Quitting is such a sweet sorrow: a grounded theory study of unassisted smoking cessation among Filipino adult smokers

Introduction

Cigarette smoking is the most common form of tobacco use. The pervasiveness of cigarette consumption has magnified worldwide in recent times. Of the estimated 1.1 billion current cigarette smokers in the world, 80% live in low- and middle-income countries based on the report of World Health Organization (1). About 600 million smokers are within the Southeast Asian burden of tobacco users (2). Cigarette smokers in the Philippines represent 17.3 million of 61.3 million Filipino adults of which 41.9% among men and 5.8% among women (3,4).

Cigarette smoking is one of the paramount global public health concerns. It has deleterious health consequences. It is the foremost avertible cause of mortality globally. It presents the prevalent risk factor for ill health and is arguably behavioral and largely modifiable. It represents the leading cause of preventable deaths in developing countries. It has globally shown an escalating disturbing effect on health outcomes in populations in these nations such as the Philippines. A growing prevalence of the risk factor of cigarette smoking, contributes to the burden of non-communicable diseases (NCDs) in the country. The consequence of cigarette smoking is that it harms just about organs in the body system and results to the deterioration of the smoker’s well being (5). Moreover, smoking is directly linked to predispose individuals to the “fatal four”—cardiovascular diseases, cancer, chronic respiratory diseases and diabetes mellitus (6,7). It is an epidemic that kills ten Filipinos every hour regardless of age and sex according to the Philippine Department of Health (8). In the Philippines, cigarette use contributes to or exacerbates eight of the ten primary causes of mortalities, specifically, diseases of the heart and vascular system, malignant neoplasms, pneumonia, tuberculosis, chronic lower respiratory diseases, diabetes mellitus, kidney diseases, and disease conditions beginning in the perinatal period (9). The unfavorable outcomes of smoking are not exclusively found in smokers. It is as well associated with the dangers of second hand smoking on health (10).

The damaging effects of cigarette to life will continue until its use is controlled. Prevention and cessation remain the only effective public health measures to reduce the harmful effects of cigarette smoking. In 2015, reports indicated that seven in ten (76.7%) Filipino tobacco smokers were interested or planned to quit smoking (6). Benefits of quitting smoking include quality of life and mortality rates for those quitting prior to age 35 resembling those of never smokers (11).

Less is known about former smokers who quitted on their own without professionally or pharmacologically mediated assistance (12). Unassisted quitting has the highest impact on decreasing smoking occurrence and accordingly should obtain more clinical and research attentions (13). Moreover, quantitative research may provide an incomplete view of the factors that smokers consider when making choices about how to quit. While, qualitative research may provide a more nuanced account of smokers’ attitudes towards treatment for smoking (14). In light of the gaps and concerns presented, using the context of Philippine setting, the study aimed to explore and to better understand the cessation experience process of a select group of Filipino adult smokers who have successfully quitted on their own without professionally or pharmacologically mediated assistance. The study was guided by these central questions: (I) How does a select group of Filipino adults go through the process of unassisted smoking cessation? and (II) What model or theory describes this process?

It is anticipated that the developed model of this study grounded on the data collected could provide rich information about the complex and highly variable process of unassisted smoking cessation. The study will be a great contribution in the enhancement of information on unassisted smoking cessation process of individuals and its impact on their lives, as well as their family, community, and health professionals. Investigating the process how cigarette smokers have successfully quitted may help guide the formulation and implementation of tobacco cessation policies. The outcomes of the study can contribute meaningfully to the understanding of characteristics and obstacles associated with successful and attempted smoking cessation. Further, the model developed in this study incorporates the journey of a select group of Filipino adults who successfully quitted smoking on their own. We present the following article in accordance with the COREQ reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-21-110/rc).

Methods

The study employed the qualitative, Glaserian grounded theory design, specifically the discovery mode to provide a deeper understanding of how Filipino adults undergo the process of cigarette cessation (15).

Study site, sample and sampling design

The study was conducted in the national capital region of the Philippines. The purposive sampling strategy focused on former cigarette smokers who had successfully quitted on their own without professionally or pharmacologically mediated assistance. The study participants (N=25) are Filipino adults aged 30–50 years old, male and female, and are residents of the national capital region of the Philippines. More than 50% of the study participants are male. Majority of them are married and employed. They had been smoking cigarettes since they were 16–19 years old and had attempted to quit in the past but failed several times. They had successfully quitted on their own without professionally or pharmacologically mediated assistance for more than one year. All recruited and selected participants joined voluntarily.

The researchers had no prior relationships with the study participants. The study participants were cognizant of the nature of their role since investigators with the full disclosure informed them that four are nursing students and the study is a partial requirement of their course in research. They likewise underscored the contributions of the outcomes of the study to practice, policy, research, and theory.

Instrumentation

Strong grounded theories are generated with rich data and interview is the main data collection procedure in qualitative research (16,17). The corpus of data was collected in private venues with only the interviewer and participant through self-report method, using face-to-face, in-depth, semi-structured interviews guided by an aide memoire. The researchers relied on audio-recorded interview data that allowed for the emergence of information that were deemed relevant rather than adhering rigidly to the pre-set interview guide (18). The guide questions contained broad, open-ended questions and key points that were piloted. There are three-step prerequisites for developing the aide memoire, namely: stating the working description of the identified layer of experience, pinpointing the a priori codes, and developing the story-oriented set of questions (19) (Table 1).

Four of the researchers served as the interviewers during the data collection process. Three were females and one was male. They had undergone interview training and education on the interview process as baccalaureate nursing students. Part of the program’s curriculum are professional courses that equip them with competencies in fundamentals in nursing where communication skill and techniques are emphasized in English communication, psychology, and psychiatry courses. They conducted numerous interview sessions in clinical areas and in the communities supervised by their clinical instructors. Their research mentor who is an expert in qualitative research also trained them.

Mode of analysis

Categories and themes gradually emerged from the collected data translated from the field notes. The constant comparative method (CCM) of data analysis was the simultaneous process in grounded theory, by which data were collected and analyzed. Data analysis was divided into 3 phases based on the types of codes that were generated. In initial coding, incidents were compared with other incidents and the patterns found were conceptualized as codes by the five researchers. In axial coding, data were broken down into lumps that were given labels known as codes or categories (Figure 1). During this phase, the researchers broke the data down into incidents that were compared with one another for similarities and differences. Properties of categories, often called subcategories, are aspects of categories such as causes, conditions, consequences, dimensions, types, and processes are determined (15). Axial coding continued until the core category had emerged. After the core category had been found, selective coding began wherein only those concepts that related to the core category were coded, and coding continued until they were all theoretically saturated. Theoretical saturation was evident when the researchers reached the point where no more properties of a particular category were found (20). The substantive codes or categories were then related to each other through an emergent theoretical code, which was simply the conceptual model of the relationship of the core category to its properties and to other categories.

Figure 1 Axial coding paradigm.

To ensure the trustworthiness—dependability, confirmability, and credibility of the study, the validation techniques of members check and critical friend were used. Member checking, also known as participant or respondent validation, is a method that confirmed the trustworthiness of the findings. Data were returned to participants to check for accuracy and resonance with what they shared with the researchers. Their feedbacks were addressed (21). Critical friend, on the other hand, provided alternative perspectives and lenses about the study. Critical friends can serve as a validation group that meets regularly to share and review their data and think about their research (22). Clarifying questions were posed by the critical friend to facilitate the researchers into the layers of meaning that were available within the context of the phenomenon under understudied (23).

Bracketing, horizontalization, and resonance were applied to increase the rigor of the study. Bracketing is used to diminish the potentially adverse effects of biases and subjectivity that may blemish the research process (24). The researchers gave equal value to all of the participants statements in horizontalization after two sets of interviews were conducted (25). Resonance refers to an attitude of openness and receptivity of the researchers toward possible meanings entrenched in the transcript (26).

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Ethics approval was obtained from the institutional ethics review committee of a multidisciplinary university in Metro Manila (No. 2018-23). The researchers were committed to adhering to the ethical principles of beneficence, respect to human dignity and justice as stipulated in the Belmont Report in undertaking this research project. Each study participant was informed verbally and in written letter about the full nature of the study. Concerns and issues as regards to the rights of individual privacy and confidentiality were addressed prior to the data collection procedure. All study participants were provided with written informed consent form with the understanding that they may withdraw from the study at any time as well as indicating the 45–60 minutes interview. The participants permitted audio recording of the interviews. Participation was on a voluntary basis. The confidentiality of the data and anonymity of the study participants were maintained at all times through adherence to standard ethical procedures. Each participant was provided a code and pseudonym to ensure that all data collected were non-identifiable. Raw data such as transcripts and recordings were stored within the appropriate period of time based on research integrity and the Code of Conduct for research.

Results

The purpose of this grounded theory study was to describe the process that a select group of Filipino adults experienced during unassisted smoking cessation. From the data analysis process, a theoretical model emerged in response to the central question of the study, which is to describe how the study participants transformed their behavioral status from smokers to nonsmokers. Core category and relationships also emerged from the data that undergirded the unassisted smoking cessation experience in both process method and substance. The core category also informed the construction of the model and understanding of the theory. Through constant comparing and aggregating the codes, four themes unfolded that describe the phases that the study participants have undergone, namely: Catalyzing phase, Channeling phase, Cultivating phase, and Characterizing phase. These are illustrated in the simulacrum known as The “C” Model of Unassisted Smoking Cessation” (Figure 2).

Figure 2 The “C” Model of unassisted smoking cessation.

Unassisted smoking cessation is a process that unfolds over time. The role of personal experience was a striking consideration when study participants embarked on the unassisted quitting process. Seemingly, It was an individual experience and one that the study participants believe only they could take control of. The presence of identifiable catalysts that motivated the study participants in response to situations, circumstances or a coming together of events that suddenly represented their desire to quit is seen as the foundation for a successful quit attempt. Though driven by their motivations, they faced certain struggles, which they managed by channeling these challenges that enable them to make quitting important enough to sustain in the long-term. Quitting became more appealing, facilitating and vital as smoking cessation cultivated positive outcomes. The participants of the study ultimately characterized their success by being exemplars to smokers and those who are attempting to quit.

Catalyzing phase

The study participants demonstrate that nature of motivation is a vital component of the unassisted smoking cessation process and a sufficient prerequisite to engage in this particular behavior in the catalyzing phase. The ex-smoker participants’ intrinsic and extrinsic motivations catalyze the roots of their desire to embark in the experience. As verbalized by these study participants:

“My partner has a daughter and she made me understand that smoking is bad for the health. I have a smoker friend who passed away because of lung cancer. I also know someone who had stroke and have been smoking for quite a while. I don’t want to be like them, thus I stopped smoking. I also thought that if I continue to smoke, I’m not only putting my work at risk but as well as my life” [Study Participant (SP)9].

“I quitted smoking a year ago and it was my birthday gift to myself. I did it cold turkey. I just really want to feel better. It’s more on health reasons. It’s not that I’m already sick; it’s more on preventing to become sick. It’s part of my fitness and wellness goal. It was timely because the smoking ban in public was strictly implemented” (SP18).

The presence of identifiable catalysts that motivated the study participants is seen as the foundation for a successful quitting.

Channeling phase

Despite all study participants affirming the preference for quitting without assistance professionally and pharmacologically, it was common for them to acknowledge the difficulties associated with it. Their self-guided route to smoking cessation process was undeniably an extremely demanding process packed with adversities and difficulties that they endeavor to manage and cope. Their ability to find within themselves and around them, the self-techniques, alternatives, and necessary resources to help them stick to their goals are described in the channeling phase. Though they have successfully quitted, they acknowledged the challenges associated with it that often arise and could lead to lapses and relapses. The ex-smoker participants successfully found ways to resist their cravings, urges, and environment triggers by channeling the strong desire not to revert.

The study participants adopted primarily the coping strategy of channeling or directing their thoughts, emotions, and actions away from triggers, urges through willpower, self-control, and engagement. To counteract the strong urges and cravings to smoke the study participants use willpower. Directing their thoughts through high-level willpower enable them to obstruct the lure of getting back at the habit they struggled to forget. As articulated by most study participants:

“I’ll have cravings but I can control it.” (SP9);

“I did have challenges however I was determined to quit thus, I had to make sacrifices. I should have the will to do it” (SP15);

“I didn’t seek any help, no advices when it came to quitting. I quit on my own. I had develop the strength of will” (SP20);

“It was abrupt when I stopped smoking and suddenly I thought, I was willing not to go back again. But of course there were urges and temptations” (SP4).

Though driven by their motivations, the study participants faced certain struggles, which they managed by channeling these challenges that enable them to make quitting important enough to sustain in the long-term.

Exerting self-control allows them to take charge of their thoughts and emotions thus maintain the abstinence. They exercise self-control to countermand, deter or stop their feelings from acceding to the prohibited behavior. Practicing self-control led to increased feelings of self-efficacy or confidence among participants. They were able to acquire the habit of no longer allowing the environmental triggers affect them. As shared by the study participants:

“The urge when I’m really irritated due to stress and I would want to smoke because it would relieved that stress. I had those cravings but I controlled them. I thought that if I got back all my efforts would go to waste. It was like a big achievement for me because even if I see people smoking I can control and not being tempted anymore.” (SP8)

“It’s really hard to quit. Every time you see people around you smoking, I want to take a hit. But I need to fight the craving and I was able to control the urge. It’s hard at first but once you get in the habit, you can fight it. My level of self-control increased every time I succeeded in controlling myself.” (SP21)

Moreover, the ex-smoker participants engage in worthwhile activities that inhibit their urges, desires, or temptations to smoke. They found channels, alternatives and coping tactics until they reached the point where they no longer get the urge to smoke. They were able to find the distractions that worked best for them. As reported by some study participants:

“When I craved a cigarette, I would eat candy or just eat in general” (SP3);

“I substituted exercise. When I’m stressed I run and after I exercise I feel good about myself.” (SP4);

“I substituted smoking for food and yoga. Because yoga helped with getting rid of the toxins in the body by sweating.” (SP9);

“I played basketball, computer games just to prevent myself from smoking cigarette” (S12);

I slept or talked with my friends to counter by craving for cigarettes.” (SP18);

I would watch television and eat to ward off the urge for smoking” (SP20).

Cultivating phase

After a year or so of successful cessation, the worst may have passed for the study participants. Subsequently, learning to effectively deal with cravings, urges and temptations that tend to become more intermittent, they were able to recognize the emergence of numerous benefits that they did not expect as described in the cultivating phase. This finding offers significant evidence that unassisted smoking cessation ensued favorable results. Generally, it promoted subjective well-being to the study participants. Ex-smoker study participants reported implicitly and explicitly the immediate benefits of quitting such as feeling better about themselves because of improved health and favorable psychological changes such as enhanced self-esteem and increased sense of self-control. In sum, unassisted smoking cessation process has positive impact on the quality of life in all its realms.

Albeit quitting was a challenge to the study participants, the evidence is overwhelming that smoking cessation has major and immediate health benefits that are worth it. They reported feeling better than when they smoked. Stopping smoking made a big difference to their health. Their sense of taste and smell improved. Quitting resulted to more energy, improved breathing and physical activity. They no longer have bad breath. These are evident by the following statements:

“I feel better, less shortness of breath, I feel more active and my sense of taste and smell came back. Never experienced high blood. Quitting got rid of the toxins like tar in my body. Mostly they are good symptoms. I saw that my body was different from smoking days, but now it’s stronger. I ate better and slept better. My senses came back, mainly my sense of taste and smell. I feel that my system is cleaner.” (SP1)

“My over-all health is better. I don’t get tired easily when I go biking and when I’m at work When I stopped smoking, I didn’t feel tightness of my chest. I feel better because I wasn’t anymore catching my breath.” (SP6)

When they gave up smoking, the study participants began to value themselves again by way of their sense of achievement. It was satisfying for them to embark on the self-managed quitting process characterized by difficulty and obstacles and then achieve the set goal. Conquering the craving and focusing on quitting successes enhanced their self-esteem and sense of self-control. As mused by some of them:

“I am happy with myself. I feel better about myself. I told myself to just help yourself and had a mantra of having less worries. “I didn’t have any cravings, because I knew it was a psychological effect. I didn’t let it get to me” (SP4)

“After one month of abstinence, whenever I see others smoking, I would get jealous. But I thought that I got through it and they can’t. Meaning I have nothing to be jealous of. I told myself that this is a reward for myself, to love myself. It makes me happy to think that I got through this.” (SP7)

Quitting became more appealing, facilitating and vital as smoking cessation cultivated positive outcomes.

Characterizing phase

As they experience the benefits and positive outcomes of having successfully quitted without assistance, the study participants could influence smokers and assist them in making the decision to quit. They used their experiences, as examples, thus serve as exemplars and positive role models as described in the characterizing phase. As affirmed by some study participants:

“I now experience that quitting is possible, even without professional supervision. Thus, it makes it easier to convince others that it’s possible. I realized that many people regard me as an example, a good example, exemplifying that it is possible to quit smoking. It is in fact, a reality. And I took pride in that. I have friends who supported my advocacy of “Quit smoking in one year”. I had two of the closest people who I convinced to take this one-year abstinence seriously, and they did it. They are non-smokers now. Feels good to initiate a change in someone else’s life.” (SP24)

“I would suggest to others that they should stop smoking because there are no benefits in smoking and to prevent further diseases.” (SP14)

“One of my friends stopped smoking because he saw that I succeeded. My other friends stop smoking as well, so it’s like, I inspire them.” (SP18)

“My influence on other people is with respect, not to the point of being righteous. I just tell them the positive effects of quitting smoking.” (SP9)

Study participants exemplify their triumphs and focus on serving as examples to their family, friends, and people they work with. They share their stories, inform the positive effects of cessation, demonstrate changes in lifestyle behavior, and offer suggestions that may help smokers find the motivation to start their own journey towards total abstinence. However, they respect that the person they are influencing to quit smoking is still in charge. They make their homes smoke free, meaning they discourage smoking in any part of the house.

The participants of the study ultimately characterized their success by being exemplars to smokers and those who are attempting to quit.

Discussion

There are varied reasons and motivating factors that catalyze smokers to the decision to quit smoking unaided. It is imperative to comprehend what drive these smokers to quit this way and to better understand their route to success (27). Smokers’ intentions may envisage quitting smoking (28). This finding concerning ex-smokers’ reasons is significant. Motivation to quit is a central predictor of quit attempts (29). The correct motivation is critical in affecting behavior change (30). Motivation, though extensively documented, has exclusive connotation that is the reason for quitting (27). Having reasons for quitting is an indication of desire to quit (31). Any extensive account of the quitting process must permit for the highly dynamic nature of motivation (32). Moreover, the extent of motivation to stop smoking has impact on the compensatory health beliefs of those who quit. The undesired outcomes of smoking can be compensated for by the performance of healthy behaviors (33).

Apparently, it is of great importance to determine and recognize smokers’ motivation to quit. Given recent findings of factors that envisage smoking cessation are multivariate, interventions and policies could enhance awareness and understanding of these motivations on smokers who wish to employ the self-quitting method as well as current smokers who are engaged in multiple strategies to assist smoking cessation. Importantly, increasing the salience of health concerns, the effects that smoking has on family and loved ones, the financial burden of smoking, and the risk of unemployment can trigger quit attempts. Therefore, ex-smokers must sustain their motivations to prevent relapse and smokers should be more strongly motivated intrinsically and extrinsically to quit smoking.

Individuals faced different levels of difficulty in the first few days after quitting, which is evident by acute withdrawal symptoms. Still, these smokers had all managed to quit, even if they found it very difficult (34). After cessation, the focus is on preparing ex-smokers for challenges that often arise and could lead to relapses (35). The major struggles were attributed to withdrawal symptoms and cravings (36). Managing constant craving is a key challenge for most smokers and is a factor associated with relapse (37,38). Throughout this phase, alternatives for the purposes functioned by smoking have to be initiated, so as to lessen the enticement of relapse, and any groundless lingering beliefs about the usefulness of smoking need to be challenged (39). It required the determination to remain distant from cigarettes (38,40). Ex-smokers are confronted with an undertaking of adapting to a smoke-free lifestyle that includes learning to think and act like a non-smoker (39). The compensatory health belief model posits unhealthy behavior choice such as smoking is justified with the intent of engaging in other healthy behaviors (33).

Seemingly, to be successful, smokers that want to quit need to have strategies in place to manage cravings and triggers. Individuals undergoing smoking cessation process adopt certain schemes to cope with the challenges associated with it. Flouting these links that have shaped the addiction habit entails learning to effectively cope with common high-risk circumstances by channeling the thoughts, feelings, and actions to focus on the positive aspects of their goal thus reinforce the will to quit. Identifying various coping tactics may guide the selection of appropriate smoking cessation support strategies that will likely promote success as a fully functional non-smoker.

Those who succeeded quitting smoking without assistance reached a milestone. Quitting smoking is worth the cravings and withdrawal because of its potential substantial benefits. There are several physical and emotional effects the body experiences following unassisted smoking cessation. These effects consist of both short-term and long-term benefits (40). Smoking cessation has well-documented health benefits. People live markedly longer when they stop smoking irrespective of the age at which they quit (41). Morbidity and mortality risk for smokers is reduced by cessation at all ages, including those older than 80 years (42). It is portrayed that smoking cessation is not only an effective strategy to prevent the occurrence of health problems but also to avoid complications and relapses of already existing tobacco related diseases (43). Additionally, it contributes to a notable increase of life expectancy and health-related quality of life (44). In children, the risk factors of many second-hand smoking such as asthma and other respiratory diseases decrease (45).

Although potential benefits of smoking cessation are substantial, perceived benefits of smokers are associated with pretreatment motivation. Hence, it is important they acknowledge the numerous benefits of smoking cessation to enhance smokers’ behavioral intentions to quit smoking.

Positive role model influences are correlated with quit attempts and cessation of smoking. Role models could be used to promote a nonsmoking norm, or help with early cessation efforts (46). As regards to smoking cessation, individuals may imitate more their peers who they can easily connect to communicate antismoking messages that could ensue an exchange of views and experiences on quitting smoking (47). Generally, the closer the relationship between contacts, the greater the influence when one person quits smoking (48). Moreover, smoking cessation efforts should aim at interaction with positive role models since implicit peer influence has impact on young adult smoking initiation (47). Positive role modelling in smoking cessation by applying the social cognitive/learning theory (49), posits that individuals observe and imitate also called ‘modeling’, other’s behavior that may deliberately lead to positive rewards such as belonging to the group or being liked.

It is likely that the influence of ex-smokers as positive role models is central to successful prevention or early cessation efforts. Positive role models can be agents of health and social influences in inspiring people to quit smoking. As such, individuals exposed to constructive role models might vicariously learn specific behaviors associated with smoking cessation. Ex-smokers who had undergone the unassisted smoking cessation method can serve as references for the media as they share their stories of struggles and success, thus educating the public and policy-makers.

Research limitations

Generalizability of the findings is not germane since this inquiry is qualitative. The design likewise precludes causal inference. The study solely focused on urban residents and only within one region of the country. The study participants are limited to adults and the female group is underrepresented. The study delimited on cigarettes from among the tobacco products.

Conclusions

Unassisted smoking cessation is a process that unfolds over time. The role of personal experience is a striking consideration when study participants embarked on the unassisted quitting process. Seemingly, it is an individual experience and one that the study participants believe only they could take control of. Process that enables change should be explored and identified, as it is of key importance for the development of effective health promotion interventions. All health care professionals such as nurses should give their utmost attention to and be more focused on the problem of smoking. They should emphasize the positive message and consider unassisted cessation smoking method. Other researchers could use the outcomes of this study, in combination with what is already known from population-based research into investigating in depth the smoking cessation process, whether assisted or unassisted to better support all smokers to quit.

Future research

Further comparative studies of assisted and unassisted smoking cessation processes must be undertaken to a much larger sample size. Supplementary research needs to be conducted on the process of cessation of former smokers in rural areas and to determine the environmental factors that may affect the quit experience. Moreover, population-based studies that investigate the use of other methods of smoking cessation are suggested. By examining these, the investigation of other smoking cessation methods can be considered. Former smokers cessation process should be compared across different quitting methods.

Acknowledgments

The authors are grateful for the support of the Manila Central University College of Nursing.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Mellissa Withers and Mary Schooling) for the series “Global Urban Health: Findings from the 2021 APRU Global Health” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Reporting Checklist: The authors have completed the COREQ reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-21-110/rc

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-21-110/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-21-110/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-21-110/coif). The series “Global Urban Health: Findings from the 2021 APRU Global Health” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by institutional review board of a multidisciplinary university (No. 2018-23) and informed consent was taken from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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