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China, where half of the adult male population smoke tobacco, has one of the highest global burdens of smoking. Smoking rates are even higher among people with HIV. People with HIV can be affected by smoking in multiple ways, including more severe HIV-related symptoms and worse antiretroviral therapy treatment outcomes. However, smoking cessation services targeted for people with HIV are not routinely integrated into HIV care in China. Given the widespread mobile phone ownership, an exploration of factors related to smoking among people with HIV in China who smoke could inform the design and implementation of mobile smoking cessation interventions that target the needs of this vulnerable population.
This study aims to explore the perspectives of smoking, barriers and facilitators to quitting, and perceptions related to a smoking cessation intervention delivered through behavioral counseling sessions and brief daily messenger service (WeChat)–delivered messages.
We recruited people with HIV from the People’s 4th Hospital of Nanning, Guangxi, China, and conducted semistructured face-to-face interviews. All interviews were audio-recorded, transcribed verbatim in Chinese, and translated into English for data analysis. We conducted a thematic analysis using a codebook, which was guided by a team-based consensus approach to identify 5 main themes. We also explored themes according to the demographic groups.
A total of 24 participants were enrolled in the study. The mean age was 37.2 (SD=13.5) years. The participants had lived with HIV for a mean of 2.4 years. The majority were male (18/24, 75%) and lived in urban or metropolitan settings (19/24, 79%). We identified five main themes: variable knowledge of the harms of smoking, both related and unrelated to HIV; willpower perceived as the primary quitting strategy; a duality of the effect of social factors on quitting; perceptions about optimal features of the smoking cessation intervention (eg, messages should be brief and most frequent during the first few weeks); and the largely negative impact of their HIV diagnosis on smoking behaviors. In addition, some themes differed according to participant demographic characteristics such as age, sex, and education level.
We identified barriers to and facilitators of smoking cessation among people with HIV in China by conducting semistructured qualitative interviews. Owing to the adverse impact of smoking on HIV outcomes, targeting cessation interventions to the unique needs and preferences of people with HIV in China may be needed to increase the effectiveness of future interventions. A pilot clinical trial will be conducted in the future to evaluate this behavioral counseling and brief daily messenger service (WeChat)–delivered messages approach among people with HIV who smoke in China.
Tobacco use is one of the most important preventable causes of premature death worldwide. In 2018, approximately 50.5% of adult males in China and 2.1% of adult females in China smoked cigarettes [
Although there is a large body of research on smoking cessation interventions for the general population [
Mobile phones are a widely used mode of delivery for behavioral interventions because they are readily accessible in many populations and have the potential for widespread use. In China, interventions using mobile technologies for smoking cessation such as SMS text messaging and mobile apps have demonstrated efficacy in smoking cessation [
The goal of this study was to identify factors related to smoking and cessation among people with HIV in China who were current or former smokers and to explore their perspectives on how to modify a draft of
The study was conducted at the People’s 4th Hospital of Nanning, Guangxi, China. The Guangxi Zhuang Autonomous Region (Guangxi) is located in the southwest region of China. From 2013 to 2015, HIV prevalence in Guangxi increased from 6.6% to 11.2% [
To recruit participants, research assistants contacted individuals who received HIV treatment at the outpatient HIV clinic or who were hospitalized in 2021. The eligibility criteria were as follows: aged ≥21 years, HIV seropositive, current or former smokers, receiving antiretroviral therapy, receiving HIV care at the clinic at the 4th People’s Hospital of Nanning, and speaking Mandarin Chinese. Exclusion criteria were as follows: any serious health problems that preclude participation, only smoke tobacco products other than cigarettes (ie, cigars and electronic devices), or inability to give consent.
A graduate student interviewer, trained by an investigator on the Guangxi Medical University team experienced with qualitative methods, conducted all interviews face-to-face in Mandarin Chinese. A health care provider from the HIV clinic (ie, physicians and nurse practitioners) was present during the interview and answered the participants’ medical questions, if any. All interviews were audio-recorded. Before the interview, the interviewer administered a survey assessing demographic information such as age, sex, ethnicity, education level, current smoking behaviors, and HIV status (self-reported diagnosis, diagnosis and time since diagnosis were later verified in the health record). The interviewer then conducted the interview following a semistructured guide with open-ended questions (
The research team entered participants’ demographic information using the Research Electronic Data Capture tools (Vanderbilt University) hosted at Boston University [
The ethics approval for this study was obtained from the institutional review boards of the Boston Medical Center (Institutional Review Board number: H-40111) and the Guangxi Medical University.
A total of 24 participants were enrolled; the majority of participants were male (18/24, 75%) and from outpatient HIV units (19/24, 79%;
Sociodemographic characteristics of smokers and former smokers with HIV in China participating in qualitative interviews (N=24).
Characteristics | Value | |
Age (years), mean (SD) | 37.3 (13.5) | |
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Male | 18 (75) |
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Female | 6 (25) |
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Primary or lower | 2 (8) |
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Lower secondary | 8 (33) |
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Upper secondary | 8 (33) |
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Tertiary or higher | 4 (17) |
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Missing | 2 (8) |
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Han | 13 (54) |
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Zhuang | 10 (42) |
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Other | 1 (4) |
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Divorced | 4 (17) |
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Married | 9 (37) |
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Unmarried | 11 (46) |
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Current | 18 (75) |
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Former | 6 (25) |
Smoking duration (years), mean (SD) | 18.6 (13.6) | |
Smoking amount (cigarettes per day), mean (SD) | 20.9 (15.4) | |
Duration of HIV diagnosis (years), mean (SD) | 2.4 (2.7) | |
Duration of ARTb (years), mean (SD) | 2.1 (2.8) |
aPrimary or lower education level in China is equivalent to grades 6 or lower in the United States; lower secondary education level in China is equivalent to grades 7 to 9 in the United States; upper secondary education level in China is equivalent to high school grades 10 to 12 or vocational training in the United States; and tertiary education level in China includes junior college, undergraduate, and graduate school.
bART: antiretroviral therapy.
Frequently noted themes with supporting codes and example quotations of smokers and former smokers with HIV in China.
Theme and parent code | Subcode | Additional subcode | Quotations | ||
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Knowledge | Source of knowledge | —a |
“I watched TV ads saying that smoking is bad and harmful to your health.” [Mb, 37, Cc] “[I learned smoking would impact my health from] Science, doctors, and people in the society.” [M, 33, C] |
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Knowledge | Health effects | — |
“Every year when I do physical examination, my lungs appear to be influenced by smoking to some extent...” [M, 24, Qd] “...I know it’s bad for health. But I don’t know the details on how and what exactly does it impact.” [Fe, 38, C] |
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Knowledge | Effects on HIV | — |
“I don’t think there’s a relationship between smoking and HIV infection. It may affect treatment.” [M, 48, Q] “There’s certainly a damage to the body, but I don't know much about it.” [M, 25, C] |
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Knowledge | Second- and third-hand smoke | — |
“I know second-hand smoke, but not third-hand smoke.” [M, 46, C] |
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Barriers and motivators to quitting | Barriers to quit | Risk perception |
“...people say it’s carcinogenic and affects my lungs. However, since I’m smoking, I shouldn’t think of those things too much.” [M, 21, C] |
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Barriers and motivators to quitting | Daily stress | — |
“Yes, it is possible [to not relapse if there were no recent stress from work].” [M, 24, C] |
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Smoking behavior | Feelings associated with smoking | — |
“When I talk about happy things, I smoke more cigarettes than usual.” [M, 25, C] “I smoked more when I was moody or unhappy and smoked less when I had lighter moods. Having stress also made me smoke more.” [M, 71, Q] |
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Strategies | Willpower | — |
“...NRTf or other medications are only facilitators. One’s own willpower is the most important and the most crucial.” [M, 46, C] |
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Strategies | Gradually decrease | — |
“I used to smoke, but it decreased slowly after I got sick, and then I really stopped smoking. When others give me cigarettes, I refused by saying I don't smoke anymore. I tend to avoid occasion involving drinking and socializing as much as possible.” [M, 43, Q] |
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Strategies | Suddenly decrease | — |
“I think it’s useless to slowly reduce the amount. If you want to resist the craving, give it up all at once, and you’ll have better chance of quitting successfully.” [M, 48, Q] |
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Knowledge | Available cessation resources | — |
“If I’m sick and the doctor says I shouldn’t smoke or drink, then I won’t smoke.” [M, 21, C] |
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QFLg intervention | Useful | Initial interest in joining |
“If I see it [smoking cessation counseling offered at outpatient clinic], I will go check it out and learn more about it.” [M, 29, C] |
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Quit attempts | Perceptions of cessation resources | Positive |
“It can be difficult to refrain from smoking without medications or other help.” [M, 37, C] |
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Quit attempts | Perceptions of cessation resources | Negative |
“No, there is no need [for other cessation resources]. I can rely on myself to quit.” [M, 30, C] |
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Additional concepts | E-cigarettes | Not useful |
“I smoked e-cigarettes and it was completely useless. So I shifted back to smoking cigarettes. After I tried smoking cessation, I smoked again and with greater quantity” [M, 48, Q] |
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Additional concepts | E-cigarettes | Useful |
“...I’ve used it [e-cigarettes] before. It can replace real cigarettes for a period of time.” [M, 24, C] |
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Smoking behavior | Reasons to start smoking | Curiosity |
“I was bored...And I was curious about the feeling of smoking, so I bought cigarettes to try.” [M, 21, C] |
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Smoking behavior | Reasons to start smoking | Social |
“I went out with friends, and they handed me the cigarettes.” [F, 22, C] |
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Barriers and motivators to quitting | Barriers to quit | Social pressure |
“After I was diagnosed with HIV, I stopped smoking for half a year and then started again. It was during banquets...I was given cigarettes...and then became addicted to it again after a while.” [M, 25, C] |
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Smoking behavior | Patterns of smoking | With whom |
“...when I’m hanging out with my friends, or when my friends give me cigarettes.” [F, 44, C] |
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Smoking behavior | Patterns of smoking | Setting |
“There is no such feeling [influencing others’ health] because most people smoke.” [M, 50, C] “When there are other people together I won’t smoke in cars. I choose to park on the side of the road, smoke and then leave. If I’m alone driving, I smoke with my windows open.” [M, 37, C] |
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Quit attempts | Details about attempts | — |
“...I was thinking too much, I couldn’t accept [the HIV diagnosis], so I started smoking again.” [M, 30, C] |
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Barriers and motivators to quitting | Motivators to quit | Social support |
“Quitting together is definitely better than quitting alone, no matter if it’s having one person as the leader or keeping track of each other’s progress.” [M, 46, C] “The encouragement of my family [helped with smoking cessation].” [M, 43, Q] |
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Barriers and motivators to quitting | Motivators to quit | Family pressure |
“My family didn’t allow me to smoke, doctors didn’t allow me to smoke either.” [M, 58, C] “When first I stopped smoking, I would go to places where I used to put cigarettes, but there was no way I could find them.” [M, 58, C] |
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Barriers and motivators to quitting | Motivators to quit | Positive impacts on others |
“[An advice for other smokers:] For the health of people around you, try your best to reduce the frequency of smoking, and be mindful of your surrounding.” [M, 33, C] “Because you have the responsibility to take care of the family, things you do are closely linked to the future of the family.” [M, 24, Q] |
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Barriers and motivators to quitting | Motivators to quit | Social influence and stigma |
“Smoking is not accepted by the society, it has no social status. Especially you are in a car with a woman. It is not good and you should not smoke continuously at least in terms of human nature...” [M, 46, C] |
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Knowledge | Second- and third-hand smoke | — |
“My family used to blame me for inhaling my second-hand smoke, but I can't control it.” [M, 48, Q] |
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HIV diagnosis | After HIV diagnosis | — |
“It probably does. I tried to control myself. After I was diagnosed with HIV, I did not touch a cigarette for at least two years. However, before Lunar New Year last year, I gradually started again. I smoked a little, then a little more, and then got used to it.” [F, 36, C] “Before, I smoked one pack in two days, after I learned it [HIV diagnosis], I decreased the amount.” [M, 29, C] “I don’t work anymore...Mainly because some jobs need a health certificate. Since I have HIV infection, I cannot apply for the health certificate.” [M, 25, C] |
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Additional concepts | ARTh use | — |
“After I was diagnosed with HIV, I stopped the quitting thoughts. I think smoking only has minor influence toward human body. I am taking medications everyday now, and that cause more problems.” [M, 46, C] |
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Barriers and motivators to quitting | Motivators to quit | Health benefits and physical changes after quiting |
“If I’m pregnant, I will definitely quit. Reminding someone like me that they have something important to concern [pregnancy etc.].” [F, 44, C] “My HIV infection and severe lung infection caused me to be hospitalized. I quitted smoking when I was being hospitalized. After I returned home, I didn’t smoke anymore...family members didn’t allow me to smoke either. I almost died.” [M, 48, Q] |
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Barriers and motivators to quitting | Barriers to quit | Daily stress |
“...I didn’t [smoke when hospitalized]. I started smoking three months after I was discharged...” [ F, 25, C] “...I was thinking too much, I couldn’t accept [the HIV diagnosis], so I started smoking again.” [M, 30, C] |
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QFL intervention | Length and time of intervention | — |
“Many people...are having a hard time accepting the fact that they’re diagnosed with HIV infection. If you talk to them about smoking cessation, they won’t be interested and won’t be willing to spend too much time on it.” [M, 24, Q] |
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QFL intervention | Modality | — |
“I will read WeChat messages. I usually read WeChat but not text messages.” [M, 24, C] “[WeChat is effective for the intervention, but] don’t construct a WeChat group [vs. private messaging]. That involves personal privacy and no one wants others to know about their condition.”[ M, 46, C] “A little bit. I am not very familiar with WeChat.” [M, 71, Q] “I might not answer all the calls...If the number is not from Nanning City, I won’t pick up.” [M, 58, C] |
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QFL intervention | Content | — |
“...I think it’s good to not send any messages at all...you are reminding me that ‘I am a smoker’.” [F, 36, C] “...most mobile messages...are advertisements so I get annoyed and don’t even read them.” [M, 48, Q] |
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QFL intervention | Length and time of intervention | — |
“When we have to wait in line to see a doctor, 40 minutes is a bit long, 20 minutes would be appropriate.” [M, 43, Q] |
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QFL intervention | Setting | — |
“It’s fine if I talk to someone face-to-face when I’m picking up my medications.” [M, 29, C] |
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QFL intervention | Frequency | — |
“The most important period for quitting in the first two weeks...If you can resist your cravings for the first two weeks, then you can stop smoking.” [M, 48, Q] |
aDashes represent when there are no additional subcodes.
bM represents participants who report to be male.
cC represents participants who report to be current smokers.
dQ represents participants who report to be former smokers and have quit smoking.
eF represents participants who report to be female.
fNRT: nicotine replacement therapy.
gQFL:
hART: antiretroviral therapy.
Most participants understood that smoking harms their lungs and health, but to different extents. For example, some participants knew that smoking leads to a worsening of their HIV treatment outcomes. Other participants had a limited understanding of the harms from smoking on their own health; for example, a person noted the following: “at least at the moment smoking does not cause any harm for me so far.” A participant expressed that as they had not heard anything from authoritative sources, they would still “take a chance” and think smoking is not harmful. When asked about the harm of smoking and the harm of second- and third-hand smoke, most participants had a general awareness from their medical providers, from television, or through social media, but they lacked specific knowledge of these terms.
Participants saw a close connection among smoking and mood, emotions, and mental well-being. About half of the participants agreed that emotions were closely linked with cravings to smoke. Several smokers mentioned that they “smoked more when [they were] moody or unhappy and smoked less when [they] had lighter moods.” Workplaces were often mentioned as environments that induced stress and anxiety, leading to smoking to calm down and escape.
When asked about known strategies for quitting, participants most often mentioned individual effort, determination, and personal willpower; for example: “quitting smoking mainly depends on [one’s] self-control of the impulse to smoke.” A few participants had tried or thought about decreasing the number of cigarettes smoked gradually, whereas others tended to decrease suddenly. Participants had limited awareness of available smoking cessation resources other than they “can rely on [themselves] to quit.” However, participants were willing to trust their medical providers. Specifically, a participant pointed out the following: “If I see it [smoking cessation counseling offered at outpatient clinic], I will go check it out and learn more about it.” Among those who understood the potential of e-cigarettes as a smoking cessation aid, almost all considered them “completely useless” and felt that e-cigarettes would worsen their cravings for cigarettes. For the subset of participants who acknowledged the availability of cessation resources, most thought that these methods would not be useful. A few participants also mentioned that candies and snacks were the distraction methods they used to quit smoking.
Most participants reported that they started smoking because of curiosity and social pressure. A participant noted that she started smoking when “[she] went out with friends, and they handed [her] the cigarettes.” Social occasions where they “were given cigarettes” prevented the participants from quitting. Several participants mentioned that they often smoked with friends; relapse after a quit attempt tended to occur because they saw friends smoking. Smoking with friends was considered a necessary part of social interaction. Regarding societal perceptions, some participants expressed a few negative connotations about smoking in public places because most people do the same. Smoking in cars was also common when passengers were smokers, but participants refrained from smoking with nonsmoking passengers. Participants noted that social stigma about their HIV diagnosis induced stress, and smoking was perceived as needed to alleviate this stigma-induced stress.
By contrast, participants also mentioned social pressure and peer support as facilitators to quitting. This included support from family and friends, supervision, and the benefits of quitting together. A participant mentioned the following: “the encouragement of my family [helped with smoking cessation].” Other social facilitators to quitting included awareness that their smoking behavior harmed their loved ones (such as children) or had a negative influence on their family. In some instances, participants felt that family members blamed them for creating harm through second- and third-hand smoke, and family members would pressure them to quit. Social stigma is believed to play a role in facilitating quitting. There was a sense that “smoking is not accepted by the society,” especially when there are others (such as women) nearby.
When asked about changes after receiving the HIV diagnosis, some participants decided to, or felt the necessity to, quit or reduce the number of cigarettes smoked immediately after the diagnosis or because of other health conditions. Participants expressed fear and sadness when they first learned about their HIV diagnoses. Some participants described the effect of hospitalization owing to severe lung infection as pivotal to quitting (“family members [prohibited him] from smoking”), whereas others described being forced to quit smoking while being hospitalized. Those people mostly “started smoking again after [they were] discharged from the hospital” owing to stress from life or work. Similarly, several participants “couldn’t accept [the HIV diagnosis], so [they] started smoking again.” Having an HIV diagnosis induced societal pressure and stigma toward patients, which was felt to prevent engagement in daily tasks. For instance, a few participants reported having trouble finding a job because some jobs required a health certificate that cannot be obtained with a HIV diagnosis. Therefore, many participants returned to smoking because of reasons such as dependency on nicotine, stress, and social pressure.
The participants were hesitant to use NRT, such as patches or gum, because they were not willing to take additional medications. Ultimately, for some participants, concerns about the side effects of antiretroviral treatment medications overshadowed the potential benefit of using NRT (eg, a participant thought the pain caused by antiretroviral treatment medications would cause more problems than smoking).
Participants were asked about their perceptions of the existing draft of the
This qualitative study is one of the first to explore the salient perspectives of smoking and quitting topics including smoking patterns, facilitators and barriers to cessation, perceptions of cessation resources, and HIV stigma in people with HIV who smoke in China. In general, participants were willing to quit if their health was affected by smoking or were told to quit by their health care providers. This finding is consistent with quantitative studies that found that people with HIV who smoke in China have a higher likelihood of reporting willingness to quit than the general population of smokers without HIV [
First, similar to previous studies examining smoking cessation strategies among smokers in China, participants identified willpower as a primary quitting strategy in this study [
Second, perceived stress was also a factor across several themes (eg, themes 1, 3, and 4). This finding is similar to previous studies conducted among teenagers and adults in China and Hong Kong, where peer pressure induced stress and need to conform, so that one could feel like they belonged to a social group—factors that could be addressed when designing cessation intervention content [
Third, regarding the exploratory demographic differences with respect to sex, we found several female participants who perceived NRT as more dangerous for them compared with men. This aligns with previous research among women who were pregnant or planning to become pregnant [
In addition, the draft telephone- and messenger-delivered smoking cessation intervention,
Similar to previous research on telephone-delivered interventions in China, participants preferred the WeChat messenger service platform rather than other mobile service platforms [
Although we obtained in-depth information from our sample, there was an imbalance across demographic categories. For example, the number of female participants was low (reflecting the lower proportion of Chinese females who smoked in general). We did not conduct additional methods such as member checking; however, our multiteam collaboration provided regular input into the analysis, which lends credibility. In addition, more recent surveillance data on national smoking trends among people with HIV in China are needed to promote targeted cessation efforts.
We examined the perspectives of people with HIV in China about smoking patterns, attitudes toward quitting, and HIV stigma to inform the development of a smoking cessation intervention to be delivered through counseling sessions and brief messenger service–delivered messages, specifically targeting this vulnerable population. In the future, the modified
Qualitative interview guide with open-ended questions.
Frequently noted themes with supporting codes and example quotations of smokers and former smokers with HIV in China.
nicotine replacement therapy
The authors would like to acknowledge the funding support from the National Institutes of Health or the National Cancer Institute under grant number R21CA243835. The paper’s contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health or the National Cancer Institute. Study data were collected and managed using Research Electronic Data Capture tools hosted at the Boston University, Clinical & Translational Science Institute 1UL1TR001430.
As this is a United States-China collaborative project, joint authorship and joint corresponding authorship is necessary to ensure joint and equal responsibility. LMQ and HL are the joint corresponding authors. SY and JH are the joint first authors. LMQ and SY contributed to the planning, monitoring, and analyzing of the study. HL and JH worked on planning, implementing, and gathering data in Guangxi, China. All authors reviewed the final manuscript.
None declared.