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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 27  |  Issue : 4  |  Page : 384-390

Knowledge and risk perception of e-cigarettes and hookah amongst youths in Lagos State, Nigeria: An exploratory study


1 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
2 Department of Community Health and Primary Care, College of Medicine, University of Lagos; Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
3 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria

Date of Submission12-Aug-2020
Date of Decision25-Aug-2020
Date of Acceptance04-Oct-2020
Date of Web Publication04-Nov-2020

Correspondence Address:
Prof. Akin Osibogun
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_261_20

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  Abstract 


Introduction: Limited research exists describing young people's knowledge and risk perception of e-cigarettes and hookah in Nigeria. This qualitative study explored the knowledge and risk perception of e-cigarettes and hookah amongst young people in Lagos, Nigeria. Methods: Participants (n = 20), aged 15–24 years who had used e-cigarettes or hookah at least once in the past 12 months, participated in three focus group (FG) discussions in January 2020. Each FG session consisted of 6–7 participants, was facilitated by a trained moderator and lasted approximately 60 min. Sessions were recorded, and notes were taken after informed consent. Recordings were transcribed verbatim and analysed using NVIVO 10 software. Results: An essential element of our findings was that the majority of the participants seemed to be more aware of hookah and used hookah compared to e-cigarettes. The participants mentioned they used these tobacco products mainly to reduce stress, for pleasure and for social acceptance. Most of the study participants reported that they were aware of some adverse health effects associated with e-cigarette or hookah use. Although some participants felt that the use of e-cigarettes or hookah could transform to cigarette smoking, many felt that e-cigarette was a harm reduction tool. Conclusion: Young users of e-cigarettes and hookah continue to use these products though they are aware of some associated adverse health effects. These products are used primarily for relieving stress and for social reasons. Raising awareness of the risks associated with the use of these tobacco products may help to reduce the acceptability of these products amongst youths.

Keywords: E-cigarettes, hookah, knowledge, risk perception, tobacco, youth


How to cite this article:
Osibogun O, Odukoya OO, Odusolu YO, Osibogun A. Knowledge and risk perception of e-cigarettes and hookah amongst youths in Lagos State, Nigeria: An exploratory study. Niger Postgrad Med J 2020;27:384-90

How to cite this URL:
Osibogun O, Odukoya OO, Odusolu YO, Osibogun A. Knowledge and risk perception of e-cigarettes and hookah amongst youths in Lagos State, Nigeria: An exploratory study. Niger Postgrad Med J [serial online] 2020 [cited 2020 Nov 24];27:384-90. Available from: https://www.npmj.org/text.asp?2020/27/4/384/299914




  Introduction Top


Globally, tobacco use remains a preventable cause of disease and death.[1] The prevalence of tobacco use amongst youth aged 10–24 years ranges from 0.2% to 32.5% in Nigeria.[2] While there are currently no published data on the prevalence of e-cigarettes and hookah use in Nigeria, research from the 2008 Global Youth Tobacco Survey conducted in five major cities in Nigeria showed higher prevalence of other tobacco products (13.1%–23.3%) compared to that of cigarette smoking (6.2%–2.6%) amongst youth aged 13–15 years.[3] Numerous studies in the United States and other parts of the world show that tobacco use is often established in adolescence.[4],[5],[6] Tobacco products contain an addictive substance nicotine, and the exposure of a young person's developing brain to nicotine tends to alter his/her reward system, thereby predisposing him/her to nicotine dependence.[4],[7] Studies show that following exposure to nicotine, adverse consequences in cognitive ability, mental health and personality behaviours tend to occur in young people due to distortion of the maturation processes of the brain.[8],[9] Tobacco use amongst young people also predisposes them to risky behaviours such as illicit drugs, binge drinking and gambling.[10] Youth experimentation with an addictive product can lead to a lifetime of nicotine dependence.

Although there has been a steady decline in tobacco use globally, in recent years, alternate tobacco products such as electronic cigarettes, 'e-cigarettes', and waterpipe, 'hookah', have been increasing in popularity amongst young people.[11],[12] The attractiveness, social appeal and perceived reduced harm of these alternate tobacco products are likely contributory to their popularity.[5],[13],[14] The aggressive marketing of the tobacco industry may also contribute to the increasing popularity of these products.[13],[14] Furthermore, these products often come with flavour options, which are particularly attractive to young people.[15]

Research examining tobacco use amongst young people has been documented in Nigeria. However, the majority of these studies have focused primarily on cigarette use.[16],[17] With the emergence of e-cigarettes and hookah as tobacco products, there is a need to explore the use of these relatively new products amongst young people in Nigeria. Thus, we aimed to examine the knowledge and risk perception of e-cigarette and hookah amongst a sample of young users of these products in Lagos, Nigeria, using a qualitative approach. The exploratory qualitative approach allows us to better understand the personal perspectives of young people's knowledge and perception of e-cigarettes and hookah. The present study aimed to address the following questions: what do young people know about e-cigarettes and hookah? Why do young people think people use e-cigarettes and hookah? What health effects do young people know are associated with using these products? Findings from this study can provide the foundation for future studies on e-cigarette and hookah for effective tobacco control in Nigeria.


  Methods Top


The present study's aim was to capture participants' own knowledge and perception of e-cigarettes and hookah; therefore, we used an approach similar to the grounded theory approach[18],[19] which focuses on the social process and context.[20] While we identified broad research questions a priori, we did not develop theories, or hypotheses a priori, but the findings were grounded in the data obtained from the study participants.

Study population

Participants (n = 20) aged 15–24 years who had used e-cigarettes or hookah at least once in the past 12 months were recruited via purposive sampling from tobacco retail outlets, bars and colleges by flyers for the focus groups (FGs) in Lagos, Nigeria. Different sample sizes have been proposed in qualitative research using FGs; some recommend a sample size of three to four FGs[21] and group size ranging from 4 to 12 participants.[22]

Data collection

Participants were recruited from areas surrounding the University of Lagos, Nigeria, by a trained female resident doctor (YO) with assistance from resident doctors. The university area was used as a reference because the anti-smoking laws in Lagos prohibit all forms of tobacco smoking in public places with the exclusion of university campuses.[23] The interviews were conducted in January 2020. Following recruitment, participants who met the inclusion criteria were gathered in a serene environment and distributed into three FGs of 6–7 participants. The facilitator and resident doctors introduced themselves, the study objectives were briefly explained to participants and consent was obtained from eligible participants before each FG discussion (FGD) was conducted. Participants' first names and ages were collected and recorded. A unique identifier was given to the participants, which was used during the FGDs. The participants were assured of the confidentiality of their participation and discussions in the FG sessions. Each FG session lasted approximately 60 min and was facilitated by a moderator. Discussions were audio-recorded, and a member of the research team took note of participants' responses. The participants were compensated with light refreshments only. Approval for this study was obtained from the Health Research and Ethics Committee of the College of Medicine, University of Lagos (CMUL/HREC/05/19/525).

Measures

A semi-structured moderator's guide was used to facilitate consistent discussion across the FG sessions (Supplementary material). The participants were asked questions about the knowledge of e-cigarettes and hookah, such as 'what they know about e-cigarettes and/or hookah?' and the 'advantages or disadvantages of e-cigarettes or hookah use'. Next, they were asked questions about the perception of e-cigarettes and hookah use, including what they felt would have made people use these tobacco products and questions on the adverse health effects of these products. They were asked if they felt that these products would enable the transition to cigarette use. Then, they were asked questions related to tobacco cessation. At the end of the FG sessions, the participants were provided with information on the harms of using e-cigarettes and hookah, including resources such as websites where they can be better informed on the harmful effects of these tobacco products.

Data analysis

The audio-recordings were transcribed verbatim according to our predefined research questions and checked for accuracy with the notes. Transcripts were imported with field notes into NVIVO 10 software (QSR International, Melbourne, Australia), which facilitated data organisation and management. Quotes were analysed for similarities and differences. Then, we conducted a narrative analysis as previously described[24] based on our predefined themes (i.e., knowledge of tobacco, perception of tobacco use and tobacco cessation). Comments regarding terminology in order for comprehension include the terms 'hookah' and 'shisha', which were used interchangeably. The present study followed the guideline of the Consolidated Criteria for Reporting Qualitative Research[25] [Supplementary Material].


  Results Top


[Table 1] shows the overall descriptive characteristics of the twenty study participants included in this qualitative study. The ages of the participants ranged from 16 to 24 years (mean 20.4 years), and five of the participants were female. Across the FGs, the age range at first tobacco use was 12–22 years (mean 15.9 years) [Table 1].
Table 1: Participants' characteristics (n=20)

Click here to view


Findings are structured according to the predefined research questions. Quotes are used as examples relevant to the theme. Age and sex accompany the corresponding quotes with the group number indicated in brackets.

Knowledge of tobacco

Types of tobacco products

All participants in the FGs mentioned cigarettes as a type of tobacco product, with eight participants also mentioning 'shisha' as a type of tobacco product. The majority of the participants reported that they sourced their tobacco products from 'mallams' or 'abokis'. Other sources of tobacco products mentioned were bars, clubs, stores and friends. Of the participants, majority stated that they had ever tried or experimented with hookah, while few mentioned that they had experimented or tried e-cigarettes [Table 1].

Knowledge about e-cigarettes and hookah

A few of the participants reported flavours as one of the popular reasons for e-cigarette or hookah use. Some mentioned that they liked to use tobacco products because it made them feel cool and calm vibes and provided relief from feelings of depression. A couple of the participants mentioned that using tobacco products made them 'slow'. A participant mentioned that e-cigarettes and hookah were a substitute for regular cigarettes.

'More advanced substitute to regular cigarettes. The reason I prefer both is that they do not have a smell. Started smoking both at 16. Shisha is not handy unlike e-cigarettes which are portable, basically that's it I don't really have anything I dislike.'

a 23-year-old male (FG 2).

Perception of tobacco use

Accessibility/challenges/cost or e-cigarettes

Most of the participants felt that the tobacco products were readily accessible to them via supermarkets, pharmacies or online. Money was a challenge in obtaining these tobacco products for six of the participants; others felt that it was affordable. Many of the participants did not know how much an e-cigarette cost, but the ranges provided were from 5000 to 20,000 naira (≈$12.9–$51.5). Some of the participants said that it depended on where one purchased the product.

Advantages and disadvantages of use

Participants discussed the advantages and disadvantages of e-cigarette and hookah use. Some of the participants reported that using hookah made one feel relaxed and forget their worries. Participants in the third FG discussed mainly on the use of e-cigarette to reduce addiction.

'E-cigarettes is used to reduce addiction but its harmful and addictive'

a 21-year-old female (FG 3).

Participants felt that despite the advantages that these tobacco products gave to the user, it was detrimental to one's health as some mentioned, it was detrimental to one's liver and lungs. In particular, a participant mentioned that sharing the mouthpiece of hookah could lead to infections.

'I don't feel there is any advantage, however, I feel sharing the mouthpiece of the pipe can lead to infections'

– a 23-year-old male (FG 2).

Opinion about who used the tobacco products and reason for use

Most of the participants said those who used these tobacco products did so because of peer pressure.

Health effects associated with the use/harmful to self or others

Most participants agreed that tobacco use could affect their liver, lungs and heart. Some even mentioned that users were liable to die young. An interesting quote from one of the participants in the study concerned the quantity and frequency of tobacco use.

'Tobacco is harmful to health. Health effects depend on the frequency and quantity. If you take it within limits, it should cause no harm'

– a 24-year-old male (FG 2).

A participant felt there was a need to create awareness regarding the harmful effects of shisha (hookah).

'Both are harmful. Shisha has a higher tendency to cause lung cancer. Need to create awareness for people to drop it.'

– a 17-year-old female (FG 2).

Opinion about e-cigarettes or hookah enabling the transition to cigarettes

Most of the participants felt that e-cigarettes or hookah made transitioning to cigarettes easier. Some of the participants felt that as e-cigarette reduces addiction, it also helps to transition to cigarette use:

'The same way e-cigarette reduces addiction people who start with e-cigarette can transit to smoking.'

– a 20-year-old male (FG 3).

E-cigarette as a harm reduction tool

Most participants felt that e-cigarette was a harm reduction tool. An interesting thought most participants voiced was concerning the lack of smoke, the presence of vapour and the fact that it was a more advanced tool.

'Yes, it is because the tobacco is vaporised as compared to proper cigarettes'.

– a 24-year-old male (FG 2).

'I feel technology finds a way to make things better so I think it reduces the harm'.

– a 21-year-old male (FG 1).

Social acceptability/advantage

Some of the study participants felt that using these tobacco products provided a social advantage, not necessarily more or fewer friends. Others thought that for men, it tended to attract more friends.

'Because people who smoke are cut across a wide spectrum. I think people who smoke it's just part of their life. In social gathering it will make you look cool. It doesn't make them have more or less'

– a 21-year-old male (FG 1).

Others felt that even if it brought friends, they would not be 'true' friends, just friends with benefits for the short term, particularly for the duration of use, for example, when smoking hookah in a social gathering.

Tobacco use first thing in the morning

Only one participant mentioned using e-cigarettes first thing in the morning, but not every morning. When asked about a strong desire to smoke again, some of the participants mentioned that they used tobacco when they wanted to, that it was by choice.

Tobacco cessation

Aware of any programme or process that helps with quitting tobacco

Participants underestimated the addictive nature of tobacco use and felt that they could choose to quit smoking at any time with little difficulty. Most were unaware of any programmes that assisted with quitting tobacco. However, few of the participants mentioned that there were rehabilitation centres and friends who could help. Few also mentioned religious organisations.

Easy or difficult to go without smoking

The majority responded that it would be easy to go without smoking. Some of the responses included them not being addicted to tobacco, so it would not be a problem. However, a few mentioned that it would be difficult to stop, as people around them used tobacco.

Ever received help or advise to quit

Some of the participants mentioned that they had never received help or advice to stop smoking. Very few mentioned that they had received such advice from their churches, and from the federal government and quoted;

'Federal government, smokers are liable to die young'.

– a 22-year-old male (FG 3).

Willingness to quit tobacco

A few of the participants mentioned that they were willing to quit tobacco, and some mentioned that they had already stopped tobacco use. There were some participants who responded that they were not willing to stop tobacco use.


  Discussion Top


This study is one of the few to qualitatively examine the knowledge and risk perceptions of e-cigarette and hookah use amongst young people in Lagos, Nigeria. The qualitative approach was to show variations in opinions within the target population regarding e-cigarettes and hookah.[26] A key element of our findings was that majority of the participants were more aware of hookah and used hookah compared to e-cigarettes. Stress, pleasure and social acceptance were the reasons young people mentioned for the use of these tobacco products. Most participants also believed that e-cigarette was a harm reduction tool, although majority reported that there was some harm associated with e-cigarette or hookah use. Most participants were not aware of tobacco cessation programmes.

The age range at first tobacco use reported by the participants was from 12 to 22 years (mean 15.9 years), and most mentioned the ease of access to obtaining these products. Previous studies on cigarette smoking conducted in Nigeria reported similar findings of an average of approximately 16-18 years for smoking initiation.[27],[28],[29] In Nigeria, mainly, in urban cities such as Lagos where this study was conducted, tobacco/nicotine products are readily accessible and within reach in retail stores, point of sale, places where young people congregate such as university campuses, clubs and cinemas. This was noted in our study. This availability increases young people's access to these tobacco products, encouraging them to initiate tobacco use. Similar practices such as restricting the sale and purchase and increasing the prices of cigarettes, which have been found to reduce the smoking rates in other countries,[30],[31],[32],[33] could prove beneficial in regulating these tobacco products.

Participants mentioned fun, pleasure and relaxation as some of the reasons for using these tobacco products, similar to a research conducted amongst 4578 university students in South Africa, where the authors found that the students used hookah to socialise (57%) or to relax (33.3%).[6] Other studies also reported that the main reasons for hookah use were socialising, relaxation, pleasure and entertainment.[34],[35] Amongst the study participants, stress and depression were the common psychosocial factors mentioned as reasons for using these tobacco products, similar to prior research on cigarette smoking conducted in Nigeria.[17],[36],[37],[38] Because psychosocial problems are usually common amongst young people, they usually use tobacco or other forms of substance use as a form of coping mechanism.[39]

E-cigarettes and hookah have recently emerged in the Nigerian market, and these products seem to be socially acceptable amongst young people. Hookah has an unusually high appeal amongst this study population, with positive perceptions in terms of low perceived risk to addiction as well as high social acceptability, similar to a cross-sectional study conducted on university students in South Africa.[5] Furthermore, in our study population, 95% reported they had ever used hookah compared to only 35% who had ever used e-cigarettes. Some of the participants mentioned that they used hookah products in clubs and bars. The acceptability of these tobacco products, especially hookah, in clubs and social gatherings where exposure to second-hand smoking is usually higher than other public places, is a cause of public health concern. Strict messaging tactics on the detriments of using these tobacco products as well as the seemingly unintended consequences of second-hand smoking are needed. Encouraging the ban on the use of these tobacco products in clubs and social gatherings may facilitate an environment that is disproving of the use of these products.[40] The implementation of comprehensive bans on smoking in public places, raising awareness about the risks associated with using these tobacco products as well as the dangers of second-hand smoke may help to reduce the social acceptability of these tobacco products.

Our study also demonstrates that few of the participants stated that they enjoy using e-cigarettes and hookah mainly because of the flavours, similar to a previous qualitative research that showed youth enjoy using e-cigarettes due to the flavours.[41],[42],[43],[44] These findings are also consistent with prior quantitative research conducted amongst youth and adults in the USA, which showed that flavours were a significant reason for e-cigarette use amongst youth,[45],[46] and that flavoured hookah use was widespread.[47] Restricting flavours in tobacco products might be an effective way to discourage young people from trying these products, which could be beneficial to public health.[46]

Although conclusive evidence regarding the adverse health effects of these products is still emerging, particularly for e-cigarettes, most of the study participants seemed aware of some adverse health effects associated with the use of these tobacco products. These findings are comparable to results from a systematic review of 56 studies that included studies from Middle-Eastern and Western countries.[34] In contrast, a study conducted amongst 389 university students in South Africa to assess the beliefs of health risk of using hookah reported that participants did not perceive hookah use as a health risk, as 48% of the students believed that the risks associated with hookah use were exaggerated.[5] However, the associated health risks did not seem to be a deterrent for most participants in our study, for initiating or stopping the use of these products, probably because of the age of these participants, as they may consider themselves relatively young. It should be noted that the aerosol in these products contains harmful substances such as heavy metals, ultrafine particles and volatile organic compounds that can be exposed to users and bystanders.[48] Additionally, majority of the study participants stated that e-cigarettes could be used to reduce harm from cigarette use, even though the research is limited on the effectiveness of e-cigarettes as a tobacco-related harm reduction tool in the long term.[49]

Participants generally stated that they were not addicted to these tobacco products, similar to a previous research which found that youth tend to believe that they have a low or no chance of becoming addicted to hookah use.[50],[51] This area warrants further research, as studies show that hookah and most e-cigarettes contain the addictive substance nicotine.[5],[52] Studies suggest that a hookah session could last approximately 45 min compared to a single cigarette smoke session of about 5 min, which increases the users' exposure to nicotine.[53] Similarly, a prior report suggested that the e-liquid in a JUUL pod (a type of e-cigarette) contained as much nicotine as a pack of cigarettes.[54]

The moderate rate of intention to quit and those who have quit in this study population demonstrates that young people may be willing to quit the use of these particular products. This shows a prospect for interventions to aid many of these young people in their attempt to quit e-cigarette or hookah use. While some participants mentioned that family, friends and religious organisations provided cessation advice or help, majority reported that they were not aware of any programmes that could help with cessation of these tobacco products. Cessation services may be underdeveloped in Nigeria when compared to many developed countries, as is the case with many other developing countries.[55],[56] Therefore, cessation clinics and services, as well as awareness of the availability of such services, are urgently needed to encourage cessation in this young population.

Over half of the participants in the current study agreed that the use of these tobacco products could lead to transitioning to cigarettes. Research examining the gateway effect of e-cigarettes to cigarettes showed that using e-cigarettes at baseline was associated with transitioning to cigarette smoking amongst young people.[57],[58],[59] Similarly, a study conducted in Jordan found that hookah use led to the initiation of cigarette smoking amongst adolescents.[60]

Strengths and limitations

The main strength of our study is the exploratory nature of our research questions in a qualitative design to understand the knowledge and perceptions of young people on e-cigarettes and hookah use in Lagos, Nigeria. This study demonstrated the mostly positive views that young adults have towards e-cigarette and hookah use, thereby contributing to our understanding of the use of these products amongst young people. Nevertheless, our study is not without limitations. First, it had a small sample size from youth aged 16–24 years recruited from areas surrounding the University of Lagos. Therefore, this would not be representative of young people in Nigeria; thus, generalisability is limited. Nevertheless, this was an exploratory study to understand young people's knowledge and perception about e-cigarette and hookah, and the findings may be transferable to other contexts and can inform future generalisable studies. Second, due to the FGs employed, some participants may have been restricted in sharing their opinions with the group. However, confidentiality was emphasised by the trained facilitators within groups. Third, only five of the study participants were females, likely reflecting the male dominance of hookah/e-cigarette use amongst young people in Nigeria. Fourth, although we did not discuss data saturation in this study, previous research suggests that 90% of themes are discoverable within three to six groups.[61] Fifth, because the study participants were recruited from areas surrounding a university, we cannot rule out selection bias. Lastly, these findings were obtained at one time point from a sample of young people, so it does not capture the changes in behaviour and attitudes that may occur in young adulthood.


  Conclusion Top


This study provides insight into young people's knowledge and risk perception of e-cigarettes and hookah in Lagos, Nigeria. These young people may become addicted, even though most do not feel they are. Research with appropriate study designs to explore the generalisability of these findings would be valuable, as it may have implications for preventive interventions. These findings also underscore a need for an increased awareness of the adverse health effects of these products, which may encourage prevention and cessation. Findings from this study may serve as a step to persuade the Nigerian government to effectively implement tobacco control regulations to discourage the use of not only cigarette smoking but also all forms of tobacco/nicotine use.

Acknowledgements

The authors thank the study participants who provided the data reported in this manuscript. The authors also thank Dr Adegoke A. B, Dr Osadiaye O. O, Dr Akano O. P, Dr Abdulraheem K. S and Miss Odunsi O, for their help with participant recruitment and interviewing.

Financial support and sponsorship

Dr Osibogun is supported by the National Institutes of Drug Abuse T32DA043449 Grant. The protected time for the contribution of Dr Odukoya towards the research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under the Award Number K43TW010704. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of interest

There are no conflicts of interest.


  Supp lementary Material Top


Focus Group Questionnaire Guide

Date:

Institution:

Age range of participants:

FGD facilitator/Moderator:

Note taker:


  Introduction Top


Thank you for accepting to participate in this Focus Group Discussion (FGD). This is not a test and there is no right or wrong answers; what is required is your opinion on the issues for discussion. Thus, we do not want the names and photographs of respondents recorded. The findings from this discuss will provide insights on whether young people are aware and what they know about tobacco products, and the perception of these products to young people. Please feel free not to respond to any of our questions or withdraw from the discussion at any time. The FGD will take about 1 h. With your permission, we would like to record this conversation to enable us capture your views correctly. Please do you have any questions or us?

A.Knowledge on tobacco

  1. Do you know of any smoked tobacco products (mention them)? Where do you source for them? Have you ever tried or experimented with any form of smoked tobacco products (e-cigarettes and or hookah)
  2. What do you know about e-cigarettes and or hookah (Interviewer: Probe into age at which smoking was started, the likes and dislikes amongst tobacco products).


B.Perception on tobacco use

  1. What are the advantages or disadvantages of e-cigarettes or hookah use? Who are the people you think smoke those tobacco products and why do they smoke them? What do you feel makes people use these tobacco products? What are the health effects that you feel may be associated with the use of these products? (Interviewer: probe into types of health effects known)
  2. Do you think smoking is harmful to your health? Do you know if the smoke of tobacco is harmful to others? Do you think smoking tobacco helps people feel more comfortable (at celebrations, parties and other social gatherings) (Interviewer: Probe into their understanding of such beliefs)?
  3. What is your opinion about these products (e-cigarettes and or hookah) enabling the transition to cigarette use? Have you ever considered that people who smoke have more or less friends and to they have any other social advantage?
  4. Do you ever smoke tobacco first thing in the morning and how often after you smoke tobacco do you start to feel a strong desire to ignore?(Interviewer: Probe into challenges faced with obtaining the products)
  5. What do you think about e-cigarettes as a harm reduction tool? How much do think it costs to get the e-cigarettes. How readily accessible are e-cigarettes to you? (Interviewer should probe into affordability of e-cigarettes to participants).


C. Tobacco cessation

  1. Have you ever received help or advice to help you stop smoking? (Interviewer should probe into specific tobacco products e.g., cigarettes, hookah)
  2. How easy or difficult would you be able to go without smoking or stop smoking altogether? Are you aware of any program or process that can help one to stop smoking? (Interviewer: Probe further and mention some of these resources available)
  3. Are you willing to stop smoking tobacco? (Interviewer: Thank the participants for their time and exchange pleasantries).


Moderator's notes

Include any comments, impressions or important information about the FGD participants and process.





 
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