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Smoking and tobacco
Original research
Young adults’ cigarillo risk perceptions, attention to warning labels and perceptions of proposed pictorial warnings: a focus group study
  1. Stefanie K Gratale1,
  2. Michelle Jeong1,
  3. Anupreet Sidhu2,
  4. Zeinab Safi1,
  5. Andrew A Strasser2,
  6. Cristine D Delnevo1,
  7. Olivia A Wackowski1
  1. 1Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA
  2. 2Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Stefanie K Gratale; skg83{at}cts.rutgers.edu

Abstract

Objective Although cigars pose similar health risks to cigarettes, they are not uniformly required to carry a warning label on their packaging in the USA. The US Food and Drug Administration’s 2016 deeming rule established a cigar warning requirement, but it was challenged in federal court for failing to document warning effects on prevention/cessation, thus necessitating an evidentiary base for such requirements. We sought to explore young adult users’ understanding of cigarillo risks and addictiveness, as well as their perceptions of current (voluntary) and proposed cigar warning labels.

Design In December 2020–January 2021, we conducted eight focus groups with young adult cigarillo smokers. We asked participants their first associations of cigarillos and beliefs about product harms/addictiveness, and then discussed existing warning labels and examples of potential pictorial warnings.

Setting Focus groups were conducted remotely via the Adobe Connect platform, with participants from 20 US states.

Participants Participants included 42 young adults (ages 18–29; 50% male), who were recent cigarillo users (ie, past 30 days) or less frequent users (ie, past 12 months).

Results Participants frequently used cigarillos as blunts and often conveyed uncertainty about cigarillo risks and addictiveness, in general and relative to cigarettes. Participants typically paid little attention to current text warnings, but many expressed that pictorial warnings would more effectively promote knowledge of product risks and discourage use among prospective users.

Conclusions US young adult cigarillo users may lack knowledge about product risks and addictiveness. Standardised warning requirements, particularly pictorial labels, may help address this knowledge gap and deter use.

  • PUBLIC HEALTH
  • QUALITATIVE RESEARCH
  • PREVENTIVE MEDICINE

Data availability statement

Data are available on reasonable request. Data may be made available by the authors upon review of reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-061064

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    Strengths and limitations of this study

    • This paper helps to address a research gap regarding the need for standard cigar warning label requirements in the USA, by exploring current young adult users’ understanding of product risks/addictiveness and the potential utility of uniform (possibly pictorial) warning labels.

    • Strengths of this study include a focus on young adults (a key demographic for US cigarillo consumption) and inclusion of both frequent/recent and less frequent users, as well as consideration of results based on patterns/type of product use (eg, for blunts).

    • A potential limitation of the study is the generalisability of our findings, as we used a relatively small convenience sample that was not demographically representative of the overall cigarillo smoking population.

    • The study was conducted online, which may have influenced the natural flow of discussion typically occurring during in-person focus groups, but this allowed us to recruit a more geographically diverse participant sample, representing 20 US states.

    Introduction

    Cigar smoking, like cigarette smoking, is associated with health risks including cancer, coronary heart disease and all-cause mortality.1 2 Cigar products, and cigarillos in particular, are popular among minority groups3–6 and young adults, the latter of whom cite features such as affordability and flavours (which increase product appeal and reduce perceived addictiveness7) as reasons for smoking.3 4 8 9 Some also misperceive cigarillos as more natural and less harmful than cigarettes and/or characterise health effects as less serious and less likely to occur.10–12 Research suggests that some of these perceptions can be influenced by product use patterns and modifications (eg, for use as blunts),13 though cigarillo risk perception studies do not consistently consider such patterns.

    Warning labels are important tools in disseminating information about tobacco risks, and can increase risk knowledge14 and encourage tobacco use cessation.15 16 Yet their effectiveness relies on prompting attention and cognitive processing.17 Pictorial warnings on cigarette and e-cigarette packs can be effective in sparking attention, recall and desired changes in attitudes and intentions,18 19 including among young adults.20 Research about cigarillo warnings is more limited, but some studies support greater success of pictorials, especially graphic ones, versus text warnings in eliciting attention and stronger reactions.21 22

    While cigarette packs have been required for decades to display warning labels,23 24 cigar packaging is not uniformly subject to such requirements. In 2016, the US Food and Drug Administration’s (FDA) deeming rule for cigars established a requirement for text warnings on all cigar packaging. But this was challenged in federal court for failing to document warning effects on prevention/cessation, indicating a need to build this scientific evidence base.25 While some companies voluntarily comply with FDA’s warning guidance, the lack of enforcement ability has resulted in non-uniform warnings (eg, regarding presence/absence, size) across brands and channels.26–28

    Given the need for a robust evidence base regarding cigar warning label requirements and factors that influence their efficacy,29 we conducted a series of focus groups exploring young adult cigarillo users’ perceptions of cigarillos and their risks, and thoughts about cigarillo warning labels. This paper describes participants’ experiences and beliefs pertaining to cigarillo risks and addictiveness (including variations in risk perceptions based on type of use, such as modifications for use as blunts), attention/reactions to current cigarillo warning labels, and opinions regarding possible pictorial warnings.

    Methods

    Participants and recruitment

    Between December 2020 and January 2021, we conducted eight online focus groups with a convenience sample of young adults (ages 18–29), each group ranging from 4 to 7 participants. Four groups included recent cigarillo users (ie, past 30 days), and four included less frequent users (ie, past 12 months). Participants were recruited electronically and screened for eligibility by a contracted research company (The Research Associates), which also hosted the online platform (Adobe Connect) used for sessions. Consent letters were sent to participants before group sessions for review, and the moderator reiterated participants’ rights and confidentiality at the beginning of sessions, at which point participants provided verbal/visual consent (raised hands) that they wished to proceed with participation. The research company instructed when a sufficient number of participants had signed up for each focus group; no participants dropped out after their focus group commenced. Prior to group sessions, participants completed a brief survey including measures on demographics, tobacco use and cigarillo perceptions. There were no repeat interviews.

    Study procedures

    Data presented in this manuscript are based on a subset of topics explored in the focus groups. Each session lasted about 75 min and was moderated by the study’s principal investigator (OAW, PhD, MPH, is a female Associate Professor with training in focus group moderation and prior experience moderating 24 focus groups and 50 interviews. OAW had no prior relationship to participants.) and recorded. Research team members (who took notes) and research company personnel joined the groups but were not visible to participants. Participants were told there are no right/wrong answers, as the moderator was interested in their perspectives on cigarillos and potential warning labels. After participant introductions, the moderator briefly showed images of different cigar product types (including cigarillos, traditional and filtered cigars) and explained that the session would focus on cigarillos. The moderator then asked what first comes to mind when participants think of cigarillos. Next, participants were asked what they had heard about health risks of smoking cigarillos, and whether they think cigarillos are addictive. The next question asked how much participants noticed or paid attention to current warning labels on cigarillo packs or ads. Then, participants viewed, rated and discussed three of seven cigar warning statements put forth by the FDA (see online supplemental table S1)25 (statements were split across groups) that were paired with a variety of test pictorial images (results regarding these specific statements/images are not included in this manuscript). Lastly, the moderator asked participants what they thought about moving from text-only to pictorial cigarillo warnings.

    Data analysis

    After session transcripts were checked for accuracy and cleaned, data were coded and analysed using a thematic analysis approach,30 consistent with previous qualitative research on this topic.22 29 Research team members cleaned and validated the transcripts, which were not returned to participants. The research team agreed that the groups achieved sufficient data saturation, with no substantive unique themes emerging by the last group. Two research team members (OAW and ZS) developed a coding guide based on questions in the moderator guide (which was based on our research questions and prior experience/literature, and included topics such as warning attention and perceived addictiveness), repeated transcript readings, and preliminary research memos and notes based on these readings. During this process, large samples of transcript text were included in the memos and annotated (by OAW) with draft codes to exemplify their use. The coding guide organised these codes per major categories of inquiry (first associations, cigarillo risk perceptions, addiction perceptions, warning attention, support for pictorial warnings).

    After discussion and agreement (by OAW and ZS) on these codes and their guide definitions and application in the sampled text extracts, the codes were applied to the full transcripts using Atlas.ti software. Drafts of results were then further developed and refined based on reviews of coded transcripts (by OAW and ZS) and agreement that the results narrative fairly represented the data. Additional project team members (SKG, MJ and AS) reviewed these draft findings (participants did not review results), which initially included numerous example quotes, to further validate the descriptions in the results narrative and provide input on final quotes selected (sometimes edited for brevity and clarity).

    Patient or public involvement

    Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

    Results

    Participant characteristics

    Forty-two young adults from 20 US states participated in study sessions. Table 1 describes participant demographics, tobacco use history and likelihood of product use within the next 6 months, as reported in the presession participant survey. It also presents presession survey results on cigarillo harm perceptions and frequency of noticing warning labels on cigarillo packs.

    View this table:
    Table 1

    Focus group participant* demographics

    First associations

    When asked what first comes to mind when thinking of cigarillo products, participants across groups commonly referred to marijuana and/or smoking blunts. Many indicated typically using cigarillos for blunts, with all tobacco removed. Participants occasionally indicated smoking cigarillos as intended:

    ….That’s the only thing I’m using them for [marijuana, blunts]…I also smoke them for tobacco sometimes, but rarely. (female past-30 day user)

    Some participants mentioned specific brands (eg, Swisher Sweets, Black & Mild), as well as cigarillos’ availability in different flavours. Participants also referenced the cheap price of cigarillos and their easy/convenient access:

    …That’s the first thing I think of, convenient price. (female past-30 day user)

    …Convenient, you can almost…get them at any corner super easily, you know, convenience shops… (male past-30 day user)

    Cigarillo risk perceptions

    When asked what they had heard/thought about health risks of cigarillos, participants offered a wide range of responses, sometimes expressing uncertainty. Participants generally did not describe specific risks, but referenced cigarillos as being ‘bad’/‘not good for you’ and/or compared them to cigarettes. Across groups, several participants stated they assumed cigarillos have the same/similar health risks as cigarettes. Some thought cigarillos/cigars might be somewhat more harmful, potentially because they are unfiltered:

    Yeah, I mean I’ve gotten the impression that cigarillos are a bigger health risk just because there’s no filters… (male past-30 day user)

    However, others across groups noted that they heard/believed smoking cigarillos was less harmful than cigarettes (a belief also endorsed by 26% of participants in the presession survey). These beliefs were sometimes influenced by how the product was used/modified (ie, as blunts, with removal of the tobacco inside):

    I don’t think a cigarillo would be as bad as like a cigarette…you take the inside out (male past-12 month user)

    Participants also believed cigars/cigarillos were more natural and had fewer chemicals and additives than cigarettes, which they thought could make cigarillos less harmful:

    …A little bit more natural. There’s less paper involved, so it’s more so just the leaves and so there’s less, you know, chemicals, paper, like that. And it’s more or so, you know, wholesome. (male past-30 day user)

    …If it is the actual leaf itself, you know, it’s nothing artificial, so, it might not cause as much harm as something, you know, made in a factory. (male past-12 month user)

    Along the same lines, I guess like why I’m more okay with cigarillos from smoking cigarettes is from what I’ve heard and read. Cigarettes have like more just chemicals sprayed on them and more things added that you know, lead to more tar or that works on your lungs. As far as I heard that cigars and cigarillos either with just the tobacco or they just have less other stuff added to it. (male past-30 day user)

    Overall, though, several participants expressed uncertainty and lack of knowledge. This included hesitation and qualifier language (eg, ‘not really sure’), as well as explicit statements indicating they lacked knowledge about cigarillos and/or their risks compared with cigarettes. One person mentioned not knowing that the outside wrapper was made out of tobacco when they first started using cigarillos. Some mentioned not having thought about potential health risks before, because, for example, they had not heard much about cigarillo risks, or because they used the product mostly for blunts:

    …I haven’t really heard as much of the risks as like, say cigarettes because I feel like that’s maybe been around for longer and people have, like, done more research on like the risks of that. (female past-12 month user)

    …I used them mostly for the wraps, so I’ve not considered the health risk much of like, actually, just smoking them… (female past-30 day user)

    Cigarillo addictiveness perceptions

    Perceptions of cigarillo addictiveness varied widely. Several participants across groups believed cigarillos could be addictive because they are tobacco products and/or because they contain nicotine. Yet others doubted cigarillo addictiveness or thought they were less addictive than cigarettes, citing patterns of product use that seemed inconsistent with addiction, like ‘not inhaling’ smoke, not using them as frequently and/or using them primarily as blunts. Others were unsure about whether cigarillos contained nicotine (including in the wrapper) and/or thought the nicotine was removed when taking the tobacco out for blunts:

    …I personally don’t think it’s addictive. It’s like if you’re using it for weed, it shouldn’t be. I mean, like the nicotine, the addictive substance, is taken out… (male past-12 month user)

    Beliefs that cigarillos were less addictive than cigarettes or not addictive were also driven by participants’ perceptions that they were not personally addicted and/or not knowing others addicted to cigarillos:

    …I’ve never personally known anyone who has been addicted to just smoking cigarillos. So, I don’t think that they’re addictive…Or as addictive as like a [normal] cigarette… (female past-30 day user)

    Cigarillo warning attention

    Participants were asked how much they noticed or paid attention to warning labels on cigarillo packs and/or ads. Some indicated they had noticed/still notice warnings. Yet, participants across groups generally expressed that they paid little to no attention to warning labels, largely because they had seen and/or read the same ones before, knew what they said, and were not getting ‘new’ information from them. Similarly, participants expressed being desensitised to warnings, either because of repeated exposure over time or because they did not find the warnings personally relevant due to their own usage patterns (eg, infrequent use, use as blunts):

    I see them, but I don’t pay attention to it. I don't think I've ever actually read one. (male past-30 day user)

    …Towards the beginning when I first started buying them, yes, I was more conscious about it. But now, it’s like, it’s just the same thing every time. So, I don’t really pay attention to it anymore. (female past-30 day user)

    I personally don’t really pay attention to them much. I’m just using it for the wrap. (female past-30 day user)

    Further, one participant stated she had not seen any warning labels on the single stick cigarillos she purchased:

    …whenever I purchased Black & Mild, I only purchased them like singles and I’ve never seen any kind of warning label on the single ones. (female past-12 month user)

    Participants also indicated that cigar warning labels are not attention grabbing relative to other parts of cigarillo packs or more distinct product warning labels. Some commented that the current warning was not visually noticeable, while several described having seen pictorial warnings, which were stronger and more noticeable, on cigarette packs in other countries:

    …Everything else, you know, on the labels, it kind of stands out more than that because, you know, it’s normally just a white label or yellow label and you kind of have it disappear compared to the other things… (male past-30 day user)

    …In the Netherlands…all of their cigarettes and all of their products were like distinctively, like disgusting images, then you’re kind of reminded every second of what you’re smoking vs like the Swisher Sweets and the packages are colorful. Like they make it look fun and inviting vs, you know, the alternative. (female past-30 day user)

    Support for and perceived effectiveness of cigarillo pictorial warning labels

    Although some participants noted the potential for pictorial warning labels (PWLs) to make cigarillo packs more ‘crowded’ or reduce the size of warning text, participants across groups generally expressed support for the use of pictorials. Participants believed PWLs would be more likely to grab their attention than text warnings, and could communicate messages more quickly and effectively. Further, they expressed that PWLs could make cigarillo risks feel more ‘realistic’ and ‘personal’, elicit stronger reactions by telling a story, and have more resonating power:

    Yeah, I think it’s totally a good idea to add images just because it’s so easy to disregard text. I mean most of the things that we buy, we don't read half of the information listed on it. So, we’re a very visual people. I think images speak louder than words in a lot of senses. (male past-30 day user)

    …It definitely does better with the pictures. It resonates with me personally. Yeah, I mean, like seeing another human being going through that, because that can be me one day, you know, we say if I continued smoking or whatnot. But with the text, you know, I mean, you can just bypass that… (female past-30 day user)

    Some participants stated that PWLs could prompt consumers to reconsider their product use by making them think about risks they might otherwise ignore; in fact, some noted PWLs might subtly/’subconsciously’ affect consumers by leaving an image in the ‘back of their minds’:

    Yeah, I think it’s a great strategy to try to gear people away from purchasing these or just at least make them think…Because I think it will draw people’s attention and it could make them rethink before purchasing or how frequently they do use them. I know for me, it would. (female past-12 month user)

    …Even if I’m not like consciously thinking about it more, I feel like, I don’t know, the images kind of like stick in your mind a little bit. So, it kind of just might be at the back of [my] mind a little bit more which I guess ultimately could change how often I bought them or something. (female past-30 day user)

    …I used to live in Canada and I had a friend who used rolling tobacco. And he had a pack once that had a pretty gruesome image on it of brown lungs. And I feel like subliminally, I was less likely to like accept his offer of a cigarette because there was that image just around like in my mind sort of. So yeah, I think it is, I think it’s very real… (male past-30 day user)

    However, across groups, several participants indicated that for various reasons, they did not think PWLs would deter them or other cigarillo smokers. Some specified that they already knew and accepted the risks, were already addicted, used cigarillos infrequently and/or primarily used cigarillos for smoking marijuana. One person explained that for a warning to be effective for more cigarillo smokers, it would have to be clearer that the warning applies to the entire product, including the outside/wrapper:

    …images are much better than just the words. So, I think I’m definitely in favor of that. With that being said, this won’t change my mind at all because, you know, I’m already addicted so I’m going in to buy it. (male past-30 day user)

    I think also a large amount of people don't use these to smoke the tobacco inside of them and just use it for weed. So, the tobacco warnings aren't really deterrent at all. (male past-12 month user)

    …[PWLs] would also have to be more targeted to like the whole of the product. So, when I think of these warnings, I think mainly of what’s inside, the tobacco inside it… (female past-30 day user)

    Yet many participants also noted that even if PWLs would not personally stop them, they could be important for discouraging use among youth/young people, particularly those who had not started:

    … I feel like it [PWLs) would discourage a lot of like first time users. I think some people are already too addicted to probably even care about the image. But let’s say it’s my first time smoking, I go buy me a cigarillo. And I look at it and I see the image on there. It may stop me from buying it. (male past-12 month user)

    Discussion

    This study presents the perspectives of young adult cigarillo users regarding cigarillo risks, current warning labels and potential use of PWLs for cigarillos. In addition to some perceptions that cigarillos are more ‘natural’ types of tobacco, results suggest a general lack of knowledge about risks, inattention to existing warnings and a preference for PWLs. Consistent with other research,8 many participants indicated typically using cigarillos for blunts, which influenced their risk perceptions and attentiveness to warnings. This shows that the manner in which cigarillos are used (eg, for blunts) is directly relevant to risk perceptions, a finding that expands prior research in this area. Infrequent use also associated with lower perceived vulnerability and reduced attentiveness to warnings. Although less frequent product use may indeed be associated with lower health risks, it was notable that participants across groups conveyed a general lack of knowledge of cigarillo harms and infrequent thoughts about such harm. Common areas of uncertainty included nicotine presence in cigarillo wrappers, potential harm of cigarillos when used as blunts and relative risks of cigarillos versus cigarettes, for which participants expressed disparate opinions. These findings indicate potential confusion regarding overall cigarillo risks and risks of smoking a whole cigarillo or part (eg, the wrap). They also highlight a need for strengthening cigar/cigarillo warning label standards to improve their efficacy as a tool for increasing understanding of product risks.

    The FDA has emphasised the importance of warning labels as a policy mechanism to promote product awareness and knowledge of risks.31 While strengthening label standards may include strategies to improve attention to them, it may also entail the development of additional warning message statements to improve knowledge,32 and/or more tailored versions of existing ones.13 29 For example, even a slight adjustment to the current FDA recommended nicotine warning to explicitly include the wrapper (eg, ‘This product, including the wrapper, contains nicotine…’) may be useful to address uncertainty and increase basic knowledge about cigar/cigarillo wrappers, which are made from tobacco.

    Our findings related to warning attention further underscore the need to optimise warnings. Participants commonly expressed inattentiveness to warnings because of low noticeability, desensitisation to warnings and/or feelings of low relevance based on use patterns. Some also indicated that warnings were not very noticeable when compared with other pack features; this underscores a challenge that regulators face in implementing effective warning standards for cigars, in light of attractive, competing visual elements on packs (eg, colours, promotions) that may overshadow and/or interact with warning labels. One participant highlighted the lack of any observed warnings on Black & Mild cigars sold as singles. This is concerning considering that users may not be getting relevant warning exposures on singles of popular brands like Black & Mild—which are typically smoked as a tobacco product (ie, not as blunts) and account for a significant portion of product sales.33 34 Many of these issues around warning noticeability could also apply to cigarette and other tobacco packaging, yet in this context, they highlight concerns about the inconsistent application of cigar warnings and the need for uniform regulations like those applied to cigarettes. Recent survey research has found high cigarillo harm perceptions among users who more frequently noticed warnings,13 but relatively low levels of noticing cigarillo warnings.35

    Despite overall inattention to warnings, participants across groups supported the use of PWLs on cigarillo packaging, even stating they were drawn to PWLs they previously encountered. Consistent with broader PWL research, participants perceived PWLs as more attention getting and better able to elicit emotional/cognitive reactions than text warnings.18 21 36 Indeed, several noted the stickiness of pictorials and their potential for subconscious influence by staying in the ‘back of [your] mind’; this hints at the utility of pictorials not just in gaining attention, but in sparking cognitive processing, which is crucial for persuasive effects.37 38 Of consequence, even though many participants did not see PWLs as likely to influence them, several attested that PWLs would be important for vulnerable populations/susceptible non-users, including youth, and could hinder initiation. The results regarding PWLs further underscore that many of the same issues regarding tobacco labelling in general affect cigarillo labelling too, and reinforce the importance of making cigar warning standards commensurate with those of cigarettes.

    This study has some limitations that warrant discussion. First the generalisability of our findings may be limited by the use of a relatively small convenience sample, which over-represented White participants and underrepresented Black participants relative to population estimates of cigarillo use. This may have influenced the dearth of discussion about ‘freaking’ (or removing the filter paper from Black & Mild cigarillos), which has been documented as popular among young people, particularly Black and Hispanic youth,39 although this was a practice about which we did not specifically probe participants. Second, due to COVID-19, groups were conducted online, which may have influenced the natural flow of discussion typically occurring during in-person focus groups, though the moderator intentionally solicited feedback from all participants and incorporated opportunities to share additional feedback. Third, our groups included a mix of participants who did and did not also smoke cigarettes; groups were not stratified by cigarette smoking status. In the context of designing effective warning messages for cigarillos, future research may benefit from a more focused examination of how cigarillo risk and relative risk perceptions may differ based on poly-tobacco use.

    In summary, our findings point to important avenues for future research and health warning strategies for addressing cigarillo risk-related knowledge gaps and use behaviours among young people; moreover, they may help inform FDA regulation of cigar/cigarillo warnings. Future research should further examine making labels more salient, (eg, colour contrast, pictorial elements)40 41 and communicating risks of the ‘whole’ product (ie, including the wrapper), and should test the interaction of potential labels with other pack features (eg, pack size, colours, ‘natural’ descriptors). From a regulatory standpoint, it may be important to pursue some minimum standards that would apply to all cigar/cigarillo products and incorporate best practices to target different user types. This could encompass considerations of pack size (eg, warnings for all cigar pack sizes; potentially banning sales of singles), tailored label content (eg, acknowledging risks to occasional users), and use of pictorials, among other options. More broadly, some of the issues raised here, such as perspectives of infrequent and/or blunt-only users that highlight potential effects of type of use/use modification on risk perceptions, could also be addressed through communication campaigns if warning standards cannot resolve all concerns. Ultimately, enhancing young adults’ knowledge of cigarillo products and their risks—and discouraging initiation/use—will likely warrant targeted public health campaign efforts as well as regulatory action to strengthen and standardise cigar/cigarillo warning label requirements.

    Data availability statement

    Data are available on reasonable request. Data may be made available by the authors upon review of reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the Rutgers Biomedical and Health Sciences Institutional Review Board (Reference: Pro2020000397). Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    The authors thank Mariam Rashid and Erin Miller Lo for their assistance with project implementation, focus group note-taking and preliminary data review/cleaning.

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    Footnotes

    • Contributors SKG contributed to focus group observation and note taking, transcript cleaning/validating, review of findings, interpretation of data, paper writing and paper editing. MJ contributed to focus group observation and note taking, review of findings, interpretation of data and paper editing. AS contributed to interpretation of data, paper writing and paper editing. ZS contributed to coding guide development, full transcript coding, drafting of results, interpretation of data and paper editing. AAS and CDD contributed to paper editing. OAW conceptualised the study, moderated the focus groups, and contributed to coding guide development, drafting of results, interpretation of data, paper writing and paper editing. OAW is responsible for the overall content of the study as the guarantor.

    • Funding This work was supported by from the National Cancer Institute (NCI) and the Food and Drug Administration (FDA), U54CA229973. Efforts by MJ were also supported by K01CA242591 from NCI and the FDA.

    • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding organisations.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.