Introduction
Tobacco use results in over 7 million global deaths yearly and is a predominant risk factor for chronic obstructive pulmonary disease (COPD) (World Health Organization, n.d.; Gakidou et al., Reference Gakidou, Afshin, Abajobir, Abate, Abbafati, Abbas, Abd-Allah, Abdulle, Abera, Aboyans, Abu-Raddad, Abu-Rmeileh, Abyu, Adedeji, Adetokunboh, Afarideh, Agrawal, Agrawal, Ahmadieh and Ahmed2017). Smoking cessation is paramount for slowing COPD progression (Polosa et al., Reference Polosa, Morjaria, Prosperini, Russo, Pennisi, Puleo, Caruso and Caponnetto2018; Centers for Disease Control and Prevention, 2019; Polosa et al., Reference Polosa, Morjaria, Prosperini, Busà, Pennisi, Malerba, Maglia and Caponnetto2020) and offers improved quality of life (Jimenez-Ruiz et al., Reference Jimenez-Ruiz, Pascual Lledó, Cícero Guerrero, Cristóbal Fernández, Mayayo Ulibarri and Villar Laguna2018), reduced mortality (Bai et al., Reference Bai, Chen, Liu, Yu and Xu2017; Global Initiative for Chronic Obstructive Lung Disease, 2020), enhanced lung function (Pezzuto et al., Reference Pezzuto, Stellato, Catania, Mazzara, Tonini, Caricato, Crucitti and Tonini2018; Pezzuto and Carico, Reference Pezzuto and Carico2019; Global Initiative for Chronic Obstructive Lung Disease, 2020), and symptom relief (Pezzuto et al., Reference Pezzuto, Stellato, Catania, Mazzara, Tonini, Caricato, Crucitti and Tonini2018; Global Initiative for Chronic Obstructive Lung Disease, 2020). However, long-term abstinence remains a challenge due to habit-breaking difficulties, insufficient patient-provider rapport (van Eerd et al., Reference van Eerd, Bech Risør, Spigt, Godycki-Cwirko, Andreeva, Francis, Wollny, Melbye, van Schayck and Kotz2017), lack of practical education, and withdrawal symptoms (Jiménez-Ruiz et al., Reference Jiménez-Ruiz, Masa, Miravitlles, Gabriel, Viejo, Villasante and Sobradillo2001; van der Meer et al., Reference van der Meer, Wagena, Ostelo, Jacobs and van Schayck2003; Eklund et al., Reference Eklund, Nilsson, Hedman and Lindberg2012; Livingstone-Banks et al., Reference Livingstone-Banks, Norris, Hartmann-Boyce, West, Jarvis and Hajek2019). Traditional cessation programs often emphasize self-help/coping strategies enriched with pharmacotherapy and counseling (Centers for Disease Control and Prevention, 2019); however, they are not always tailored to the needs of individuals from certain populations and communities.
Emerging digital technologies and telehealth interventions facilitate virtual delivery of smoking cessation programs, offering increased accessibility and potential cost reduction (Taylor et al., Reference Taylor, Dalili, Semwal, Civljak, Sheikh and Car2017; Hallensleben et al., Reference Hallensleben, van Luenen, Rolink, Ossebaard and Chavannes2019; Haluza et al., Reference Haluza, Saustingl and Halavina2020; Shoenbill et al., Reference Shoenbill, Baca-Atlas, Smith, Wilhoit-Reeves, Baca-Atlas and Goldstein2022). Dahne et al. (Reference Dahne, Player, Strange, Carpenter, Ford, King, Miller, Kruis, Hawes, Hidalgo and Diaz2022) reported that a virtual cessation approach increased pharmacotherapy adherence for individuals trying to quit smoking compared to telephone-based counseling. Still, the effectiveness of virtual interventions depends on individual access to and comfort with using technology, as well as provider proficiency (Haluza et al., Reference Haluza, Saustingl and Halavina2020; Cobos-Campos et al., Reference Cobos-Campos, Cordero-Guevara, Apiñaniz, de Lafuente, Ampudia, Escudero, Llanos and Diez2023). Therefore, understanding user perceptions is pivotal for optimizing such interventions (Taylor et al., Reference Taylor, Dalili, Semwal, Civljak, Sheikh and Car2017).
Electronic cigarettes (e-cigarettes) and vaping products are devices that deliver nicotine or other substances to users in a vaporized form and are viewed by some as smoking cessation tools (West et al., Reference West, Shahab and Brown2016; Filippidis et al., Reference Filippidis, Laverty, Mons, Jimenez-Ruiz and Vardavas2019). In 2020, the prevalence of e-cigarette usage stood at 11% globally but reached 43% among smokers (Tehrani et al., Reference Tehrani, Rajabi, Ghelichi- Ghojogh, Nejatian and Jafari2022). Although associated risks exist (Anderson et al., Reference Anderson, Majeste, Hanus and Wang2016; Bhatta and Glantz, Reference Bhatta and Glantz2019; Kligerman et al., Reference Kligerman, Raptis, Larsen, Henry, Caporale, Tazelaar, Schiebler, Wehrli, Klein and Kanne2020; Werner et al., Reference Werner, Koumans, Chatham-Stephens, Salvatore, Armatas, Byers, Clark, Ghinai, Holzbauer, Navarette, Danielson, Ellington, Moritz, Petersen, Kiernan, Baldwin, Briss, Jones, King and Krishnasamy2020), some studies show e-cigarettes might be beneficial for COPD smokers seeking harm reduction (Morjaria et al., Reference Morjaria, Mondati and Polosa2017). Determining the role of e-cigarettes in cessation strategies requires understanding patients’ attitudes toward these devices (Morjaria et al., Reference Morjaria, Mondati and Polosa2017; Farsalinos, Reference Farsalinos2017).
While the benefits of smoking cessation are well-recognized, standard interventions often do not meet the specific needs of individuals with chronic conditions like COPD, who face unique challenges when quitting (Feng et al., Reference Feng, Lv, Wang, Chu, Dai, Jing, Tong, Liao and Liang2022). Recognizing the urgent need for practical, customizable strategies (Ho et al., Reference Ho, Li, Cheung and Xia2021), this study seeks to address this gap by exploring the perspectives of tobacco-smoking COPD and asthma-COPD overlap (ACO) patients on emerging topics in smoking cessation. Specifically, we investigated participants’ views on the use of telehealth in cessation efforts and their attitudes toward e-cigarettes as a potential alternative to traditional quitting methods. The research questions are: What are the essential components of effective smoking cessation programs as perceived by individuals with COPD or ACO? And what alternative cessation methods do individuals with COPD or ACO consider beneficial? The insights gained from this study aim to facilitate patient-centered cessation strategies, catering to the preferences and needs of this demographic.
Methods
We used the COnsolidated criteria for REporting Qualitative research, a checklist for reporting qualitative research (Tong et al., Reference Tong, Sainsbury and Craig2007) (Appendix 1).
Overview & study design
This study was conducted in 2019 in Vancouver, Canada, using a qualitative exploratory design (Stebbins, Reference Stebbins2001). We employed a thematic analysis within the framework of Qualitative Grounded Theory to systematically explore and conceptualize the experiences and needs of COPD and ACO patients in smoking cessation, aiming to inform the development of tailored, patient-centered cessation strategies. Data were sourced from two focus groups and two individual interviews. The study received ethics approval from the University of British Columbia Office of Behavioural Research Ethics (H12-03689).
Participant eligibility & recruitment
Inclusion criteria were English-speaking adults (≥ 19 years), either current smokers (≥ 5 cigarettes/day) or recent ex-smokers (< 12 months) with a diagnosis of COPD or ACO. Participants were recruited through convenience sampling from collaborating lung clinics and pulmonary rehabilitation programs in the Greater Vancouver Area, along with database of lung clinic patients who had agreed to be contacted for future research opportunities. A research assistant contacted potential participants via both email and telephone to share information about the study, verify eligibility, and determine their willingness to participate.
Focus group & interview content development
For the development and validation of the focus group and interview content, we conducted a thorough literature review on smoking cessation approaches, incorporated both professional and patient perspectives, and drew insights from prior studies (FitzGerald et al., Reference FitzGerald, Poureslami and Shum2015; Poureslami et al., Reference Poureslami, Shum and FitzGerald2015; Poureslami et al., Reference Poureslami, Shum, Aran and Tregobov2020; Tregobov et al., Reference Tregobov, Poureslami, Shum, Aran, McMillan and FitzGerald2020). The initial questions were then refined in collaboration with cessation experts from the Vancouver Coastal Health (VCH) Tobacco Control Clinic and the BC Lung Association. While the interview guide covered four key topics, for the scope of this manuscript, we concentrated on: Topic 2) The structure of a smoking cessation program and Topic 4) The feasibility and application of alternative cessation methods, including e-cigarettes and telehealth. It’s important to note that insights from: Topic 1) Risk perceptions, attitudes, and beliefs regarding smoking and Topic 3) The impact of smoking on health were part of a separate project with distinct research questions, but are noted in this manuscript for completeness. The full interview guide can be found in the Appendix.
Focus group and interview structure, procedures, and data collection
The semi-structured focus groups (Britten, Reference Britten2006) were conducted by a male author, I.P., who holds a PhD and is a senior health evaluation research scientist with extensive experience in the field. With over 25 years of experience in various research methodologies, including qualitative studies, I.P. brought a significant depth of knowledge to the research process. Some participants may have been previously acquainted with I.P. through their involvement in prior smoking cessation and lung health studies. For those participants who were unable to attend the in-person focus group session at the research center, individual interviews were arranged. Participants provided informed, written consent before sessions. Content questions were discussed openly, with the facilitator also ensuring all participants had an opportunity to share their thoughts prior to moving on to the next topic. Group sessions and individual interviews were audio recorded, transcribed, and de-identified by members of the research team. Observational/field notes were also taken by study facilitators to facilitate contextualization of participants’ data and served as a reference point during analyses. Focus group durations were approximately 90 minutes, while individual interviews took about 30 minutes to complete. Participants received a $30 CAD stipend to reimburse their travel and parking expenses.
Data analysis
Data were reviewed independently by two research team members. Guided by the research questions, a primary coding guide was established and discussed by the team. Initial coding was conducted using NVivo software (QSR International, Version 12). An inter-coder reliability check between a member of the research team and the senior health evaluation research scientist reached 94% agreement; ≥80% is considered an acceptable level of agreement (O’Connor and Joffe, Reference O’Connor and Joffe2020). Following the reliability check, the team member coded the remaining transcripts, with definitions iteratively revised to ensure contextual relevancy, including through referencing observation notes. Throughout coding, the corresponding author reviewed every fifth code, and a 90% agreement was achieved on remaining transcripts. Subsequently, the transcripts and all assigned codes were thoroughly reviewed by the team to check for accuracy. Any discrepancies were addressed by a mediator from the research team. The codes were then analyzed and placed into higher-level nodes and subsequently grouped into themes. This paper discusses three emergent themes related to the research questions, as explained in the Findings section.
Results
In September and October of 2019, 78 individuals were contacted, and 47 individuals were eligible. From this group, 22 individuals attended one of two focus group sessions (10 and 12 participants per session) and the remaining 25 individuals could not attend the group sessions due to various constraints such as scheduling conflict or transportation limitations. Amongst those who did not attend a group session, two participants were interviewed individually (using the same interview guide).
All 24 participants had made three or more attempts to quit smoking in the past. Sixteen males and eight females participated, and their ages spanned from 40 to 80 years. Participant demographics are detailed in Table 1.
Participant characteristics (n = 24)
Findings
Participants discussed numerous topics related to smoking and cessation based on their knowledge, perceptions, and lived experiences (refer to Appendix). Three main themes emerged: (1) the structure and elements of an effective smoking cessation program; (2) the integration of telehealth and digital technologies in cessation programs; and (3) the utilization of e-cigarettes for smoking reduction or cessation. Participants’ quotes for each specific theme are summarized below and additional quotes for each theme can be found in Table 2.
Participants quotes
Theme 1: The structure and elements of an effective smoking cessation program
Participants shared their smoking histories, patterns, and cessation experiences, while also discussing ways to enhance and improve current cessation resources and services.
A prevalent sentiment was the importance of both social (e.g., friends, peers) and professional (e.g., clinicians, educators) support, and its accessibility during the quitting process: ‘I, as an addict, I need that support. Yes, it’s fine to go through this [group session], but now I’m going to leave… I’m on my own’.
The potential role of ex-smokers as mentors during cessation was emphasized, with many wanting insights from those with firsthand lived experience: ‘Hearing other people’s stories about how they’ve quit would be immensely helpful’. The relatability of ex-smokers was highlighted: ‘Ex-smokers are easier to relate to, they know what you’re going through’. The emphasis was on application of valuable strategies used by ex-smokers in smoking cessation attempts: ‘I think that the [ex-smokers] that I was dealing with in [a prior smoking cessation] program have a lot of credibility and were helpful certainly in getting the wheels moving as to a couple of different techniques, tools to try’.
Participants debated individual versus group-based cessation approaches. Group settings were generally favored for shared experiences and peer support: ‘Yeah, I think this kind of a [group cessation] forum with several different people orchestrating it is helpful because you’ve all got your different perspectives…so I think this kind of a setting would be more helpful than the one-on-one [format]’. Another added: ‘I think that would be great…people could encourage one another’. However, the significance of individualized cessation plans was also emphasized by some participants: ‘I think the community is great, however, we are also seeing that each one of us has a different reason to quit…[a cessation plan] needs to become individualized’. A concern about group settings potentially triggering cravings for smoking was also shared: ‘There’s a flip side to [using a group approach to quit] – the group may help quit, but it could go the other way too…the talking makes you think about [smoking]’.
Theme 2: The integration of telehealth and digital technologies in cessation programs
Participants largely viewed telehealth and digitial technologies favorably for smoking cessation. A main perceived advantage was immediate and convenient access during cravings or moments of difficulty: ‘If [smokers] just have a quick question, they can get a response immediately…as opposed to [having to] wait for their next [consultation] which is two to three days from now. What do you think is going to happen in those two to three days? They’re probably going to open that pack’. Another participant valued this digital interface due to the stigma associated with smoking: ‘If I could have face-timed or video chatted with a support worker, my earlier [quitting] attempts would have been far more successful. There’s so much shame attached to being a smoker these days…it’s hard to talk to your friends, especially if they’ve never smoked’.
The notion of timely contact during cravings was emphasized as comforting: ‘I think having [telecommunication] and knowing you have somebody there to talk to you [is important]’. Another added: ‘Access [to support] if you are in a position where you feel you’re going to fail or drop off, you need some support right now to be able to communicate to somebody’. However, a few participants questioned whether telecommunication without the in-person interactions would be meaningful in smoking cessation: ‘I’m not sure an app would make a big difference, you need the physical’.
Many viewed telehealth as especially valuable for underserved or remote smokers: ‘I would absolutely say that any form of communication, especially for people living in rural areas, who don’t have a lot of interpersonal connection, it can be great’. Virtual support groups (e.g., via Zoom meeting) were also proposed as a cost-effective approach: ‘You could just join in, up to twelve people easy. It’s not expensive’.
Theme 3: The utilization of e-cigarettes for smoking reduction or cessation
Participants offered diverse views on e-cigarettes as alternatives to traditional smoking cessation methods. Many, particularly those with experience using e-cigarettes, perceived vaping as less harmful than traditional cigarettes: ‘I don’t consider it to be as serious as smoking a cigarette, for sure’. Another said: ‘We still feel that [vaping is] better, it’s not the best…Quitting is the best, but it’s better at this point than smoking’. In contrast, those generally more unfamiliar with e-cigarettes expressed uncertainty about potential adverse outcomes of vaping. One argued: ‘If I did the vaping…now instead of the cigarettes, I think it would have done a lot more damage to the lungs more quickly than the cigarettes’.
The conversation frequently shifted to the composition and harm of e-cigarettes versus cigarette smoke. A participant noted: ‘[E-cigarette smoke] doesn’t have all the carcinogens. It has the nicotine in there, so you’re still hooked on something, but you’re not getting all the carcinogens’. Another compared: ‘I believe that [vaping] is the lesser of two evils and I think there is something like seven-thousand different chemicals in a cigarette and something like seven hundred in a vape’.
Opinions varied on e-cigarettes’ role in cessation. Some highlighted the possibility of reducing nicotine content over time: ‘I feel if you’re trying to quit, it actually is useful because you can get ones with progressively less nicotine’. Another supported this: ‘And on the e-vaping thing again, I do know a number of people who have quit by going down [in nicotine dose], they have done it’. Yet, another raised concerns about e-cigarettes’ nicotine content: ‘[E-cigarette smoke is] high nicotine though, and when you smoke it a lot you end up being more addicted to nicotine, more than you normally would’.
A few participants advocated for further research. One suggested: ‘I think if you could prove that vaping is controlled… if you could prove that it was not detrimental to your lungs, I would think that would be a valid way to go to try to get people off of traditional cigarettes’. Another cautioned against potential societal impacts of normalizing e-cigarettes: ‘No, I don’t think it’s going to be a way to [quit]… it’s going to make nicotine addiction more appealing to youth’.
Discussion
In this qualitative study, we explored the perceptions of respiratory patients (COPD and ACO) regarding the structure and features of an effective smoking cessation program. The majority of participants emphasized the importance of a support network that extends beyond professionals, highlighting the perceived value of peers, friends, and family in providing emotional support, accountability, and encouragement throughout the cessation process (Barnes et al., Reference Barnes, Hanson, Novilla, Magnusson, Crandall and Bradford2020). This study also contributes to the existing body of knowledge surrounding the perceived importance of non-professional social supports in the smoking cessation process. The influence of social networks on successful quitting is supported by van den Brand et al. (Reference van den Brand, Nagtzaam, Nagelhout, Winkens and van Schayck2019) and literature stressing the heightened intent to quit smoking when backed by social and community support (Carlson et al., Reference Carlson, Goodey, Bennett, Taenzer and Koopmans2002; Meijer et al., Reference Meijer, Gebhardt, Van Laar, Kawous and Beijk2016; Patten et al., Reference Patten, Goggin, Harris, Richter, Williams, Decker, Bradley-Ewing and Catley2016; Soulakova et al., Reference Soulakova, Tang, Leonardo and Taliaferro2018). The potential of an interdisciplinary approach, encompassing family, professionals, and peers, holds promise for fulfilling diverse support needs (Poureslami et al., Reference Poureslami, Shum, Cheng and FitzGerald2014; Campbell et al., Reference Campbell, Starkey, Holliday, Audrey, Bloor, Parry-Langdon, Hughes and Moore2008; Ford et al., Reference Ford, Clifford, Gussy and Gartner2013). Participants highly endorsed group-based sessions for their potential to nurture shared experiences, collective learning, and peer motivation. It may be advantageous for program administrators to integrate structured peer-led support groups into smoking cessation programs, leveraging the collective strength and shared experiences of individuals on their quit journey. This communal approach, supported by evidence from Stead et al.’s meta-analysis (2017), can strengthen self-perception, learning from lived experiences, and positivity (Jenks, Reference Jenks1994).
The involvement of an ex-smoker as a peer supporter in a smoking cessation journey emerged as a key finding. Ex-smokers’ firsthand lived experience and personal relatability, more so than professional staff, were seen as beneficial in addressing queries, sharing insights from their cessation journey, and offering pertinent advice on managing cravings and withdrawal symptoms. Such peer involvement not only aligns with the literature emphasizing empathetic peer support (Campbell et al., Reference Campbell, Starkey, Holliday, Audrey, Bloor, Parry-Langdon, Hughes and Moore2008; Westmaas et al., Reference Westmaas, Bontemps-Jones and Bauer2010; Ford et al., Reference Ford, Clifford, Gussy and Gartner2013), but also underscores their role in reducing smokers’ feelings of isolation, bolstering their ability to manage addiction, and enhancing their motivation and confidence in their smoking cessation endeavors (Westmaas et al., Reference Westmaas, Bontemps-Jones and Bauer2010; Williams et al., Reference Williams, Dwyer, Verna, Zimmermann, Gandhi, Galazyn, Szkodny, Molnar, Kley and Steinberg2010; Zhao et al., Reference Zhao, Wang, Cha, Cohn, Papandonatos, Amato, Pearson and Graham2016). Considering these insights, health professionals and policymakers should consider the role of ex-smokers in peer support capacities, acknowledging their potential to contribute meaningfully to the smoking cessation process.
Participants recognized the potential benefits of integrating telehealth into smoking cessation programs. A primary advantage of telehealth or virtual modalities is the immediate access to support, a finding consistent with Haluza et al. (Reference Haluza, Saustingl and Halavina2020). Knowing that real-time access is available during challenging moments or intense cravings could alleviate anxiety and stress for some individuals. Participants also highlighted the possibility of facilitating support groups or networks through virtual platforms or apps, with online peer exchanges and daily automated messages having shown effectiveness in engaging smokers and fostering online support communities (Pechmann et al., Reference Pechmann, Pan, Delucchi, Lakon and Prochaska2015). Such digital interventions reportedly enhance feelings of provider support and overall motivation for quitting (Liebmann et al., Reference Liebmann, Preacher, Richter, Cupertino and Catley2019). Moreover, telehealth may improve accessibility for underserved or remote areas where smoking prevalence is notably high (Roberts et al., Reference Roberts, Doogan, Kurti, Redner, Gaalema, Stanton, White and Higgins2016; Buettner-Schmidt et al., Reference Buettner-Schmidt, Miller and Maack2019; Bhaskar et al., Reference Bhaskar, Bradley, Chattu, Adisesh, Nurtazina, Kyrykbayeva, Sakhamuri, Moguilner, Pandya, Schroeder, Banach and Ray2020). However, despite reported advantages of telehealth in smoking cessation, concerns were expressed regarding the potential decline in personal interactions with an increased digital focus. In addition, for elderly participants, virtual programs could alleviate physical access challenges, although other challenges may still arise such as inadequate digital literacy and lack of access to relevant devices (Arcury et al., Reference Arcury, Sandberg, Melius, Quandt, Leng, Latulipe, Miller, Smith and Bertoni2018; Bhaskar et al., Reference Bhaskar, Bradley, Chattu, Adisesh, Nurtazina, Kyrykbayeva, Sakhamuri, Moguilner, Pandya, Schroeder, Banach and Ray2020; McGee et al., Reference McGee, Meraz, Myers and Davie2020; Merianos et al., Reference Merianos, Fevrier and Mahabee-Gittens2021; Kotsen et al., Reference Kotsen, Dilip, Carter-Harris, O’Brien, Whitlock, de Leon-Sanchez and Ostroff2021). While virtual cessation platforms present an avenue for broader service delivery, it is crucial to tailor them to the unique lifestyles, capabilities, and needs of target populations (Phillips and McLeroy, Reference Phillips and McLeroy2004). Overall, our findings suggest that a nuanced approach to telehealth, which considers unique challenges such as digital literacy and access issues, could bridge critical service gaps in current cessation efforts, especially in underserved or remote areas.
Discussions on the merit of using e-cigarettes as a smoking cessation tool elicited mixed opinions. Reflecting on these varied viewpoints, our study advocates for the inclusion of patient experiences and preferences in the development of cessation tools, thereby aligning strategies with patient needs and the complex realities of quitting smoking. Participants with e-cigarette experience largely viewed them as less harmful than traditional tobacco and appreciated the adjustable nicotine levels, which could facilitate gradual nicotine reduction. The perceived benefits of e-cigarettes reported in literature include suitability for indoor use (Hanafin and Clancy, Reference Hanafin and Clancy2020), enhanced social acceptability (Simmons et al., Reference Simmons, Quinn, Harrell, Meltzer, Correa, Unrod and Brandon2016), and anecdotal improvements in respiratory health, including in COPD patients, upon transitioning to e-cigarettes (Morjaria et al., Reference Morjaria, Mondati and Polosa2017; Singh et al., Reference Singh, Hrywna, Wackowski, Delnevo, Jane Lewis and Steinberg2017). Conversely, participants less familiar with e-cigarettes voiced concerns about potential increased tolerance and dependence. Some research suggests that smokers perceive nicotine-containing e-cigarettes as more addictive than conventional cigarettes (Jankowski et al., Reference Jankowski, Krzystanek, Zejda, Majek, Lubanski, Lawson and Brozek2019; Hanafin and Clancy, Reference Hanafin and Clancy2020). While positive attitudes toward e-cigarettes correlate with successful cessation attempts in some studies (Harrell et al., Reference Harrell, Simmons, Piñeiro, Correa, Menzie, Meltzer, Unrod and Brandon2015; Rutten et al., Reference Rutten, Blake, Agunwamba, Grana, Wilson, Ebbert, Okamoto and Leischow2015), others have found that e-cigarette use, regardless of motivation, might reduce the chances of quitting smoking (Kalkhoran and Glantz, Reference Kalkhoran and Glantz2016; Patil et al., Reference Patil, Arakeri, Patil, Ali Baeshen, Raj, Sarode, Sarode, Awan, Gomez and Brennan2019). Consequently, individuals’ perceptions and prior experiences with cessation tools, including e-cigarettes, should be included in program development. The known and possible undiscovered harms of e-cigarettes must be considered and communicated against their potential benefits for some individuals. Further patient-centered research like stakeholder interviews, scoping reviews, and analysis of administrative datasets is needed. This research could improve our understanding of how e-cigarettes might be utilized as a population health tool to reduce smoking morbidity and mortality and identify research and practice gaps, which can guide the creation of tailored smoking cessation programs for diverse population groups.
This study has several limitations. Patients were primarily sourced from clinical settings, potentially skewing their smoking and cessation-related perspectives compared to the broader population we target. The sample size of 24 participants was determined by the availability and willingness of participants to engage in the study, characteristic of a convenience sample. While saturation was not assessed, the findings form a base for the conduction of further investigations, especially around the views and preferences of COPD and ACO patients to guide further research. Additionally, the utilization of both focus groups and individual interviews, while providing a means to include a wider array of participant experiences and accommodate individual availability, introduced a potential limitation by adding variability in response depth and context, which could influence the comparability and consistency of the data analysis. Next, the focus group format might have influenced social desirability and response biases (Barbour and Kitzinger, Reference Barbour and Kitzinger1999; Grimm, Reference Grimm2010; Nyumba et al., Reference Nyumba, Wilson, Derrick and Mukherjee2018), especially when discussing sensitive topics like cessation challenges. Despite this, we endeavored to create an open dialog, with many participants later expressing appreciation for the discussions and comfort in connecting with peers with similar smoking and quit attempt experiences. Language barriers might have also influenced participation since sessions were conducted in English. Moreover, socioeconomic status of patients was not considered in this study despite potential associations between lower socioeconomic status and cigarette use (Hiscock et al., Reference Hiscock, Bauld, Amos, Fidler and Munafò2012). This omission could restrict the generalizability of the results to populations with more varying socioeconomic backgrounds. We recognize that larger studies engaging a broader participant base would not only corroborate these findings but also enhance the generalizability to other disease contexts and the general population. For future work, engaging individuals from varied ethnocultural backgrounds is crucial to ensure culturally and linguistically appropriate care (FitzGerald et al., Reference FitzGerald, Poureslami and Shum2015; Poureslami et al., Reference Poureslami, Shum and FitzGerald2015; Poureslami et al., Reference Poureslami, Shum, Aran and Tregobov2020; Tregobov et al., Reference Tregobov, Poureslami, Shum, Aran, McMillan and FitzGerald2020), acknowledging that the dynamics of smoking cessation can differ across cultural and socioeconomic spectrums (Nguyen-Grozavu et al., Reference Nguyen-Grozavu, Pierce, Sakuma, Leas, McMenamin, Kealey, Benmarhnia, Emery, White, Fagan and Trinidad2020; Thomson et al., Reference Thomson, Emberson, Lacey, Lewington, Peto, Jemal and Islami2022).
This study provides insights for a patient-centered smoking cessation program focusing on practicality, accessibility, and relevance. Patients’ voices should be considered in framework development, including aspects such as: (1) engagement of ex-smokers as mentors, alongside family and peers for support; (2) group sessions for knowledge dissemination; and (3) digital access to essential resources and services. Such innovations aim to provide timely resources and align with the needs articulated by our study’s participants. Given the preliminary nature of this study, more evidence is required to validate the practical integration of these strategies.
In our future research endeavors, we aim to delve into two broad areas. Our focus will be a gap analysis to identify shortcomings in the field through a scoping review of programs and review of administrative/gray documents. Subsequently, our attention will shift to qualitative studies, seeking to understand the perceptions of specific demographic groups of smokers in relation to e-cigarettes and potential cessation techniques. This exploration will also encompass investigations into the potential of select models to bring about changes in smoking behaviors, utilizing a diverse range of methods.
Conclusion
Our study describes the perspectives of COPD and ACO patients on smoking cessation programs. Participants have identified that cessation efforts might be improved through personalized support mechanisms, tailored resource access, and the integration of innovative approaches such as telehealth. Additionally, our findings shed light on the complex attitudes patients hold toward e-cigarettes, weighing potential benefits against concerns. Such nuanced viewpoints are crucial in designing patient-centered cessation strategies that not only meet but are also shaped by the specific needs and preferences of the COPD and ACO smoking populations.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1463423624000306
Acknowledgments
We would like to thank all the COPD and asthma-COPD overlap patients for their involvement in this study as well as express thanks to Richard Hohn and Jenny IP for their contributions.
Funding support
The Legacy for Airway Health at VCH Research Institute provided funds for this study [Grant #: LRH9322018] and was not involved in the study design; in the collection, analysis, and interpretation of data; in the writing of the article; and in the decision to submit it for publication.
Competing interests
None.
Ethical standards
Written informed consent was obtained from all subjects/patients.
Open access
