Exploring Stigma Among Lung Cancer Survivors: A Scoping Literature Review

Lisa A. Webb

Karen K. McDonnell

Swann A. Adams

Rachel E. Davis

Tisha M. Felder

lung cancer, stigma, smoking, scoping review, psychometrics
ONF 2019, 46(4), 402-418. DOI: 10.1188/19.ONF.402-418

Problem Identification: Lung cancer survivors face many challenges that affect their quality of life and survival. A growing concern is the layered effect of stigma related to cigarette smoking and the perceived life-threatening diagnosis of lung cancer. This experience may affect lung cancer survivors’ physical, psychological, and social well-being, negatively influencing their quality of life.

Literature Search: CINAHL®, PubMed®, PsycINFO®, and Web of Science were searched from January 2000 through August 2017, using combinations of four keywords: lung cancer, lung neoplasm, stigma, and smoking.

Data Evaluation: Extracted data included research aims, design, method, analytical approach, sample size, gender, ethnicity/race, setting, stigma measure, smoking status, and major results.

Synthesis: Of 163 studies initially identified, 30 (19 quantitative, 8 qualitative, 2 theoretical reviews, and 1 mixed method) were included. Quantitative studies were analyzed by statistical significance and relevant findings. Thematic analysis was used to evaluate qualitative studies.

Implications for Research: Future research should focus on the development and testing of tailored and multilevel interventions to support the management of stigma and lessen the negative impact it has on quality of life, with special considerations for vulnerable subpopulations.

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    Lung cancer is the second leading cause of cancer among adults, accounting for 27% of all cancer deaths in the United States (American Cancer Society [ACS], 2018; American Lung Association [ALA], 2018). Because of advances in screening practices, early detection, and improved treatments, lung cancer survival rates continue to slowly improve (ACS, 2018; de Moor et al., 2013). In 2018, the one- and five-year survival rates for lung cancer were 50% and 18%, respectively, up from 37% and 15% in 2013 (ACS, 2018; ALA, 2018).

    The Institute of Medicine (2013) reported that 14 million cancer survivors lived in the United States in 2012 and estimated that number to increase to 18 million by 2022. Survivorship is defined as the time from diagnosis to the end of life; the increasing number of cancer survivors, including lung cancer survivors, warrants examination of the challenges these survivors face, particularly stigma in the lung cancer population.

    Stigma is “an undesirable stereotype leading people to reduce the bearer from a whole and usual person to a tainted, discounted one” (Goffman, 1986, p. 3). Health-related stigma is the perception of possessing a trait that produces an unfavorable health outcome. For lung cancer, the health-related stigma is a perception that individuals diagnosed with lung cancer must be tobacco users, because tobacco use is the leading cause of lung cancer (Cataldo, Slaughter, Jahan, Pongquan, & Hwang, 2011). Cigarette smoking is viewed as a poor life choice, and individuals who make this choice are perceived as being responsible for their lung cancer diagnosis (Cataldo et al., 2011; Lehto, 2014). This perception stems from the U.S. Department of Health, Education, and Welfare (1964) report that heightened public awareness of the effects of tobacco use and its link to chronic illnesses. Subsequent reports have validated that groundbreaking finding and revealed more concerns regarding tobacco use that affect nonsmokers (U.S. Department of Health and Human Services, 2014). Pervasive antismoking initiatives have denormalized smoking, leading to smokers being blamed for diseases with which their behavior is linked (Bayer, 2008; Gielen & Green, 2015; Peretti-Watel, Legleye, Guignard, & Beck, 2014).

    Lung cancer survivors experience higher levels of psychological distress in comparison to other cancer survivors (Brown Johnson et al., 2015; Chambers et al., 2012; Chambers, Morris, et al., 2015; Chapple, Ziebland, & McPherson, 2004; Gonzalez & Jacobsen, 2012; Hamann et al., 2014). Stigma is thought to lead to further psychological distress, social isolation, and negative effects on physical and functional well-being (Brown Johnson et al., 2015; Cataldo et al., 2011; Chambers et al., 2012; Chambers, Baade, et al., 2015; Gonzalez & Jacobsen, 2012; Hamann et al., 2014).

    Although there is an acknowledgment of the negative ramifications related to lung cancer stigma, there are scant studies addressing possible interventions for oncology healthcare providers to assist with alleviating the widespread effect stigma imposes on lung cancer survivors. To date, existing research has evaluated lung cancer stigma and the impact it has on physical, social, and psychological challenges experienced by survivors. The examination of existing literature will not only assist with enhancing the conceptualization of lung cancer stigma but also identify gaps and provide suggestions for oncology practice and future research. The authors chose a scoping review to provide this direction. This review captures emerging knowledge, identifies areas where scientific advancement is needed, and assists with future development of interventions applicable to oncology practice that will mitigate stigma-induced distresses and improve quality of life (QOL).


    Using the process delineated by Arksey and O’Malley (2005), a scoping review was conducted of the stigma experience among lung cancer survivors. The five-step process involves the following:

    •  Identifying the research question

    •  Identifying relevant studies

    •  Selecting the studies

    •  Charting the data

    •  Summarizing the data and reporting results

    Following this process, pertinent research questions were identified and are as follows:

    •  How is lung cancer stigma measured?

    •  How can we fully describe the stigma lung cancer survivors face?

    •  How does lung cancer stigma affect survivors’ overall QOL?

    Existing research was delineated by the measures of lung cancer stigma, the scope and depth of stigma among adult lung cancer survivors, and the impact it has on QOL. Existing research was categorized and summarized. Clarification of the conceptual definition and identification of research gaps were reported, and suggestions of future paths for research were recommended (Peters et al., 2015).

    Identification of Relevant Research Studies

    CINAHL®, PubMed®, PsycINFO®, and Web of Science were used to identify research studies that were published from January 2000 through August 2017. Searches included four keywords (lung cancer or neoplasm, stigma, and smoking) in various combinations.

    Keywords could appear in the title, abstract, or body of the article. For an article to be included, it had to be published in English and in a peer-reviewed journal. The inclusion criteria also required that sample participants be aged 18 years or older and be survivors of small cell or non-small cell lung cancer. Studies included had to examine an outcome variable associated with lung cancer stigma, such as smoking status, depressive symptoms, and QOL. Studies that did not consider stigma associated with lung cancer as one of their aims were excluded from the review. Studies using both qualitative and quantitative research methodologies were included.

    A search across all four databases yielded 163 articles. Duplicate articles (n = 114) and non-research articles, commentary articles, and theoretical reviews (n = 48) were excluded. After making these exclusions, 30 relevant publications remained and were included in the review (see Table 1). Existing research was delineated, categorized, and summarized by the study methods, measures of lung cancer stigma, scope and depth of stigma among adult lung cancer survivors, and impact on QOL.

    Data Extraction, Analysis, and Synthesis

    Evaluated data included research aims, design, method, analytical approach, sample size, gender, ethnicity/race, setting, stigma measure, smoking status, and major results. Studies aimed to define internal, external, and perceived stigma and understand the health consequences and QOL impact that stigma has on lung cancer survivors.


    Reviewed Studies

    The four earliest studies were published from 2004 through 2009; the remaining 26 were published after 2011. A majority of studies (n = 17) were conducted in the United States. Others took place in Australia (n = 3), the United Kingdom (n = 3), Canada (n = 2), China (n = 2), and Korea (n = 1). The remaining two studies were literature reviews, one a systematic review and the other a meta-analysis. The U.S.-based studies evaluated lung cancer stigma in three different regions: the Northwest, Midwest, and Southeast. Study designs included analysis of covariates, correlational analysis, factor analysis, multiple linear regression, and repeated measures with interventions. Study participants were generally homogeneous in terms of Caucasian ethnicity and age range of 60–65 years.

    The studies’ aims included understanding the impact on QOL experienced by lung cancer survivors, specifically depression, guilt, shame, caregiver support, and patient–provider communication from the survivors’ perspectives. Not all studies reported smoking status of the participants. Studies that did reported a higher incidence of stigma among current and former smokers. Eight studies (Brown & Cataldo, 2013; Chapple et al., 2004; Hamann et al., 2014; Lehto, 2014; Liu et al., 2016; Rowland et al., 2016; Scott, Crane, Lafontaine, Seale, & Currow, 2015; Tod, Craven, & Allmark, 2008) used an exploratory approach with a qualitative design. This allowed researchers to capture participants’ perspectives on stigma, societal attitudes toward smoking and lung cancer, challenges related to stigma, and positive and negative results from the experience of stigma. In the included quantitative studies, investigators used survey instruments to measure lung cancer stigma, anger, anxiety, causal attribution, depression, QOL, self-blame, timing of medical help, diagnosis concealment, and patient–provider communication (Brown Johnson, Brodsky, & Cataldo, 2014; Carter-Harris & Hall, 2014; Carter-Harris, Hermann, Schreiber, Weaver, & Rawl, 2014; Cataldo et al., 2011, 2012; Chambers, Baade, et al., 2015; Criswell, Owen, Thornton, & Stanton, 2016; Else-Quest, LoConte, Schiller, & Hyde, 2009; Gonzalez & Jacobsen, 2012; Gonzalez et al., 2015; Hamann, Shen, Thomas, Craddock Lee, & Ostroff, 2018; Lebel, Castonguay, et al., 2013; Lebel, Feldstain, et al., 2013; LoConte, Else-Quest, Eickhoff, Hyde, & Schiller, 2008; Shen et al., 2015; Shen, Hamann, Thomas, & Ostroff, 2016; So, Chae, & Kim, 2017; Weiss et al., 2017; Yang, Liu, Yang, Ji, & Li, 2014). One systematic review (Chambers et al., 2012) assessed lung cancer stigma and its association with nihilism, health-related outcomes, and public health programs and included studies with medical professionals as participants along with studies focused on support programs. A meta-synthesis (Jeong, Jeong, & So, 2016) explored the experience of stigma among lung cancer survivors. Because of this review’s broad aims, seven qualitative research studies were included.

    Instruments Measuring Stigma

    To evaluate lung cancer stigma among survivors, researchers measured stigma and related constructs with six instruments across the 30 studies (see Table 2). The Cataldo Lung Cancer Stigma Scale (CLCSS) was used in nine studies. This 31-item instrument was adapted from Berger’s HIV Stigma Scale (Berger, Ferrans, & Lashley, 2001; Cataldo et al., 2011). The four factors that emerged from this instrument (stigma and shame, social isolation, discrimination, and smoking) represent perception, blame and shame from others, the feeling of social strain and judgment, and the responsibility of acquiring the disease. Carter-Harris and Hall (2014) conducted a psychometric analysis of this instrument and reduced the number of items to 21.

    LoConte et al. (2008) developed a six-item scale, the Perceived Cancer-Related Stigma Scale, derived from qualitative data obtained from lung cancer survivors’ focus group discussions. This instrument assessed self-blame, guilt, shame, and embarrassment among lung, breast, and prostate cancer survivors. Gonzalez and Jacobsen (2012) and Gonzalez et al. (2015) used the Social Impact Scale to measure the perception of stigma in relation to social rejection, financial insecurity, internalized shame, and social isolation. This scale assessed stigma in cancer populations and individuals diagnosed with HIV/AIDS. Shen et al. (2015) adapted the head and neck cancer Shame and Stigma Scale (SSS) for lung cancer survivors. The SSS assessed stigma, regret, and feelings of guilt and regret related to cigarette smoking.

    The Lung Cancer Stigma Inventory (LCSI) was developed by Hamann et al. (2018). This 25-item instrument was derived from the conceptual model of lung cancer stigma developed by Hamann et al. (2014). Three subscales emerged: perceived stigma, internalized stigma, and constrained disclosure. LCSI was psychometrically evaluated and had adequate internal consistency and convergent validity with related constructs. Lebel, Castonguay, et al. (2013) and Lebel, Feldstain, et al. (2013) both used the Explanatory Model Interview Catalogue. This semistructured interview was adapted into a 13-item questionnaire that explored stigma and illness disclosure and social rejection related to stigma. To date, there are two instruments (CLCSS and LCSI) to evaluate lung cancer stigma that have been psychometrically tested and proven to have adequate reliability and validity.

    Definitions of Lung Cancer Stigma

    The work of Goffman (1986) has been the most commonly used conceptualization of health-related stigma. His work laid the foundation for the initial conceptualization of stigma. He defined stigma as “an attribute that is deeply discrediting,” where the attribute in question is different from the normal status quo (Goffman, 1986, p. 3). A cancer diagnosis is often stigmatized because of a general misunderstanding or fear of cancer (Daher, 2012). Stigma can increase when a particular lifestyle or behavior is linked to the cancer (Cataldo et al., 2011; Lehto, 2014), such as lung cancer and cigarette smoking (ALA, 2018; Dela Cruz, Tanoue, & Matthay, 2011). Although Goffman (1986) provided the foundation, researchers have given meaningful but also different definitions and descriptions of lung cancer stigma. This is true even though associated constructs are in alignment with all descriptions and definitions of stigma and the overall effects it has on QOL among lung cancer survivors.

    Internal, external, and perceived stigma: Chapple et al. (2004), Hamann et al. (2014), Lebel, Feldstain, et al. (2013), and Shen et al. (2016) described stigma as having both internal (felt) and external (enacted) components. Felt stigma is internal to the survivor, like feelings of shame and guilt (Chapple et al., 2004; Lebel, Feldstain, et al., 2013). Qualitative studies by Chapple et al. (2004), Hamann et al. (2014), and Tod et al. (2008) reported that participants felt shame and guilt, which negatively affected seeking health care, social interaction, and support. Internalized feelings may manifest as negative outcomes, such as social isolation and depression. Enacted stigma is external to but directed toward the patient; it is stigma from others that produces an action (reaction or behavior), such as discrimination, blame, or social rejection (among other negative behaviors) (Chapple et al., 2004; Gonzalez & Jacobsen, 2012). Stigma also has been characterized as a perception that is felt both by the survivor and others (Brown Johnson et al., 2014; Cataldo et al., 2011, 2012; Criswell et al., 2016; Gonzalez et al., 2015). Perceived stigma is the negative association that survivors believe others have toward them and their cancer diagnosis (Brown & Cataldo, 2013; Cataldo et al., 2011; Chambers, Baade, et al., 2015; Lehto, 2014).

    The current study concludes that lung cancer stigma is a threefold complex concept that involves survivors’ perceptions, survivors’ internalized feelings, and feelings and actions of others toward survivors. There is often interplay among felt, enacted, and perceived stigma, amplifying or reinforcing the other stigmas. For example, lung cancer survivors are aware that others may believe that their cancer is self-inflicted through tobacco use, holding the patient responsible for the diagnosis. The anticipated blame, discrimination, and social rejection may lead to a sense of internal shame (Cataldo et al., 2011; Lehto, 2014).

    Health Consequences of Stigma

    Of the studies that reported smoking status (n = 23), lung cancer survivors felt some sense of responsibility for their disease, regardless of their smoking status (Brown & Cataldo, 2013; Cataldo et al., 2011, 2012; Else-Quest et al., 2009; Gonzalez et al., 2015; Shen et al., 2015). Current smokers experienced a higher level of guilt, shame, anxiety, and depression in comparison to former and never smokers (Cataldo et al., 2012; Else-Quest et al., 2009; LoConte et al., 2008). Former and current smokers also experienced a higher level of depression and anxiety in comparison to individuals with breast, colon, lung, stomach, cervical, and head and neck cancers (Lebel, Castonguay, et al., 2013; Lebel, Feldstain, et al., 2013; So et al., 2017). Further validation was reported (Cataldo et al., 2011, 2012; Gonzalez & Jacobsen, 2012) where there was a statistically significant strong positive association between stigma and depression in a study of lung cancer survivors. Brown Johnson et al. (2014) found significant statistical associations among lung cancer stigma, depression, and anxiety. Chambers, Morris, et al. (2015) introduced a cognitive behavioral intervention focused on lung cancer stigma in their pilot intervention study. They reported higher levels of depression, anxiety, and stigma preintervention, which significantly decreased postintervention.

    Stigma affects psychological challenges and complicates patient–provider communication (Brown & Cataldo, 2013; Brown Johnson et al., 2014, 2015; Cataldo et al., 2011; Chambers, Baade, et al., 2015; Gonzalez & Jacobsen, 2012; Hamann et al., 2014; Lehto, 2014; Shen et al., 2015; Yang et al., 2014). Brown and Cataldo (2013) explored the experiences of women with lung cancer and found that lung cancer stigma negatively affected the patient–provider relationship. Other studies reported strong associations between the presence of stigma and adverse outcomes of depression, anxiety, self-esteem, QOL, and patient–provider communication (Brown Johnson et al., 2014; Cataldo et al., 2012; Chambers, Baade, et al., 2015; Gonzalez et al., 2015; Gonzalez & Jacobsen, 2012; Lehto, 2014; Yang et al., 2014). Researchers also found that perceived and internalized stigma altered patients’ communication with their friends, families, and healthcare providers (Brown & Cataldo, 2013; Chapple et al., 2004; Hamann et al., 2014; Lehto, 2014).

    In their qualitative studies, Tod et al. (2008) and Scott et al. (2015) reported that blame, fear, and stigma all delayed seeking medical care. Carter-Harris et al. (2014) reported that lung cancer stigma was predictive of increasing the time to seeking care for lung cancer symptoms, which prolonged the time to diagnosis of lung cancer. Studies have reported that many lung cancer survivors are afraid of others’ reactions to their diagnosis (LoConte et al., 2008; Tod et al., 2008). Reactions of others may include discrimination by family, friends, and healthcare providers, which led some to conceal their diagnosis (Cataldo et al., 2011; Hamann et al., 2014; Shen et al., 2015). Gonzalez et al. (2015) found that internalized shame was a factor for those who did not disclose their diagnosis in comparison to those who did. Internalized shame and nondisclosure are two factors that validate the intertwining of the constructs related to lung cancer stigma. In addition, survivors reported experiencing feelings of isolation from friends and family as well as feelings of loneliness (Cataldo et al., 2011; Hamann et al., 2014). Gonzalez and Jacobsen (2012) evaluated depressive symptomology, including social support and its relationship with stigma. They reported an inverse relationship between social support and stigma experienced by participants in their research study (n = 95).


    This scoping review presents the results of 30 peer-reviewed studies that investigated stigma and lung cancer. The studies concentrated on the perspective of survivors and on the physical, psychological, and social influences on stigma. The findings present varied definitions of lung cancer stigma in terms of how this health-related stigma is experienced among survivors. Chapple et al. (2004) presented a foundational conceptualization that encompassed enacted stigma of others and internal and perceived feelings of lung cancer survivors. It is important to note that lung cancer stigma is a combination of awareness of social identity and survivors’ personal identity, which, in turn, leads to the awareness of potential negative actions of others. This combination may result in negative consequences for the survivors. Hamann et al. (2014) captured this in their conceptual model, which led to an instrument to measure the constructs of perceived/felt and internalized/self-stigma. Hamann et al.’s (2014) model with the incorporation of adaptive and maladaptive consequences contributed to this conceptualization.

    Lung cancer stigma stems from the link between cigarette smoking and the disease itself. LoConte et al. (2008) found that current or former smokers with lung cancer experienced a higher level of guilt, shame, and perceived stigma in comparison to women with breast cancer and men with prostate cancer. However, there is an association of lung cancer stigma among those who are never smokers. Cataldo et al. (2012) found a small difference in perceived stigma, depression, and QOL among ever and never smokers. This indicates that individuals with lung cancer experience altered QOL outcomes and depression, regardless of their history with tobacco use.

    Self-blame and guilt may affect the decision to seek and the timeliness of seeking medical care (Carter-Harris et al., 2014). Although lung cancer survivors cannot control others’ perceptions or behaviors, perceived stigma negatively affects their self-evaluation, internalizing the stigma. Gonzalez et al. (2015) and Webb and McDonnell (2018) found that some lung cancer survivors concealed their diagnosis from family, friends, and acquaintances. Concealment of a chronic illness linked with stigma fosters a lack of support and social isolation. This may lead to further devaluation of self and increase psychological challenges that may already exist among these survivors (Quinn, Weisz, & Lawner, 2017). Good healthcare provider communication has a direct impact on the level of internalized and perceived stigma. Communication between providers and survivors is vital for management of lung cancer, and positive communication identifies and supports the needs of lung cancer survivors. The quality and quantity of positive and beneficial communication between a healthcare provider and a survivor is associated with decreased lung cancer stigma (Shen et al., 2016). When survivors perceive blame, responsibility, or fatalism, positive communication is hindered. This may lead to delay in seeking medical assistance when needed and conceal symptoms that need assessment and management.

    Although this review summarizes and synthesizes substantial evidence of lung cancer stigma, knowledge gaps remain. Certain subpopulations of lung cancer survivors are underrepresented. African Americans, Pacific Islanders, and Native Americans have higher incidence and mortality rates among all populations diagnosed with lung cancer (ACS, 2018). Only five studies had samples with adequate African American representation (Carter-Harris et al., 2014; Criswell et al., 2016; Gonzalez et al., 2015; Hamann et al., 2014; Shen et al., 2016). No study had adequate representation of Pacific Islanders and Native Americans. Never smokers, who constitute 20% of individuals diagnosed with lung cancer (ACS, 2018), were not adequately represented in half of the studies. Further research is needed involving vulnerable populations, given the increased risk of negative outcomes for those living with lung cancer.

    This scoping literature review focused on stigma from the viewpoint of lung cancer survivors; however, exploration of the perceptions of family members, friends, caregivers, and healthcare providers is needed. A better understanding of how stigma affects family members, friends, and caregivers may assist with developing strategies to support and help survivors moderate stigma, which would improve survivors’ QOL. Another area that warrants investigation is the influence of antismoking campaigns, both on survivors’ internalization of lung cancer stigma and perceptions of family, friends, and healthcare providers.

    Lung cancer stigma affects a growing population of cancer survivors. Advancing knowledge about stigma can improve the care and QOL of this population. Developing effective education programs, awareness campaigns, and interventions can assist lung cancer survivors with the negative consequences of stigma.


    To the authors’ knowledge, this is the first scoping review to synthesize evidence from quantitative and qualitative studies relative to lung cancer survivors and stigma. For this reason, a scoping review was conducted rather than a systematic review or metasynthesis. This review evaluated research on lung cancer stigma, determined the extent and type of research conducted to date, and identified gaps in this research area (Arksey & O’Malley, 2005). Despite best efforts to uncover all relevant literature, the authors cannot disregard the possibility that some studies may not have been identified. Lastly, the authors did not limit this review to a specific methodology. The diversity of methods may have interfered with the ability to make accurate inferences related to lung cancer stigma.

    Implications for Nursing

    Oncology nurses play a significant role in the lives of lung cancer survivors and their family members and friends. To provide patient-centered care, it is essential for oncology nurses to understand the harmful impact of stigma. Developing strategies to promote meaningful communication with providers is essential for survivors and their family members, friends, and caregivers. In clinical settings, oncology nurses can advocate for improved communication and an evaluation of stigma to assist with planning individualized care. Advocating for the development and implementation of interventions that target outcomes related to decreasing physical and psychological burdens and social isolation is warranted. Although instruments have been developed for the evaluation of lung cancer stigma, more research is needed to develop practical strategies to measure these constructs and develop interventions to minimize negative effects.


    Additional investigations examining lung cancer stigma are imperative to improve patient-centered health care and QOL for lung cancer survivors. Research should focus on capturing specific experiences of stigma among subpopulations and amass the formative data that support the development of tailored interventions for the most vulnerable subpopulations of lung cancer survivors. Such data will assist with decreasing the experience and consequences of stigma for all lung cancer survivors.

    About the Author(s)

    Lisa A. Webb, PhD, RN, CEN, is a faculty member in the VA Nursing Academic Partnership at the Ralph H. Johnson VA Medical Center in Charleston, SC, and Karen Kane McDonnell, PhD, RN, OCN®, is an assistant professor in the College of Nursing, Swann Arp Adams, PhD, MS, is an associate professor in the College of Nursing and Arnold School of Public Health, Rachel E. Davis, PhD, is an assistant professor in the Department of Health Promotion, Education, and Behavior in the Arnold School of Public Health, and Tisha M. Felder, PhD, MSW, is an assistant professor and director of Diversity, Equity, and Inclusion in the College of Nursing and core faculty in the Cancer Prevention and Control Program in the Arnold School of Public Health, all at the University of South Carolina in Columbia. This study was funded by a 2018 Research Doctoral Scholarship from the Oncology Nursing Foundation Endowment and the Sigma Gamma Omicron at-Large Chapter. Manuscript content is solely the responsibility of the authors and does not necessarily represent the official view of the Oncology Nursing Society or Sigma Gamma Omicron at-Large Chapter. All authors contributed to the conceptualization and design and the manuscript preparation. McDonnell and Webb completed the data collection. Adams provided statistical support. Webb, McDonnell, Davis, and Felder provided the analysis. Webb can be reached at, with copy to (Submitted June 2018. Accepted December 11, 2018.)



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