A qualitative assessment of the perceived risks of electronic cigarette and hookah use in pregnancy

This work was done in accordance with an approved IRB protocol from Baylor College of Medicine (H-34725). This work adheres to RATS guidelines for reporting the results of qualitative research [32]. Eleven focus groups were conducted at three clinics in the greater Houston area with a total of 87 pregnant women participating. A minimum of three focus groups were conducted at each location to minimize bias based on clinic demographics. Inclusion criteria included gravidae currently enrolled in the CenteringPregnancy® prenatal care group who had English or Spanish proficiency and were able to provide informed consent. Through the CenteringPregnancy® model, pregnant women meet once to twice a month for routine clinical prenatal care and are able to share pregnancy experiences with women who have similar due dates [33‐35]. At our clinics, women are offered either the standard of care (ie to meet with their physician or midwife one-on-one) or to participate in the CenteringPregnancy® groups. Due to the nature of focus group research, having a group of 6-12 people is ideal [36], making the CenteringPregnancy® groups suited for this research. Women were informed about the research project at the meeting prior to our focus group, and it was explained that their participation is voluntary and not part of their prenatal care. The focus groups were conducted after their regularly scheduled meeting so women who did not wish to participate were able to leave before commencement of the focus group.

The groups were conducted at the Cullen Teen Health Clinic, Vallbona Health Clinic and The Center for Children and Women (Table 1). At the Cullen Clinic the majority (57 %) of pregnant women who participate are African American, and 40 % are Hispanic. At Vallbona Health Clinic the overall composition of the CenteringPregnancy® program are 6 % African American, 6 % Caucasian, 82 % Hispanic and 6 % Other. The groups at The Center for Children and Women are 68 % Hispanic, 23 % African American, 6 % Caucasian and 2 % Other. No identifying or demographic information was collected from the participants in accordance with our approved IRB.

For the 11 focus groups, we utilized established CenteringPregnancy® prenatal care groups. Ten semi-structured, focused, lead-in prompts were used as a framework for discussions (Table 2). These prompts were designed to understand the women’s perceived risk of e-cigarette and hookah use in pregnancy, to determine alternate terms used when discussing e-cigarettes and to determine if there is a potential stigma associated with e-cigarette use in pregnancy. A minimum of two study facilitators, as well as a Spanish translator (as needed), attended each group. Upon entering the room the facilitators introduced themselves, explained the purpose of the study, and explained that the discussion would be audio recorded. The facilitators discussed that no names should be used during the focus group to protect anonymity. Informed consent was obtained in writing from all participants prior to starting the discussion. All participants received a $10 gift card for completing the study.

All facilitators and translators are experienced researchers in the field of OB/GYN. Our team was advised by two behavioral psychologists (T. Northrup and A. Stotts) and two obstetricians (J. Levison and K. Aagaard) with expertise in focus group research. Analysis was performed under the direction of T. Northrup and A. Stotts.

Each focus group lasted approximately 20 min including introduction and obtaining informed consent. Questions were asked in English, and translated into Spanish as necessary. Answers in Spanish were translated into English as necessary. Facilitators transcribed the responses in writing and compared their written reports at the end of each group discussion. Focus groups were conducted until saturation was achieved and no new data were emerging as determined by a lack of additional themes from the final two focus groups. Any questions the participants had concerning e-cigarettes or hookah were answered upon completion of the focus group in order to avoid potential bias.

All audio recordings were transcribed by individuals proficient in English and Spanish. NVivo 9 software (QSR International, Burlington, MA) was used for line-by-line coding of the transcribed audio recordings. Data coding and interpretation was performed by three independent facilitators. Due to the large number of study participants, each subject was not assigned a code number. Instead, data were coded into nodes (a node being defined as an overarching content area) according to the lead-in prompts. Each facilitator independently searched for themes (a theme being defined as an interpretive narrative which often stems from or connects nodes) which emerged from the focus groups [37, 38]. The three facilitators discussed their interpretation of both major and minor themes, and only ones which were unanimously agreed upon were considered as themes of the focus group discussions. Major themes were defined as the most common theme brought up in discussion for the specific lead-in prompt; while the minor themes were the second most common theme.

To increase rigor in our analysis, transcripts were given to two obstetricians who had not attended the focus group discussions and who were instructed to find the themes which emerged throughout the focus groups. These obstetricians have experience with nicotine research in pregnancy as well as focus group analyses. Their analysis was completely separate and blinded from the analyses of the three facilitators. Only themes which were unanimously determined are reported herein.

Focus group discussions started with the prompt, “Tell me what you know about electronic cigarettes.” This allowed assessment of the baseline knowledge of study participants. While there was generally one person in each group who had not heard of them, participants were overall familiar of e-cigarettes with an awareness that they (1) were sold in different colors and flavors, (2) contained nicotine, (3) may be used as a smoking cessation device, and (4) can be addictive. Participants were also asked where they had seen e-cigarettes advertised and sold. The responses revealed that they had seen them sold in gas stations and at the mall, and advertised on television and via the internet. The following are representative of overall participant responses:

Further prompts were used to understand how participants perceived e-cigarettes, especially in comparing them to traditional tobacco cigarettes. They were asked, “How do electronic cigarettes compare to regular cigarettes?” One major theme that emerged is that women believed e-cigarettes to be a healthier and safer alternative to smoking combustible tobacco cigarettes. Subthemes addressing (1) the lack of smell or second hand smoke, (2) that e-cigarettes contain vapor and are not lit or burned, (3) that e-cigarettes do not have as many chemicals, and (4) that e-cigarettes can be used indoors were reasons given that they were thought to be a better alternative to smoking regular cigarettes.

In order to assess the perceived risks of e-cigarette use during pregnancy, two different lead-in prompts were utilized. First, gravidae were asked, “What would you say to a pregnant friend who is using electronic cigarettes?” After they finished answering this question a follow-up prompt was asked: “What would you say to a pregnant friend who is using electronic cigarettes to quit smoking traditional cigarettes?” Although a common theme emerged in all focus groups that e-cigarettes are a safer alternative compared to regular cigarettes, when the discussion focused on their use during pregnancy, the major themes that emerged were that e-cigarettes are (1) not safe, (2) likely damaging to the baby, and (3) as bad as regular cigarettes during pregnancy. Minor themes which emerged were the suggestions to quit smoking either (4) cold turkey or (5) using the patch or gum. However, a contradicting minor theme which emerged was that e-cigarette use in pregnancy is not as bad as smoking if they are being used as a smoking cessation device. Because the focus groups were deidentified subjects and no personal information was collected, the current smoking status of participants was not known.

There is a well documented stigma against smoking combustible tobacco cigarettes in pregnancy [39, 40]. In order to determine if there is a similar stigma against e-cigarette use in pregnancy, two lead-in prompts were utilized. Women were asked, “What do you think when you see a pregnant woman smoking cigarettes?” followed by the question: “What would you think if you saw a pregnant woman using an electronic cigarette?” The women reported that smoking is not an acceptable option for pregnant women. When asked about smoking regular combustible tobacco cigarettes in pregnancy, participants said that (1) there are many health problems that can arise from smoking during pregnancy and (2) the behavior is selfish and irresponsible. When asked about the use of electronic cigarettes in pregnancy, facilitators noted that reactions were subjectively not as strong, but the women iterated their belief that there were still risks and therefore thought that the mother was not taking care of her baby’s health. However, a minor theme emerged that because there are fewer side effects, the mother might be using them to reduce the risks to her child.

Smoking stigma:

Electronic cigarette use stigma:

To determine what words are colloquially being used to discuss and describe electronic cigarettes participants were asked, “What words or terms have you heard used to describe electronic cigarettes?” The main term utilized is “Blu,” which is a brand name of e-cigarettes. Other terms which were mentioned, but were minor themes were (1) e-cigs, (2) vaporizers and (3) smokeless/ smokefree.

To assess baseline knowledge of perceived risks of hookah use in pregnancy, participants were asked “Tell me what you know about hookah.” Of note, hookah is known in the Hispanic community as “Pipa.” Although few Hispanic women knew what hookah was, translation to Pipa led to the majority of participants to engage in conversation. The two major themes which arose from discussion of hookah use were that (1) it is popular with teenagers and (2) hookah bars are a common place to use them. Other minor themes which arose included that (1) the tobacco comes in different flavors and (2) many have seen hookah being used on television programs such as reality shows and telenovelas.

When asked “What would you say to a pregnant friend who is using hookah?” the major theme across all groups was unanimous. Women believed that hookah use was dangerous for the mother and baby. Of note, one participant had been using hookah until she found out she was 8 weeks pregnant. She immediately quit and was worried about the potential damage she had done to her fetus.