The analysis team met to review and finalize the coding scheme. An iterative process of coding, assessing intercoder agreement, and resolving differences in coding was repeated until a Krippendorff’s α = 0.862 was reached. Research assistants then coded all focus group data. The principal investigator created a subcode for each coded data fragment, which was reviewed by research assistants for appropriateness. The analysis team met and resolved conflicts to achieve a consensus subcoding of data fragments. Research assistants then recoded the data with subcodes within Atlas.ti. A phenomenological approach was utilized to analyze the focus group data . Data relating to EVALI were extracted for participants who reported past 30 days use of e-cigarettes and analyzed for major thematic elements which provided an initial framework to conduct the phenomenological analysis. Following the process described by Moustakas , a textural and structural description of e-cigarette users’ understanding of and behavioral response to EVALI was created for each participant from the focus group transcripts. Textural and structural commonalities among individual experiences were organized into themes to construct a composite description of how e-cigarette users understand and respond to EVALI. The composite description identifies both essential structures of experience as well as thematic variations in meaning. The experience of e-cigarette use within the context of EVALI was composed of four essential structures: awareness, information filtering, risk rationalization, and behavior. Awareness is the initial stage of becoming alerted to and learning about any element of EVALI. Information filtering is the process of comprehending, accepting, and prioritizing the information encountered about EVALI. Risk rationalization refers to the development of rationalizing a course of action in light of information accepted about EVALI, perceptions of harm associated with EVALI, and past and existing e-cigarette behaviors and experiences. Behavior is the action taken in response to risk rationalization. Each domain is composed of interrelated themes which constitute patterns of experience . The highly visible reporting of EVALI cases resulted in a considerable amount of – and sometimes conflicting – information and opinions that had to be comprehended, accepted, and prioritized as salient. The first level of filtering pertained to the very legitimacy of reported EVALI cases. While EVALI cases and reported symptoms were generally accepted as conveyed through information channels, five participants questioned whether EVALI was “fake news,” a “government conspiracy” funded by the tobacco industry, or part of a government effort to ban ecigarettes. A second level of filtering by some participants focused on causes of EVALI.
Three causes of EVALI were the most salient: “fake” cannabis vape products, any “fake” vaping product, and excessive vaping. The most accepted cause of EVALI, reported by nearly a quarter of respondents, was “more of the THC,cannabis grow equipment like fake THC carts” or identification of a particular brand: “Most [EVALI cases] were using something called a Stizzy… a weed type of vape and most of them get fake cartridges.” EVALI was also thought to be caused by any “fake” product , including nicotine and cannabis vaping together. Irreputable products and sources were described as “bad carts… you buy off the street” or “fake cartridges… [that] weren’t like Juul, they weren’t like Suorin, weren’t these name brand trusted sources.” A third accepted cause of EVALI noted by five participants was excessive vaping of nicotine products. Participants were told that “you can actually be harmed by smoking too much” or viewed cases as people who “were smoking three pods a day or something” or “were really addicted to [Juuls].” Accepted information from the filtering process was one variable in developing a risk rationalization which also incorporated previous or existing experiences and beliefs. Among those who accepted the legitimacy of EVALI as a potential source of harm without engaging a second level of filtering on the causes of EVALI, increased risk was rationalized as either a basis for modifying behavior or disregarded altogether .I’m going to do it anyway.” Dual users of cigarettes and e-cigarettes said that “if I wanted to be healthy, I wouldn’t smoke [cigarettes]” or that “I’m already dead right? Because cigarettes are worse.” Among those who engaged in a second level of information filtering, two dominant risk rationalizations were developed which minimized the perceived risk of continued use. The first risk rationalization constructs harm as tied to perceived causes of EVALI, and avoidance of those specific causes as the basis of protection from harm . Participants who concluded that EVALI was related to “fake” cannabis products, any “fake” products, or excessive vaping suggested that because they either did not use “fake” cannabis or nicotine products or vaped infrequently or “in moderation,” they were not at risk for EVALI because they did not use specific product types or vape excessively.
The second risk rationalization references not having experienced EVALI-like symptoms in the past as the basis of protection from harm . For example, one participant suggested that “at this point, I feel that if it [e-cigarette] was going to do that I feel that it would have done it already or something like that, so… I don’t think it’s going to be me that that happens to” encapsulates this point well. Participants who acknowledged but disregarded increased risk of harm from EVALI reported no change in or intention to reduce or stop ecigarette use. On the other hand, participants who perceived increased susceptibility to harm from EVALI considered changing their e-cigarette use with varying degrees of follow up . Some made no change because of chemical dependence/addiction . Though people knew they should not vape, quitting “was easier said than done.” Inability to carry through on desires to quit or cut back were also due to vaping as “like a lifestyle.” Reported behavior change due to EVALI included transitioning to exclusive cigarette use or increased hookah use to reduce vaping. Others were able to reduce use without substituting for other products. Participants “cut back a lot,” were “trying to Juul a lot less,” and not “buying my own” e-cigarettes and only using when offered by another person . Participants who developed a risk rationality which minimized perceived harm based on their understanding of the causes of EVALI or because of past experiences used those rationalities to justify continued e-cigarette use. EVALI “didn’t do anything to dissuade” people from vaping because they felt that “I don’t fall into the category of vaping” that puts them at risk for EVALI, such as cannabis vaping or frequent ecigarette use. Similarly, some participants continued vaping because they only “hit it every once in a while” or thought EVALI was “not going to happen to me because I’ve been doing this for a couple years now. I’ll be fine, you know?” In this study, three essential structures were found to mediate the relationship between exposure to EVALI information and behavior: awareness, information filtering, and risk rationalization. Awareness of EVALI was universally reported, and the legitimacy of EVALI as a health concern was generally accepted. There was suspicion, however, about whether EVALI was “fake news” or part of a government conspiracy. Accepted information about the causes of EVALI included fake cannabis vaping products, any fake vaping products, and excessive e-cigarette use. Behavior was linked to information filtering and EVALI risk rationalization. Those who acknowledged but disregarded the harms associated with EVALI reported no change in behavior. Those who accepted the harms associated with EVALI either reduced their e-cigarette use or intended to but did not follow through due to challenges of addiction.
Continued use was rationalized by not using implicated products, moderate use, or lack of previous EVALI-associated experiences. At the time data were collected, numerous reports on the harms associated with EVALI had been released and reported and the CDC recommended that people should refrain from using all e-cigarette products . Health communications research has found that harm messaging may be effective in discouraging vaping ,vertical grow system which would support the presumption that government reports of harm from e-cigarettes and warnings to refrain from e-cigarette use during the EVALI outbreak would be salient and heeded. However, the results of this study provide possible insights into why harm messages may not discourage vaping in young adult e-cigarette users. The essential structures in e-cigarette users’ experiences described above suggest a central role for cognitive processes in mediating the effect of EVALI information on behavior. Eveland’s emphasis on attention and elaboration as essential cognitive elements of learning from the news are reflected in the awareness and information filtering constructs . Participants were universally aware of EVALI-related harms and connected EVALI information to past experiences and existing knowledge. However, learning from news is also tied to motivation, and Kunda suggests that individuals motivated to reach a particular conclusion may attempt to be rational but selectively search for beliefs and rules or combine knowledge to create new beliefs to support a desired conclusion . This “motivated reasoning” would suggest that participants in this study filtered for information and developed risk rationalizations based on the underlining motivation to continue vaping. Thus, non-compliance with recommendations to refrain from e-cigarette use based on harm messaging may have less to do with the information needs of target audiences and more with their motivation to continue vaping. Importantly, this study identified EVALI specific situational rationalizations that could inform future public health efforts to address EVALI and e-cigarette-related harms that may have an impact on future quitting or cessation behavior . For participants who expressed a desire to cut back use or had begun to successfully do so, the EVALI outbreak acted as a focusing event on the dangers of e-cigarettes. The opportunity to support e-cigarette cessation was missed for some whose difficulty in cutting back or quitting led to continued use or transition to another product. Though both universities from which study participants were recruited have student health centers that offer cessation services, none of the participants who attempted or considered cutting back or quitting mentioned knowing about or seeking services from the student health center or other resources.
This underscores a potential need to make available cessation services tailored to young adult e-cigarette users and communicating the benefits of these programs from a harm reduction perspective; the results of this study provide some potential dimensions on which to tailor such programs. Outreach for cessation services for young adults through colleges and universities may be particularly important during focusing events to take advantage of heightened interest in cessation due to concerns related e-cigarette harm prompted by EVALI. The study was limited to college-going young adults, and thus additional research is needed among a community sample of young adults. Limiting participants to students at two universities may bias results to reflect the pool of knowledge or experiences available at those two universities. In addition, the sample of students in the analysis was drawn from those who have used tobacco products in violation of university policy and may have been particularly amenable to information justifying e-cigarette use, dismissive toward information discouraging ecigarette use, or doubtful of their ability to change behavior. Because this study focused on current users, we were unable to explore the ways in which adverse events may lead to quitting e-cigarettes. The results of this study are not generalizable to all college going young adults but provide descriptions of risk rationalities to be explored in future inquiry. While the risk rationalities described may not be exhaustive of e-cigarette user experiences and textural and structural descriptions could not be created for 9 focus group participants, the study findings provide a basis for guiding future research for public health actions against EVALI. Finally, this study highlights the need for greater understanding of how urgent public health events with large information gaps, such as EVALI and COVID-19, are understood by at-risk groups, and the most effective communication and intervention strategies to bring about desired change. Emotional health is an important component of overall well-being. Negative emotional functioning is closely associated with poorer physical health and everyday functioning, greater disabilities, and shorter lifespans . Poor emotional outcomes are common among persons living with HIV . Compared to HIV- individuals, PLWH are at greater risk for major depressive disorder and experience worse health-related quality-of-life, depression, and anxiety .