# What are the effects of smoke-free and tobacco-free university campus policies, and how can they be assessed? A systematic review

Etienne Gnonlonfin, Diane Geindreau, Karine Gallopel-Morvan

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Etienne Gnonlonfin, Diane Geindreau, Karine Gallopel-Morvan. What are the effects of smoke-free and tobacco-free university campus policies, and how can they be assessed? A systematic review. Journal of Epidemiology and Population Health, 2024, 72 (2), pp.202520. 10.1016/j.jeph.2024.202520. hal-04557508

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Original article

# What are the effects of smoke-free and tobacco-free university campus policies, and how can they be assessed? A systematic review

Etienne Gnonlonfin*, Diane Geindreau, Karine Gallopel-Morvan

Univ Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS - U 1309, 35000, Rennes, France

<figure><img src="image_2.png" /></figure>

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## ARTICLE INFO

**Article History:**

Received 6 November 2023

Accepted 28 February 2024

Available online 4 April 2024

**Key words:**

Smoke-free policy

Smoking prevention

Program evaluation

Young adults

Smoke-free/tobacco-free campus

## ABSTRACT

**Objective:** This article looks at the evaluation of smoke-free (SF) and tobacco-free (TF) university campus policies that ban smoking (and often vaping) both indoors and outdoors. To assess the effectiveness of these policies, we performed a systematic literature review to answer the following questions: what is the effect of SF/TF policies on campus users' behaviors/norms/perceptions around smoking? Are the SF/TF policies an effective measure for reducing smoking among young adults? What methods and indicators can we use to assess the impact of SF/TF campus policies? What is the theoretical model underpinning the influence of SF/TF policies on the behavior of campus users?

**Methods:** Three databases (PubMed, Scopus, and Web of Science) were searched over the period from January 2005 to December 2022. The article selection process included 54 articles published in scientific journals that analyzed the post-implementation impact of SF/TF campus policies. The quality of these articles was analyzed using six ad hoc indicators based on the Critical Appraisal Skills Program checklist and Joanna Briggs Institute scoping tools.

**Results:** Most of the research on SF/TF campus policies has been conducted in the United States using quantitative methodologies. Most of these studies show that SF/TF policies reduce positive beliefs about smoking and its acceptability, influence smoking behavior (reducing smoking initiation and increasing the number of quits and quit attempts), and reduce exposure to passive smoking and pollution from cigarette butts. User acceptability of SF/TF policies is generally high. Limitations of SF/TF campus policies include difficulty for smokers to comply with them, persistence of passive smoking around campuses, and limited uptake of on-campus cessation support services provided to smokers.

**Discussion:** The various mediating and moderating variables identified in the literature have made it possible to propose a model of the potential influence of SF/TF policy on campus users, based on the theory of planned behavior. Based on this review, we provide health professionals and higher education institutions wishing to implement a SF/TF campus policy with a set of indicators that can serve to assess the impact of a SF/TF campus policy (attitudes, acceptability, beliefs, norms, exposure to passive smoking and pollution, changes in smoking behavior).

**Conclusion:** Based on scientific evidence, the implementation of SF/TF campus policies in France is an important measure to help combat smoking in young adults.

© 2024 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-

ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

## 1. Introduction

Smoking is the leading cause of avoidable deaths in France, which registers around 75,000 smoking-related deaths a year [1]. In 2022, 24.5 % of French people aged 18–75 said they smoked daily [2], and the figure rises to 28.3 % in 18–24 year-olds [3]. These prevalence rates are high compared with other countries (7.1 % of 18–24-year-olds in Australia [4] and 13.2 % in the UK [5]). This raises the question

of what preventive measures France needs to deploy to protect young people from smoking.

Here we assess the impact of smoke-free (SF) campus policies that ban smoking (i.e. cigarettes, cigars) on the entire campus (inside buildings, in housing, and also outside: on the grounds, in car parks) and tobacco-free (TF) campus policies that prohibit all forms of tobacco and nicotine products (i.e. e-cigarettes, snus) anywhere on campus. Beyond these measures, SF/TF campus policies also feature other components, such as cessation services, educational campaigns, and enforcement strategies (with ambassadors and fines) [6]. Prompted by the fact that 98 % of smokers start before the age of 26 [7], the American College Health

<footnote>* Corresponding author at: Ecole des Hautes Etudes en Santé Publique, 15 avenue Professeur Léon-Bernard - CS74312 35043 Rennes cedex, France.
E-mail address: mahouna.gnonlonfin@ehesp.fr (E. Gnonlonfin).</footnote>
Association advocated SF/TF policies in the United States in 2009 [8], and SF/TF campus policies have since garnered wide adoption. Out of about 5900 higher education campuses listed in 2021, 2614 had banned tobacco and 2274 had banned all tobacco and nicotine products as of 2023 [9,10].

In France, smoking is prohibited in enclosed workplaces and public places, including universities [11]. The second National Program for Tobacco Control (2018–2022) [12] has expanded to encompass non-smoking outdoor areas (parks, beaches, hospitals). The third National Program for Tobacco Control (2023–2027) promotes further adoption of smoke-free campuses [13]. There is no reliable data available to provide an overview for French SF universities. As the third Program aims to develop them, further studies are needed to assess whether SF/TF campus policies are effective in reducing smoking. It is the aim of this paper. Here we performed a systematic review of the scientific literature evaluating the post-implementation impact of SF/TF campus policies, in order to answer the questions:

- What is the impact of SF/TF campus policies on smoking behavior, norms, perceptions, etc. among campus users?

- Are SF/TF campus policies an effective measure for reducing smoking among young adults?

- Based on the scientific literature, what is the theoretical model underpinning the influence of SF/TF campus policies on smoking behavior among campus users?

- How is the impact of SF/TF campus policy assessed: using what indicators, what methodologies?

## 2. Method

We conducted this systematic review using the PRISMA method [14]. Three databases (PubMed, Scopus, and Web of

Science) were searched over the period from January 2005 (when SF/TF campus policies first appeared in the United States) to December 2022, using the keyword search string “tobacco-free” OR “smoke free” AND “campus*” OR “university*” OR “college” AND “policy*”. The rationale for choosing these keywords was that nature of Scopus and Web of Science are largely multidisciplinary (including humanities and social sciences, biology, health sciences, arts, etc.) whereas PubMed is more specialized in medicine and public health. In addition to this search, we also screened the references cited in the articles identified and used Google Scholar (reading through the first 30 pages and alerts created) to complete the initial list.

The inclusion criteria for relevant articles were: 1) articles presenting the results of a post-deployment evaluation of the impact of SF/TF policies on students, employees and visitors or on the campus environment (air quality, etc.); 2) publications in English or French; 3) articles using quantitative, qualitative, or mixed methodologies (thus ruling out descriptive articles and reflections on the evaluation of SF/TF policies).

The exclusion criteria were: 1) articles where the SF/TF policy evaluated was not clearly defined and/or only partially smoke-free; 2) articles on process evaluation rather than impact evaluation; 3) articles evaluating smoke-free places other than universities (home, workplace); 4) systematic or narrative reviews (included in the discussion, but not in this systematic review); 5) records not published in peer-reviewed scientific journals (bulletins, conference papers, posters).

Based on these criteria, 733 articles were identified, and 330 duplicates removed. After reading the titles and abstracts, 292 articles were excluded as they were not directly related to SF/TF policies. The 111 articles retained were then read in full, which led to 57 being removed as they did not evaluate the post-implementation impact of SF/TF policies. Ultimately, 54 articles were included in this literature review (Fig. 1).

<figure><img src="image_3.png" /><figcaption>**Fig. 1.** PRISMA flow diagram of the selection process for articles on the impact of smoke-free/tobacco-free university campus policies.</figcaption></figure>
The 54 articles selected were tabulated in an Excel© file giving the names of the authors, publishing journal, year of publication, country where the evaluation was carried out, a description of the study, the evaluation method used, the results obtained, and the limitations of the study.

The quality of these articles was analyzed using six *ad hoc* indicators based on the Critical Appraisal Skills Program (CASP) checklist [15] and Joanna Briggs Institute [16] scoping tools. The criteria used assessed the aim of the study, sample size and recruitment strategy, study design, method for data analysis, study limitations, and ethics approval (Appendix 1). Each of the 54 articles was then independently scored from 0 to 6 on these indicators by two researchers. If disagreement emerged (which was the case for 7 articles), a third researcher read the papers and a discussion was held to reach a consensus score. Unanimous consensus was achieved for 3 of the 7 articles, and the coding adopted by the majority of researchers was used for the remaining 4 articles. At the end of the process, the rate of agreement (inter-rater reliability) on all the quality indicators for the articles selected was 98.76 % (Cohen's k = 0.92).

## 3. Results

The majority of the 54 articles concerned the evaluation of SF/TF campus policies in the United States. Of these 54 articles, 36 assessed the impact of the policy after implementation, and 18 were before-and-after assessments, using mainly quantitative methods (Table 1, Appendix 2).

### 3.1. Overall quality of the 54 articles

All the studies were assessed for risk of bias (Appendix 1). Mean quality score for the 54 articles was 5.38 out of 6, i.e. a high level of quality. Mean quality score was 5.40 for quantitative studies, 5.25 for qualitative studies, and 5.33 for mixed-method studies. The weaknesses identified concerned a lack of precision in the method of recruiting respondents, the software and the analyses carried out, and whether or not the qualitative material was double-coded.

### 3.2. Effect of SF/TF campus policy on user attitudes, acceptability and satisfaction

Thirty articles assessed the effect of SF/TF campus policy on 1) attitudes and acceptability: users' agreement with and support for the policy; 2) attitudes toward smoking: feelings about smoking (positive and negative), perceptions of health risks from active and passive smoking, etc.; 3) satisfaction with the policy: perceived fairness and effect, accessibility to smoking areas, etc.

The vast majority of research showed that SF/TF policies decrease positive attitudes toward smoking and have good acceptability [17–41]. Eleven studies showed that acceptability and support for SF/TF policies improve over time (at 3 months, 1 year, 3 years, 5 years) with students [18,19,29,39,42,43], employees [20,28,30,42], and users in general [17,44]. One study found a high level of satisfaction with the SF/TF campus in general, due to less discomfort from second-hand smoke at building entrances [45]. Support from SF/TF policy users is important as it is associated with negative perception of smoking on campus [38], better knowledge of the risks and waste associated with cigarettes [24,39], and positive perceived effectiveness of SF/TF policies on users' health [37].

Some rare studies showed that SF/TF campus policies trigger opposition from smokers and ex-smokers [33,40,41,46], particularly because they stigmatize smokers and infringe individual freedoms [37].

### 3.3. Effect of SF/TF policy on campus users' knowledge and perceptions

Nineteen articles assessed the effect of SF/TF policies on understanding, knowledge and perceived effectiveness of the policy and knowledge of the risks associated with smoking and vaping.

Seven studies showed that a large majority of students [25,27,43] and users [23,46] were aware that they worked in a SF/TF campus but about half of them had little knowledge of the related rules (difficulty identifying areas where smoking is permitted/prohibited) and cessation support services made available [47]. Four studies showed that smokers and ex-smokers are more aware than non-smokers of the SF/TF campus policy [17,26,35,45]. Four studies indicated that SF/TF policies are perceived as effective by students [29,48], employees [22] and users [37] at reducing smoking and exposure to second-hand smoke, encouraging people to stop smoking, and protecting health. One study found that SF/TF policies do not increase students' knowledge of the risks of smoking [49]. Four studies showed that SF/TF policies reduce positive beliefs about smoking among students [19,27,36] and users [50] (e.g. beliefs about the harmful effects of smoking, the effectiveness of SF/TF campus policy, and beliefs about using nicotine for weight loss).

### 3.4. Effects of SF/TF campus policy on social norms

Five articles evaluated the effect of SF/TF campus policies on social norms regarding smoking. The results show that once implemented, SF/TF campus policies increase social disapproval of smoking among students [18,38] and employees [22,38]. Furthermore, over time, students become more inclined to intervene with peers who break SF/TF policy rules and to encourage them to comply [31,36].

<table><caption>**Table 1**
Countries studied and evaluation methods used in the 54 articles selected.</caption><thead><tr><th>Country</th><th>Saudi Arabia</th><th>Israel</th><th>Japan</th><th>South Korea</th><th>Lebanon</th><th>Australia</th><th>United States</th><th>Total</th></tr></thead><tbody><tr><td><strong>Following implementation of the SF/TF campus</strong></td><td><strong>1</strong></td><td><strong>1</strong></td><td><strong>1</strong></td><td><strong>1</strong></td><td></td><td><strong>3</strong></td><td><strong>29</strong></td><td><strong>36</strong></td></tr><tr><td>Mixed Method</td><td></td><td></td><td></td><td></td><td></td><td>1</td><td>4</td><td>5</td></tr><tr><td>Qualitative method</td><td></td><td></td><td></td><td></td><td></td><td></td><td>4</td><td>4</td></tr><tr><td>Quantitative method</td><td>1</td><td>1</td><td>1</td><td>1</td><td></td><td>2</td><td>21</td><td>27</td></tr><tr><td><strong>Before and after implementation of the SF/TF campus</strong></td><td></td><td></td><td></td><td></td><td><strong>2</strong></td><td><strong>1</strong></td><td>15</td><td>18</td></tr><tr><td>Mixed Method</td><td></td><td></td><td></td><td></td><td></td><td></td><td>1</td><td>1</td></tr><tr><td>Quantitative method</td><td></td><td></td><td></td><td></td><td>2</td><td>1</td><td>14</td><td>17</td></tr><tr><td><strong>Total</strong></td><td><strong>1 (2%)</strong></td><td><strong>1 (2%)</strong></td><td><strong>1 (2%)</strong></td><td><strong>1 (2%)</strong></td><td><strong>2 (4%)</strong></td><td><strong>4 (7%)</strong></td><td><strong>44 (81%)</strong></td><td><strong>54 (100%)</strong></td></tr></tbody></table>
### 3.5. Effects of SF/TF campus policy on behavior and behavioral intentions

Thirty-four articles used surveys and direct observation to evaluate the effect of SF/TF policy measures on smoking behavior (prevalence, initiation, cutting down, cessation), compliance with SF/TF policy, use of the cessation support services offered, and student enrolment at the university.

Fifteen studies found that SF/TF campus policies are associated with a reduction in smoking prevalence that increases over time [17–19,21,22,28,29,38,43,51–56]. For example, one study showed a greater increase in smoking cessation in the second year of SF/TF campus policy compared with the first year [57]. In addition, students on SF/TF campuses smoke less cigarillos, cigars and hookahs [32]. Note that while a majority of smokers at a SF/TF campus express an intention to stop smoking, only a minority actually do so [17,21,30,36]. In terms of reducing consumption, both staff and students at a SF/TF campus smoke less than those at a smoking campus [18]. Ohmi et al. [21] added that none of the ex-smokers surveyed cited the SF/TF campus policy as their main motivation for quitting smoking, and they concluded that while SF/TF campus policy initiatives are effective at reducing tobacco consumption, they are insufficient, on their own, to bring about cessation. In terms of smoking initiation, one study found that SF/TF campus users showed a decrease in experimentation with smoking but an increase in initiation of vaping [57]. Four studies found increased e-cigarette use among students in an SF/TF campus [28,32,49,56] but one study found decreased e-cigarette use among employees [38].

Compliance with SF/TF policy remains a challenge, as only three studies found that most smokers comply with policy [29,30,51] whereas 12 found that most smokers do not [20,21,23,34,46,58–64]. Non-compliance could be explained by users' under-awareness of the policy [65].

Few studies have analyzed the use of cessation support services offered by SF/TF campus policies, but they all find that smokers make little use of these aids [30,43].

Finally, it has been shown that adoption of a SF/TF campus policy had no influence on student enrolment levels at universities [43,66].

### 3.6. Effects of SF/TF campus policy on the environment

Twelve articles analyzed the impact of SF/TF campus policies on exposure to second-hand smoke and on in-air concentrations of PM2.5 mm particulates (measured with an aerosol monitor) at building entrances or in the vicinity of the campus. The results indicate that while SF/TF campus policies reduce self-reported exposure to passive smoking [17,19,26,31,32,39,42,48,51,52, 58,67], air quality is degraded in the vicinity of campuses (where users smoke more).

Seven articles analyzed the effect of SF/TF campus policies on pollution by measuring the number of cigarette butts found on the ground and by interviewing users. They found that SF/TF campus policies helped to reduce the number of cigarette butts thrown on the ground, thereby leaving the campus environment cleaner and improving the quality of the air breathed [22,30,37,53,68–70].

### 3.7. Effects of SF/TF campus policy on financial costs

To measure the impact of SF/TF campus policies on university finances, researchers assessed the actual and perceived costs to employees of cleaning up cigarette butts. One study concluded that

SF/TF campus policies generate savings because they reduce the cost of cleaning up discarded cigarette butts and deploying ashtrays [37]. More than a third of employees believe that SF/TF policy saves the university money [22].

### 3.8. Factors moderating the effects of SF/TF campuses

Smoking status has an influence on the effects of SF/TF campus policy: acceptability of SF/TF campuses is higher among non-smokers [24,39,41,44] than smokers or ex-smokers [21,24,32,38,41], and women are more supportive of SF/TF campus policies than men [20,33,36,39,40,42]. A handful of studies have shown that university staff (teachers, researchers) are more supportive of SF/TF campus policy than students [37], that smoking by parents and peers and exposure to tobacco marketing reduces support for SF/TF campus policies [24], that living on-campus [58] and frequent alcohol consumption [59] have a negative influence on compliance with SF/TF policy, and that younger people have a better chance of quitting smoking than older people during SF/TF policy implementation [57].

## 4. Discussion

This systematic literature review examined the effectiveness and public health benefits of implementing an SF/TF campus policy to reduce smoking. It brings four main contributions and completes previous reviews published on this topic in 2015, 2020 and 2021 [65,71,72,73].

First, it has updated previous reviews by integrating 13 new articles published between January 2021 and December 2022. Second, whereas Bardus et al. [65] included articles that cover the evaluation of both process and impact, here we focused exclusively on post-impact evaluation assessing the effectiveness of ST/TF on smoking behaviors and attitudes. Third, whereas Lupton & Townsend [71], Mohmad & Ismail [72] and Dilliot [73] included papers that analyzed variables related to attitudes, smoking behaviors, social norms, and exposure to second-hand smoke, here we went further by incorporating studies that focused on broader variables liable to influence behavioral change (i.e. users' satisfaction, users' action to ensure compliance on SF/TF campus policy). Fourth, previous reviews did not propose a theoretical framework to explain how SF/TF campus policy can impact smoking behaviors. Here we addressed this gap by proposing a model based on the theory of planned behavior (TPB) [74] that integrates all the variables identified in the literature, and by suggesting new variables that should be tested in future research (see Fig. 2 further down).

To sum up the results, our review shows that SF/TF campus policies are effective because they reduce pro-tobacco beliefs, reduce the acceptability of smoking in a place of education, and denormalize smoking. The acceptability of SF/TF policies is quite high overall and is found to increase over time. SF/TF campus policies reduce smoking initiation, exposure to passive smoking and on-campus pollution (cigarette butts), and increase smoking cessation. However, the literature points to certain limitations of SF/TF campuses: SF/TF policies are not always properly enforced, do not reduce exposure to second-hand smoke around campuses (where campus users go to smoke), and increase vaping. In addition, any cessation aids provided on campus are rarely used.

Despite their overall quality, the 54 articles included suffer from certain limitations. First, information on how long SF/TF campus policies had been deployed prior to evaluation was sometimes lacking (whereas the literature shows that acceptability
<figure><img src="image_4.png" /><figcaption>**Fig. 2.** Model of the influence of smoke-free/tobacco-free campus policy on users' behaviors (based on the theory of planned behavior)</figcaption></figure>

increases over time). Second, included papers did not state whether there had been a national decrease in tobacco consumption between implementation of the SF/TF campus policy and a later SF/TF policy assessment. However, any concurrent decline in national prevalence of smoking among young people/the general population would also explain a declining rate of smoking among SF/TF campus students/users. Third, most of the studies used questionnaires to evaluate SF/TF policies, whereas qualitative methodologies are more relevant to fully understand how complex interventions such as SF/TF policies work and how they influence behavior [75].

Our review highlights that certain topics have received little or no attention and need to be explored in further research. For example, what sanctions or measures would improve compliance with SF/TF campus policy? Existing studies focused mainly on financial sanctions, which would appear ill-suited to French culture [76]. Campus ambassadors [77] and/or a cross-community approach (where all users are encouraged and trained to enforce the policy) [78,79] make interesting options that have not yet been properly evaluated. The effect of components of SF/TF campus policy (cessation services, educational campaigns, enforcement strategies, etc.) on users' smoking behaviors have rarely been assessed [65] and warrant greater attention. More research is also needed to determine whether prohibiting vaping on campus has an impact on smoking initiation among young non-smokers (i.e. the gateway effect)[80] and on smoking cessation by smokers. Furthermore, cessation services increase the chances of quitting smoking [81], but they are rarely used by smokers in SF/TF campuses. It is therefore important to identify the barriers to uptake of on-campus cessation services and to test more student-

adapted cessation aids [84]. Finally, deeper analysis is needed on the economic impact of an SF/TF campus policy (i.e. saved costs of cleaning up cigarette butts, less absenteeism among employees who smoke [82], etc.) and on SF/TF policy impact on quality of life at work.

To conclude our review, we propose a theoretical model based on the TPB [74,83] that helps understand how SF/TF campus policy can influence smoking behaviors. The TPB posits that health behaviors are influenced by: 1) attitude towards the recommended behavior (beliefs about its consequences/benefits); 2) subjective norms (beliefs about social referents' expectancies around the behavior); and 3) perceived behavioral control (perceived ease or difficulty adopting the behavior). The TPB also includes individual and contextual factors. We integrated indicators identified in the literature into the three categories of the TPB, and added new ones specific to the TPB that should be tested in future research (Fig. 2).

## 5. Conclusion

This systematic review finds that SF/TF campus policy holds relevancy as a public health measure. We thus recommend developing SF/TF campuses in France, with attention paid to the weaknesses identified in the literature (such as policy compliance and under-use of the on-campus cessation support). It is also important for higher education establishments to assess the impact of the policy deployed, using the impact indicators and methodologies presented in Table 2.

<footnote>* Variables in underlined italics are variables proposed in our TPB model but that have not yet been tested in research.</footnote>
<table><caption>**Table 2**
Which indicators can be used to evaluate SF/TF campus policies?</caption><thead><tr><th colspan="2">Indicators to be measured</th></tr></thead><tbody><tr><td><strong>Knowledge and perceptions</strong></td><td>Knowledge of:<br/>- harm caused by tobacco products<br/>- benefits of stopping smoking<br/>- the SF/TF campus policy and its rules<br/>- the effectiveness of cessation aids</td></tr><tr><td><strong>User attitudes, acceptability and satisfaction</strong></td><td>- Attitudes towards smoking and second-hand smoke<br/>- Acceptability of the SF/TF campus policy and its rules<br/>- Satisfaction with working and studying at a SF/TF campus</td></tr><tr><td><strong>Subjective norms</strong></td><td>- Social acceptability of smoking<br/>- Social support for smoking cessation<br/>- User engagement to ensure compliance with the SF/TF campuses</td></tr><tr><td><strong>Smoking intentions and behaviors</strong></td><td>- User compliance with SF/TF campus policy and rules<br/>- Use of cessation aids available on-campus<br/>- Motivation to quit<br/>- Attempts to quit<br/>- Successful quitting<br/>- Reducing tobacco consumption<br/>- Vaping and nicotine substitutes (with the aim of stopping smoking and reducing risks)<br/>- Reduction in smoking initiation<br/>- Stopping ex-smokers relapsing after quitting</td></tr><tr><td><strong>Other indicators</strong></td><td>- On-campus exposure to second-hand tobacco smoke<br/>- Campus cleanliness (cigarette butts)<br/>- Financial costs (cleaning, absenteeism)<br/>- Student enrolment rates at the SF/TF campus university</td></tr><tr><td colspan="2"><strong>Methods</strong></td></tr><tr><td colspan="2">- Questionnaires<br/>- Semi-structured interviews/focus groups<br/>- Observations on compliance<br/>- Analysis of comments on the university's social networks<br/>- PM2.5 measurement (air quality)<br/>- Mapping the density of cigarette butts on campus (photos, collection and counting of butts)</td></tr></tbody></table>

## Authors' contributions

Etienne Gnonlonfin conducted the literature review and analysis. D. Geindreau conducted the PRISMA search. Etienne Gnonlonfin and D. Geindreau selected the articles on smoke-fee/tobacco-free policy assessment and tabulated the quality of the articles. Etienne Gnonlonfin and K. Gallopel-Morvan drafted the paper. D. Geindreau critically reviewed the paper and suggested corrections.

## Declaration of Competing Interest

We certify that all co-authors have validated the article as submitted and the choice of journal, and that they have no conflicts of interest.

## Funding

This research was funded by the French National Cancer Institute (project PRODEVCAMPUS INCa/16312). Etienne Gnonlonfin is funded by the French National League Against Cancer (doctoral grants). The funders did not contribute to the writing of the article nor to the collection or analysis of the data.

## Supplementary materials

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.jeph.2024.202520.

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