American Heart Journal, vol. 160, no. 3, pp. 458–463, 2010. View at: Publisher Site | Google Scholar
  27. A. Festa, R. D'Agostino Jr., G. Howard, L. Mykkänen, R. P. Tracy, and S. M. Haffner, “Chronic subclinical inflammation as part of the insulin resistance syndrome: the insulin resistance atherosclerosis study (IRAS),” Circulation, vol. 102, no. 1, pp. 42–47, 2000. View at: Publisher Site | Google Scholar
  28. P. M. Ridker, C. H. Hennekens, J. E. Buring, and N. Rifai, “C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women,” The New England Journal of Medicine, vol. 342, no. 12, pp. 836–843, 2000. View at: Publisher Site | Google Scholar

Copyright © 2015 Sami Aldaham et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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