Experiences of women with cervical dysplasia and associated diagnoses using electronic cigarettes for smoking substitution

Abstract Introduction The aim of this qualitative study was to describe the motivation and experiences of women with cervical dysplasia and associated diagnoses who used electronic cigarettes (ECs) to reduce the number of cigarettes they smoked. Methods Qualitative interviews were conducted with 26 women aged 18‐65 years with cervical dysplasia and associated diagnoses who smoked at least three cigarettes daily for the past year or more and who enrolled in an intervention designed to substitute regular cigarettes with ECs. At the 12‐week follow‐up, patients were contacted by telephone. Semi‐structured interviews were recorded, then transcribed, coded and analysed for themes. Results When confronted with a new diagnosis associated with smoking, women in this study were eager to try ECs to help them reduce their intake of cigarettes. Women reported that physical cues similar to smoking, delivery of nicotine sufficient to assist with smoking reduction and the security of having the device available to use in instances where temptations to smoke may occur were all positive experiences in trying the device. Other women in the study reported negative experiences, such as a lack of sufficient nicotine to eliminate cravings, heaviness of the device and the need to keep it charged. Depression, nicotine addiction and habit were factors that made it difficult to decrease cigarette consumption. Conclusions Findings suggest that ECs may help with smoking substitution in patients who must reduce smoking due to medical conditions or diagnoses.

intervention for all women diagnosed with HPV or cervical dysplasia who smoke. [3][4][5] Because continued smoking significantly increases the risk of all-cause and cancer-specific mortality, smoking cessation is also important after cervical cancer diagnosis. 6 To date, only one study has been reported using smoking cessation in this population.
Santosa and associates counselled women with cervical dysplasia to stop smoking using the five "As": Ask, Advise, Assess, Assist, and Arrange follow-up. 7 This study highlighted the importance of counselling, as 32% of their 125 subjects quit smoking with no other intervention. Because available research is limited, our understanding of cessation-related barriers and motivators for this high-risk population is incomplete.
Evidence-based smoking cessation strategies include nicotine replacement therapy (NRT), prescription medications such as varenicline (Chantix or Champix) and bupropion (Wellbutrin or Zyban), and counselling, often used in combination. 8 While these aids help smokers quit, they have low appeal and satisfaction. 9 A smoking alternative showing promise for smoking substitution or reduction is cigalikes, or electronic cigarettes (ECs) that look like regular cigarettes. ECs demonstrate promise for immediate smoking cessation or reduction because although they provide nicotine, which is an addictive component, they also provide the helpful hand to mouth cues of smoking, without the carbon monoxide and combustion that cause regular cigarettes to be most harmful. 10 Since 2007, the United States has observed an increase in the sale and use of ECs, both for nicotine delivery and for nicotine reduction, or cessation purposes. 11 Whether or not these devices are effective for smoking cessation is a question that remains unanswered.
Results of two randomized controlled trials suggest that ECs may contribute to smoking cessation or at least be as effective as the nicotine patch. 12,13 In addition, qualitative studies can help clinicians and researchers understand why some smokers are able to successfully transition to ECs but others are not. Studies have been published with naive [14][15][16] as well as experienced EC users, [17][18][19][20][21][22][23] and the most common theme reported was the high level of satisfaction and acceptability of ECs. 14,15,18,19,22,23 Users stated the devices helped with smoking reduction or cessation 20,22,23 were less costly than cigarettes, 21 posed fewer health risks than smoking, 19,21,23 lacked the negative smell of cigarettes 14,21,24 and provided the positive physical cues of hand to mouth simulation. 14,16,17,[21][22][23][24] EC users also reported requiring less nicotine from ECs to satisfy their nicotine addiction, which led to lower nicotine dependence. Some EC users report nicotine withdrawal relief within five minutes of using the devices. 21 Alternatively, EC users have also reported negative effects, stating they were not helpful for smoking cessation and caused a burning in the throat or a dry mouth. 16,19,22,23 The use of ECs for smoking substitution or reduction in groups of individuals receiving medical intervention or who are at an elevated risk for cancer has not been investigated. The aim of this qualitative study was to describe the motivation and experiences of women with cervical dysplasia and associated diagnoses who used electronic cigarettes to substitute for or reduce the number of cigarettes they smoked.

| ME THODS
This study was approved by the University of Oklahoma Health Sciences Center Institutional Review Board. Participants were women who had been diagnosed with cervical dysplasia, cervical cancer or lower genital tract dysplasia within the last month, and who enrolled in a research intervention designed to substitute regular cigarettes with electronic cigarettes. 25 The physician in charge of the clinic determined medical eligibility for the study.

| Inclusion criteria
Inclusion criteria included current female smokers, aged 18-65 years.
All participants were diagnosed with and being medically treated for cervical dysplasia, cervical cancer or lower genital tract dysplasia by the doctor in charge of the clinic. Smokers were defined as those who in a typical week smoked an average of three or more cigarettes a day and had done so for at least the last year.

| Exclusion criteria
Exclusion criteria included patients unwilling to commit to a 6-week intervention; with current diagnoses of or treatment for other cancer as ascertained from their medical record; and with a diagnosis of stroke, heart disease or high blood pressure not well controlled with medication as documented in their medical records. Additional exclusion criteria included women who were pregnant, ascertained via urinary analysis, lactating or planning pregnancy in the next 6 months, ascertained by their report, and currently using ECs or vaping systems.

| Procedures
After an initial screen for eligibility, women were consented into the study. Women then sampled ECs and decided if they were willing to use them for a 6-week intervention period designed to assist with smoking reduction/cessation. Women received two sessions of motivational interviewing, a Blu ® EC starter kit containing two batteries and a charger at the first session, and a 6-week supply of nicotine cartridges, given according to manufacturers' recommendations.

| Measures
To assess smoking behaviours and EC use, women were asked, "In the last week, on average, how many cigarettes did you smoke each day?" If at follow-up the answer was none, women were asked the date they smoked their last cigarette, "even a puff." During follow-up phone calls, women were also asked how many EC cartridges they had used. EC use was recorded as the total number of cartridges each woman used during the previous 6-week period. This measurement of smoking behaviours and EC use was completed at baseline, at a 6-week follow-up and after an additional 6-week period when intervention products were no longer supplied.
At the 12-week follow-up telephone call, women were interviewed about their experiences with ECs. Twenty-six women participated in the interviews and were compensated with a $20 gift card at the 12-week follow-up to partially compensate for their time. Women were also able to keep their EC device, their charger and carrying case.

| Qualitative interview coding
Semi-structured telephone interviews were conducted at 12 weeks to determine women's motivation to reduce smoking, as well as their response to the ECs provided by the study to assist them in doing so. Interviews lasted 20-45 minutes and were audio-recorded, and then transcribed. Transcription was completed by one of the authors (SJ) and included verbatim transcription including nuances of the interviews not apparent from the actual wording of the conversation. Two of the authors (SJ and MC) then developed a detailed codebook, coded four transcripts together using NVivo (version 10; QSR International) and made revisions to the codebook. When satisfied with the initial codebook, these authors separately coded each interview. The two authors then reviewed the codes on a weekly basis until consensus was achieved on the core codes. Authors then sorted the codes into developing themes using the NVivo program for thematic maps. The two authors then refined the themes, assuring the data fit well into each theme without overlaps. Authors then reviewed the entire data set to assure consistency within the themes and were satisfied the coding fits the data well.
Following thematic analysis, the transcripts were reviewed again for additional supporting and disconfirming evidence of themes by the third author (LB). When all three authors met consensus on the main themes reached, quotes representing the themes were added to illustrate themes and subthemes with quotes identified by subject number.

| RE SULTS
Twenty-six women with a mean age of 40 years completed followup interviews. Twenty-seven per cent did not finish high school, and 23% finished high school or had a general education diploma.
Almost one in four (23%) had no insurance, and over a third (42%) had Medicaid only. Most women in the study (85%) had an annual income of <$25 000 (Table 1).

| Smoking and EC use at the 12-week follow-up
In a self-report telephone interview, after their 6-week trial of ECs for smoking cessation, followed by their 6-week trial with no intervention, 17 of 26 women continued to use ECs. Eight women using ECs quit smoking cigarettes entirely, 11 reduced cigarette use by 50% or more, and seven reduced by <50%. Four women in the study no longer used nicotine of any kind (Table 2).
Overall, 12 women reported overwhelmingly positive experiences with ECs; four reported primarily negative experiences; and ten de-  (Table 2).

| Qualitative results and themes
An overview of themes discussed by women in this study is displayed in Figure 1. Included are motivators for using ECs, problems women encountered during their smoking reduction attempts and whether their experience was positive, negative or mixed, and why.

| Theme one: Motivating variables
The impact of a new diagnosis

| Theme two: Psychosocial comorbidities
As women struggled to reduce smoking regular cigarettes and replace them with ECs, 14 mentioned stress, eight mentioned addiction, six mentioned depression, and five mentioned habit as difficulties they experienced.

Stress
Women experienced stress related to their new diagnosis and treatment, combined with the need to reduce smoking to improve their prognosis. When additional stressors were added to their lives from outside sources including family, friends, work or lack of income, many were especially tempted to revert back to previous smoking habits as a form of stress relief.

| Theme three: Women's experiences with ECs
Positive experiences with EC use Most women stated that the nicotine they received was sufficient to satisfy their cravings. The most common attribute reported by these women was the important physical cues the EC provided, including the feel of the device in their fingers, the hand to mouth motion, the ability to inhale and exhale the vapour, and the ability to play with the device.
Women who had substituted most or all of their cigarettes with ECs felt secure knowing they could carry the device with them. They noted it was available when they "just had to have a smoke," especially in nightclubs, bars and parties where others were smoking.

| Theme Four: Women's recommendations
Most women in this study (18/26)

| D ISCUSS I ON
The results of this qualitative study are consistent with others suggesting ECs can provide helpful physical cues, as well as nicotine substitution, for smokers attempting to reduce their cigarette intake or quit smoking altogether. 14,16,17,21,22 The population in this study was unique, because added to their desire to reduce cigarette consumption for general health reasons, was the desire to reduce cigarette consumption to prevent invasive cervical cancer. Women had used a wide variety of smoking cessation aids, ranging from traditional nicotine replacement therapy to hypnosis with little success. Some, but not all women, found ECs to be more helpful.
Consistent with reported literature, several women in this study reported that the EC device did not deliver enough nicotine to reduce cravings, was too heavy and required charging, all making it unappealing for smoking reduction. 16,19,22,23 At the point of discontent, these women may have been more successful if they had been allowed to try a different aid. 8 Examples include the nicotine inhaler, or a second-generation vaping system that would provide larger doses of nicotine more quickly, with a wider variety of flavours and nicotine strengths. 26 Especially provocative for women with positive experiences with ECs was the presence of strong physical cues including bringing the device from hand to mouth, drawing the vapour into the lungs and holding the device between the fingers, all well documented in other studies. 14,16,17,21 Unique to this population of women with cervical dysplasia was the need for the security the device provided. Women noted the device was available "when they needed it," or "when they had the urge to smoke," particularly helpful in social situations when others around them were smoking, or when stressful life situations made it appealing to return to previous smoking habits. Zhou and associates found providing a replacement for smoking cues was especially important for smoking cessation over time, noting relapse was associated with exposure to smoking cues, cravings, withdrawal symptoms or lack of a smoking cessation aid, 27 problems resolved using ECs.
When these women with cervical dysplasia struggled with cigarette reduction, they most often cited habit, addiction, depression and stress as factors making it difficult. Habit and addiction are not surprising, given these women's smoking histories, which ranged from seven to fifty-seven years. Several women in the study expressed defeat and resignation at yet another unsuccessful smoking reduction attempt, and their interviews reflected strong feelings of failure, which could derail future quit attempts. When these women experienced overwhelming stress from life situations, it was not realistic to expect them to additionally reduce or quit smoking, because smoking constituted their coping mechanism for stress. 28 The point at which they begin to resort to old habits of using smoking for stress relief is the time when additional support, including depression or mental health counselling, is most important. Several women also noted the importance of long-term follow-up support. Although many women in this study did not completely substitute their cigarettes with ECs, any reduction in the number of cigarettes smoked daily represents success. In a qualitative study, Hughes & Carpenter concluded that smoking reduction increased the probability of future cessation. 30 The potential value of EC use for smoking reduction, even in women not completely successful, was best represented by women's willingness to recommend them to a friend who was trying to quit smoking.
It is difficult to determine whether the information gained from these women's experiences will be generalizable to other women with cervical dysplasia or to patients with other medical conditions associated with smoking and whose prognosis depends on smoking reduction or cessation. Only four women in this study had exclusively negative experiences with ECs for smoking substitution, making it difficult to determine whether a complete description of possible negative experiences was accurately represented. It is important to note that while using ECs is a harm reduction technique, ECs still provide nicotine, an addictive substance. Additionally, this study only examined experiences with cigalike devices. Smokers are turning to second-or third-generation vaping devices for more successful smoking reduction and cessation, 17,31 due to improved levels of nicotine delivery and satisfaction. 32 In future studies, these devices should be included as a substitution/reduction method.

| CON CLUS ION
Twenty-six women with cervical dysplasia and associated diagnoses were given the opportunity to try smoking reduction using ECs and were then given the opportunity to share their experiences through qualitative interviews. Women in this study believed that the potential medical complications that could arise if they continued to smoke were severe enough to warrant a serious attempt to reduce or eliminate their cigarette consumption with the help of ECs.
Despite the fact that ECs have not been proven to be a safe longterm alternative to smoking, this study adds to the growing body of research that suggests that ECs can provide adequate nicotine delivery for the alleviation of cravings and the strong physical cues smokers miss when trying to cut down on smoking. These benefits may be relevant to other patients with medical conditions in which the danger of smoking is magnified.

CO N FLI C T O F I NTE R E S T
James, Cheney, Smith and Beebe have no financial disclosures.

DATA AVA I L A B I L I T Y S TAT E M E N T:
The data that support the findings of this study are available from the corresponding author upon reasonable request.