The purpose of this community-based study was to create and advance knowledge on the social impacts of COVID-19 on mental health of Two-Spirit, gay, bisexual, and queer (2SGBQ+) cisgender and transgender men in Manitoba, Canada.Participants (n = 20) from 2SGBQ + men’s communities were recruited across Manitoba using printed flyers and social media. Individual interviews explored questions relating to the impacts of the COVID-19 pandemic on mental health, social isolation, and service access. Data were critically examined using thematic analysis and the social theory of biopolitics.Key themes focused on COVID-19 pandemic’s negative impacts on 2SGBQ + men’s mental health, loss of safe queer public spaces, and exacerbated inequities. During the COVID-19 pandemic in Manitoba, 2SGBQ + men experienced a profound loss of social connections, community spaces, and social networks which are specific to their socio-sexual identities, thereby intensifying pre-existing mental health disparities. These findings show how COVID-19 restrictions have come to reinforce the value of close personal communities, families of choice, and social networks among 2SGBQ + men in Manitoba, Canada.This study supports the line of research on minority stress, biosociality, and place by highlighting some potential links between 2SGBQ + men’s mental health and their social and physical environments. This research points to important role of safe community spaces, events, and community organizations that support 2SGBQ + men’s mental health. I’m back on antidepressants after having been off them since 2012 because I found I was having a little bit of trouble coping. There are some elements. My depression usually doesn’t have an element of anxiety, but my anxiety has been really high about it too. It’s not so much worrying about contracting COVID or knowing somebody contracting it. It’s more about the social isolation. It’s just been horrible for us both. 47 years old/Cis/Gay/CaucasianSocial isolation was cited as one of the most common causes of mental distress among participants, with three respondents explaining:Right. I’m somebody who, I don’t cry a lot but last year in December, when things were really bad, I was crying more days than I wasn’t just because I was just feeling so alone all the time. So, it was very difficult, probably the hardest time in my life I would say. 20 years old/GayIt took a really tough turn. I was actually … since 2015, I have been dealing with a crystal meth addiction. I was six months, seven months sober, and then the pandemic hit, and then that really changed everything because all my meetings, my AA meetings and stuff, were gone right away. They were online, but it was way different. I definitely relapsed then, and that was right at the start of the pandemic. 28 years old/ Agender/Gay/CaucasianParticipants described the sudden shifts and challenges they faced as the world rapidly changed due to the pandemic. As the following quote exemplifies, for some individuals, the stress of adapting to these changes resulted in a relapse:The hardest part for us was being isolated but we only did that for about three months. And we would see a small group of friends, we have a core group of about 12 friends that we would, I guess you could say, illegally see. Probably we phased ourselves into it by not seeing them much, like maybe once a month we would see somebody. But even now, with the restrictions we have in Manitoba you can’t go anywhere or go to somebody’s house, we still do see people once a week. There is a great deal of benefit to us seeing people, so we had to kind of weigh it out. So, we did see quite a few, we did see people often but not a large group of people. 47 years old/Cis/Gay/CaucasianThe intensive loss of both formal and informal support groups, as well as the loss of access to social gatherings and friend groups were often discussed within the context of abrupt changes to everyday living. Such drastic changes, whether to social life, access to health and social services, or to work and employment, were expressed as particularly difficult given the dynamic nature of restrictions and gathering protocols. Participants often sought out several coping strategies to mitigate the mental distress that came with such abrupt shifts in their social worlds. For many participants, coping often took the form of resistance to gathering restrictions altogether:No, no, it wasn’t always bad. I would say that the bad times got worse, but the fear of missing out has been relieved because no one could go anywhere or do anything for a while. I go for walks every morning, and when I see people together and they are with a lot of friends, it makes me feel bad because I don’t have that. But when I would go for walks during the pandemic and people were just walking by themselves, or most people stayed home, I didn’t have that loss of missing out. That has eased a little bit, as well as the isolation, because anyone I would talk to says, well, they are just binging Netflix. I said, yes, that’s what I’m doing, too. I don’t feel as odd by staying home all the time. 52 years old/Gay/CisSuch balancing “of the benefit” was often a point of reflection for those participants who chose to obfuscate restriction policies to reduce mental distress, depression, or anxiety. Conversely, involvement in prohibited gatherings also created anxiety and apprehension as much as it served to alleviate long standing forms of isolation. While many participants openly discussed their involvement in rejecting social distancing to maintain social bonds, some participants also described how acceptance of social distancing measures served to create a sense of community, understanding, and empathy around shared isolation, which ultimately helped to alleviate feelings of distress:I think we’re being pushed more into the margins because even our social spaces are disappearing. 28 years old/ Agender/Gay/CaucasianMany respondents espoused the view that safe queer spaces were disappearing or transforming, thus further perpetuating social exclusion of 2SGBQ + men in Manitoba, particularly the marginalized members of the community. The quotes in this section illustrate the situation regarding participants’ experiences and perceptions of the disappearance of the gay community in Winnipeg due to the COVID-19 pandemic. The following quote exemplifies a common response from study participants, highlighting the connection between social exclusion and the disappearance of queer social spaces:When you’re queer and you haven’t seen your community or been around your community in such a long time, I feel like that’s the thing I’m missing the most is just being around other queer people….There’s a community in Winnipeg that’s a pretty solid queer community, like a lot of sort of social activism and there’s a really cool drag community… I realize that that was a pretty important part of my identity as a queer person was just being able to be part of those events and support marginalized people in our community and stuff. And now it’s like that just hasn’t happened for so long and it’s a little bit lonely I guess….I know that for my very close friends, they’ve expressed the same thing, just feeling a little alienated or lonely or whatever since the pandemic started, just missing other queer people…it’s like when you’re queer, you make your own family sometimes. Not having access to that in spaces that are safe like gay bars, it’s really challenging for people to not have that. When it’s absent, it’s something you miss for sure. 42 years old/Cis/Gay/CaucasianSome respondents commented on the absence of socializing with other queer people, highlighting the importance of community on queer identity, and discursively making links between reduced access to queer safe spaces and isolation from community and friends:As a queer community, as a marginalized community, strength in numbers is super, super important for us, and we don’t have that right now. We’re all just in our little silos, and then we have people like me, and I know I’m not the only one who is living with family members who are deeply homophobic, and so it just exacerbates everything else that we were already feeling so we don’t have that community. The medical system is taxed, and exhausted, and is homophobic to begin with. These resources in the community that were there are far less available… The groups were cancelled, and then they were moved online, but it’s just not the same thing. 32 years old/Cis/Gay/CaucasianOther respondents also shared how the loss of safe spaces  during the stay-at-home restrictions made them confined in hostile home environments with unsupportive, homophobic family members:Let’s say 2019, it was packed, we were doing everything. Pride was packed…And then, COVID hit, and for a while…we were still meeting each other because we didn’t really know what was going on. But then…once the bar closed, we had no forum to meet up or hang out or do shows. Thank God, I also am involved with the [agency], and they are amazing. Once COVID hit, they kind of ramped up and took charge of it. It’s okay if you need something, just drop in, 15 minutes, that’s it, and you can go, and there was a rotating door. The space that we had there, which is like that, every time I came, it was always very inclusive. We deal with a population that is … the homeless population. Some people that do show up are very, very, let’s say, not queer-friendly, or they don’t know what is going on or who is there. Slowly, I started noticing that it wasn’t a gay drop-in anymore. There were three queer people, and then the rest would be just drop-in drop-ins….Once you start putting our safe space that we created in jeopardy by saying ‘faggot’, ‘these fucking faggots’, blah, blah, blah, queer this … Slowly, I started feeling very unsafe there. 37/Cis/Gay/SalvadoreanThe findings also reveal how the profound effects of the gradual disappearance of safe spaces for some marginalized members of the 2SGBQ + men’s community – homeless people:Like holy shit, queer people are my family, but I can’t see them anymore because the spaces are closed. I also think spaces might even become less accessible to people, like gay bars. We only have one in Winnipeg … and it’s inaccessible to people who don’t feel like they’re part of the queer community, like Indigenous people. 42 years old/Cis/Gay/CaucasianSome respondents also commented on how the disappearance of social spaces exacerbated the social exclusion of people who were already disenfranchised from within mainstream gay/queer community in Winnipeg, such as Indigenous people:Lots of them [2SGBQ + men] were finding their relief going to the bathhouse or something like that because this is the only space where they can actually express themselves at. I think they are serving a certain function within the community…. people are still not quite there yet on going out as they used to go before COVID-19. 55 year old, Jewish, cis gay manMany participants often commented on the social function of public spaces for 2SGBQ + men, highlighting their role as places of refuge and self-expression, which were now being impacted by the COVID-19 pandemic:The queer community in Winnipeg is kind of weird. When you go into a lot of other cities, and there’s definitely a core, especially in the big cities, like, Montreal, Toronto, and Vancouver. There’s a very clear gay village. Winnipeg doesn’t have that. It’s always been just kind of scattered…I’m concerned that we’re going to lose a lot of those meeting places…And then all of the restrictions are going to end, but we’re still going to be restricted because those places are going to be gone, and that’s sad. If you look at what they’ve tried to do with Pride this past year, Pride Winnipeg, hats off to them, they tried, but it paled in comparison to the normal thing and sure, it would. Yeah, it’s going to be a different world in all sorts of different respects, but especially with this community…For me, having those community spaces was super helpful to have other like-minded people... 32 Years Old/Cis/Gay/CaucasianMany expressed concerns over disappearance of  physical meeting places for 2SGBQ + men (served a function of meeting other like-minded people), and commented that Pride events were taking a more subdued form during the pandemic:I think that the social spaces that we have are going to remain the same. Like the bars that we have, the bath house, people seem to want to keep these. I have seen on social media people supporting them with fund raising money to pay their rent and stuff. So, I think that gay people want to keep the spaces that they have… COVID is going to … transform some things, like if they may locate to another location but I think all the services that have been available will remain after COVID. 20 years old/GaySome respondents expressed optimism that while community spaces may be transformed due to the pandemic, they will still remain available after the pandemic is over :I want to put an emphasis on accentuated systemic discrimination, stigmatization, or whatever you want to call it that existed before. All of that inequity that queer people face has been an issue that’s as old as time, and yet, I think the pandemic just exacerbated those things, made them worse. 32 years old/Cis/Gay/CaucasianMany respondents commented that the discrimination and stigmatization of queer people existed before the pandemic, and how the COVID-19 pandemic exacerbated many pre-existing inequities for community:I think prior to the pandemic, there was a period of gentrification of our scene. I wasn’t quite comfortable with the bar scene prior to the pandemic, and then, of course, the bars closed. I think we only had one that I would be comfortable going to, but it closed for a lot of the pandemic. I think the apps… people are using apps to meet people for hook-ups, but that started, again, prior to the pandemic. I think the pandemic just sort of cemented that this is the new way that people meet. 52 years old/Gay/CisRespondents also talked about how gentrification of the gay scene started before the COVID-19 pandemic  and how the pandemic exacerbated and facilitated these processes:I guess my hope is that there would be, maybe, a bar spring up or more groups, more activities. There might be such a relief that the pandemic is over that there will be more opportunities. My fear is that it will revert back to pre-pandemic times, where everything was done by apps and our community was gentrified. It was taken over by straights, really, or bars became … gay bars used to be such a safe space for the gay community, and then they turned into gay-themed bars for straight people. Part of my sadness is that there are limited gay community spaces in Winnipeg. Even the Rainbow Resource Centre, I find that … I identify as a gay man. I was born a gay man in my experience. But see, I think there is only one group every second Sunday for gay men. In other cities, there would be more. They would have something daily, several options daily, and unfortunately, in Winnipeg, I don’t have that option….I also feel, with Pride, at one time, it meant something. It was … when I came out, we didn’t want to be fired from our jobs or denied an apartment, and I had experienced both. We didn’t want to be bashed in the streets, and I had experienced bashings. Now, if I tried going to a Pride … it was a lot of straight people. 52 years old/Gay/CisOthers also commented on how gentrification and segregation of the physical queer community in Manitoba was taking place, and how the physical venues in the gay community or Pride events were already being taken over by non-queer people before the pandemic started:Findings from this study underscore existing research that highlights the deleterious impacts of the COVID-19 pandemic on the mental health of 2SGBQ + men in Manitoba. Results also highlight the importance of access to safe spaces for 2SGBQ + men while contributing to the body of research related to the loss of social connections due to the COVID-19 pandemic. First, safe spaces were by and large lost by many of the participants in this study with pronounced effects to their social and mental health. For example, participants spoke of losing opportunities to engage in activism while also being required to spend time in unsafe situations with families, roommates, etc., who were not supportive of their identities and/or sexualities. In our view, the COVID-19 pandemic has increased stigma-based stress for participants as outlined by Banajeree & Nair , and PetWith regards to place-based minority stress, our findings are also consistent with work by McConnell et al. , which dIn general, our study brings forth significant contributions to the existing literature on the impact of the COVID-19 pandemic on the mental health of 2SGBQ + men. Firstly, our findings highlight the profound intensification of stigma-based stress experienced by the participants because of the pandemic. Additionally, our study uncovers the detrimental effects of pandemic restrictions on the vital health-promoting aspects of queer socialization. Furthermore, our research contributes to the ongoing discourse on place-based minority stress by elucidating a distinct form of situated stress resulting from the closure of safe spaces for 2SGBQ + men in Manitoba.Our results also build on current critical social theory centered around the concepts of biocitizenship, biosociality, and sexual citizenship . The COVThe COVID-19 pandemic, in re-organizing access to (and definitions of) spaces of sexual citizenship, also profoundly changed the ways that 2SGBQ + men came to identify, or reaffirm their identities as, ‘biosexual citizens’ within peer-led, activist, and other social communities. As physical spaces of meeting and organizing transitioned online, or disappeared altogether, access to formal and informal spaces came to dictate new modes, experiences, and expectations on the responsibilities and rights of membership within specific biosexual groups. In the context of COVID-19, new emergent biosocialities became actualized in the context of pandemic experiences for 2SGBQ + men, which includes both shared illness experiences and the collectively felt effects of exclusion from private and public spaces of sexual citizenship. As in the case of Hakim et al , our res2SGBQ + community members who participated in our study also shared concerns related to the shifting landscape of social spaces in Manitoba. As mentioned above, Winnipeg was regarded as a social hub for queer communities in throughout Manitoba and in neighboring provinces. However, over time, gentrification and the shift to online socialization  have deteriorated the need for such physical locations leading to a reduction of meaningful place-making for this community. It is also important to note that these impacts are not felt unilaterally by members of the 2SGBQ + community; those who are considered the most marginalized are often in positions to feel these losses more severely. With this in mind, our results support the work of Ristock  and McLeBecause of the extremely diverse and non-representative sample consisting of twenty 2SGBQ + men, it would be a mistake to generalize about any group or make any wide-reaching cultural comparisons between specific identities. For example, Indigenous Two-Spirit people within the queer community in Manitoba also face added oppression and experiences of discrimination due to the continuation of colonial control and governance. The diversity of 2SGBQ + populations require tailored strategies for these groups. We also acknowledge that the fact that most participants were over the age of 35 may impact the generalizability of our findings and their broader applicability. In addition, confirmation bias may have influenced data collection, analysis, and interpretation. Steps were taken to address confirmation bias, including engaging in the practice of reflexive thematic analysis, member checking the findings with community members, and involving multiple interviewers as part of our data collection methods.Health professionals who work with 2SGBQ + men should pay attention to the negative impacts of social isolation on mental health to better engage these men in health promotion activities or when designing services. Health intervention efforts may seek to focus on increasing culturally sensitive and affirming mental health supports, programs, and services. Service providers, including doctors, nurses, social workers, and other professionals involved in the provision of mental health services and care, need to be informed about the unique mental health needs of 2SGBQ + men in Manitoba and identify coping strategies and resources to deal with negative mental health outcomes accrued from the COVID-19 pandemic. From a holistic perspective, interventions to improve access to economic and social resources designed with the unique needs of 2SGBQ + men may also be required to improve this communities’ mental health. Furthermore, to mitigate the impacts of COVID-19 on depression, anxiety, and social isolation on 2SGBQ + men, service providers also need additional training to meaningfully address the discrimination, stigma, oppressions, and social exclusion that perpetuate minority stressors for this group. From a systemic perspective, primary and secondary care  need to adequately meet the needs of 2SGBQ + men by seeking out 2SGBQ + specific training to learn how to remove and reduce barriers in mental health access for this population.Our research also highlighted some potential links between 2SGBQ + men’s mental health and their social and physical environments. While COVID-19 restrictions have eased in Manitoba, it is still essential that 2SGBQ + men are provided with spaces, organizations, events, support services and opportunities for socializing aimed at counteracting the negative impacts on mental health that they accrued during the pandemic. It is important that 2SGBQ + men are provided with opportunities to connect and find intimacy with members of their communities. This includes supporting safe community spaces/places, events, and community organizations that cater to 2SGBQ + men’s communities financially, socially, and politically. Queer spaces  enable social connections within 2SGBQ + men’s communities and are important for 2SGBQ + men’s mental health because they serve as safe havens within mainstream heteronormative Canadian society. Queer safe spaces are also crucial for providing a sense of social inclusion, identity, and community belonging as well as being key platforms for delivering mental health promotion and services. Continued financial investment in such spaces which allow 2SGBQ + men to safely express themselves and re-establish their connections and social networks is recommended.Finally, these findings also highlight the need to address stigma, promote social equity, and eliminate discrimination of 2SGBQ + men that existed prior to the COVID-19 pandemic. Structural changes, community interventions, and public-awareness campaigns are essential for reducing disparities and improving mental health outcomes for 2SGBQ + men.During the COVID-19 pandemic in Manitoba, 2SGBQ + men experienced a marked loss of social connections, community spaces, and social networks which are specific to their socio-sexual identities. This, in response, has intensified pre-existing mental health disparities. The findings highlighted how COVID-19 restrictions have reinforced the value of close personal communities, families of choice, and social networks among 2SGBQ + men in Manitoba, Canada. The research points to important role of safe community spaces, events, and community organizations on 2SGBQ + men’s mental health. Utilizing theoretical constructs of minority stress and biopolitics, the findings from this study point out the political role and utility of safe queer community spaces, places, organizations, and events for 2SGBQ + men’s mental health.


In line with the global trends, electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) have found their way to the Lebanese market. The present study aims to explore the determinants of e-cigarette and HTP use among young adults in Lebanon. Convenience and snowball sampling were used to recruit participants aged 18–30 residing in Lebanon, who were familiar with e-cigarettes products. Twenty-one consenting participants were interviewed via Zoom and the verbatim transcriptions were analyzed thematically. The outcome expectancy theory was used to categorize the results into determinants and deterrents of use. HTPs were viewed by participants as another mode of smoking. The results showed that most participants perceived e-cigarettes and HTPs to be healthier alternatives to cigarettes/waterpipes and to be used as smoking cessation tools. Both e-cigarettes and HTPs were found to be easily accessible in Lebanon; although, in the recent economic crisis, e-cigarettes have become unaffordable. More research is needed to investigate the motivations and behaviors of e-cigarette and HTP users if effective policies and regulations are to be developed and enforced. Furthermore, greater public health efforts need to be made to increase awareness of the harmful impacts of e-cigarettes and HTPs and to implement evidence-based cessation programs tailored to those modes of smoking. Electronic nicotine delivery systems (ENDS), referred to here as e-cigarettes, are devices that deliver nicotine to the consumer and allow them to mimic the sensory effects of smoking without burning tobacco and inhaling the smoke from the combustion as one does with tobacco cigarettes . SimilarE-cigarettes have been marketed as less harmful than tobacco cigarettes because of the claim that they contain lower levels of toxicants and that they are smoking cessation aides ,4. YouthAlthough to date no prevalence data exist for e-cigarette use in Lebanon, the prevalence of cigarette smoking in Lebanon is documented as being among the highest in the world, with 35.1% of males and females smoking cigarettes . It alsoThis study is a qualitative study which followed a qualitative research methodology. It used convenience sampling as the primary method of recruitment. Following approval from the American University of Beirut’s Institutional Review Board , flyers advertising the study objective, recruitment details, information on incentives, and contact information were posted on Facebook and Instagram, between May 2021 and June 2021. Snowball sampling was used as a secondary means of recruitment where people were asked to forward the study invite to others they thought would be interested and willing to participate. An incentive, in the form of phone credit valued at 15 USD, was given following participation.After posting the flyer, 31 respondents completed the online survey, all of whom were contacted for the interview. Interested participants were directed to a link for eligibility screening. The eligibility criteria included: (1) being of ages between 18–30 years old, (2) residing in Lebanon, and (3) being familiar with e-cigarettes regardless of their use of these products. Among the total respondents, 1 was under 18 years of age, 1 refused to do the interview, 2 skipped the interview, and 6 did not respond to messages or calls, resulting in a total of 21 eligible participants—12 females and 9 males. The eligible participants were first contacted by phone to review and explain the objective and details of the study and the elements of the informed consent forms. The final date and time were then set for the interview. Electronic consent forms were sent to all participants to read and approve. In addition to outlining issues of confidentiality, anonymity, and voluntariness, the participants were asked to consent to participation, and then provide consent for the recording of the interview and for the use of individual quotes  in the reporting of the findings.The eligible participants were directed to complete a short online survey which captured their socio-demographic information and their e-cigarette use. Semi-structured interviews were then conducted over Zoom, following an interview guide of open-ended questions in which participants were asked about their perceptions on e-cigarettes, their patterns of use, comparisons to other tobacco and nicotine products, the marketing of these products, and their future intentions concerning use. The interviews took 20 min on average. The data analysis was iterative; therefore, once data saturation was reached at 21 interviews, no further interviews were conducted.The interviews were recorded then transcribed verbatim by a hired research consultant. A thematic analysis was then conducted, and a codebook was developed. Both deductive and inductive coding were used. Two interviews were coded by SM and MT independently. Comparisons of the independent coding showed similar codes by both coders. Following multiple rounds of discussions and revisions by SM, RN, and MT, the research team reached an agreement on all the final themes and a codebook was developed.The results were themed according to outcome expectancy, which is a factor that has been found to play a significant role in substance abuse behavior . It refeThe demographic characteristics of the participants are summarized in A cross-cutting finding that is important to note is that, although the aim of the study was to focus on the determinants and drivers of e-cigarette use, several participants also mentioned HTPs in their discussion, namely IQOS products, which had been widely marketed around the time of the data collection. We distinguish the findings pertaining to e-cigarette versus HTP use when possible and indicate when participants were referring to both by providing relevant quotations.The emerging themes in which both e-cigarettes and IQOS were mentioned included the substitution of cigarette smoking, positive sensory experience, convenience/ease of use, curiosity and novelty, marketing and advertisement, availability, health concerns, and addictiveness. For the remaining themes, i.e., social enhancement, affect regulation, peer pressure, social acceptability, and affordability, only e-cigarettes were mentioned.The brand IQOS was the only HTP product referred to by the participants. Consequently, the term IQOS is used throughout.The most common determinant for initiating both e-cigarette and/or IQOS use was the perception that they are healthier alternatives to cigarettes and waterpipes.… we don’t have the combustion [in reference to vapes], we don’t have the carbons that come out of the combustion.—male, 23, e-cigarette user… [with] IQOS, there isn’t this coughing or those irritating things [like with tobacco cigarettes]—female, 21, IQOS product userAlthough some participants acknowledged the negative health impacts that vapes/IQOS products have, they were still seen as healthier than tobacco cigarettes.Smoking everything is bad. But maybe there are things more harmful than others.—female, 25, e-cigarette userIn fact, many reported using e-cigarettes/IQOS products to quit or reduce smoking cigarettes and/or waterpipes. Many others reported that their peers, family members, and even their physicians, encouraged them to switch to e-cigarettes/IQOS products for smoking cessation.the doctors say “… Stop smoking [cigarettes] and turn to this [vaping]. Stick to this, it’s less harmful”.—male, 23, e-cigarette userWanting to fit in and being accepted within a certain social group were repeatedly reported as motivators for initiating e-cigarette use.They think it’s [vaping] cool … they see … people [and think] like oh if I want to be cool … like oh I’m bad I break rules …—female, 20, e-cigarette userThis notion was echoed by other participants who mentioned that e-cigarettes gave one a sense of confidence and portrayed a certain desirable image.Participants were also attracted to e-cigarettes for the sense of community or belonging they bring. Online forums, Facebook pages, WhatsApp groups, and face-to-face events were all mentioned as mediums in which e-cigarette users discuss their products, recommend flavors, and support each other.We have a huge community, especially in Lebanon. We used to be like from 5 to 6 vapers, we are now around 3–4000 vapers … we all get in contact mainly weekly or monthly through selling devices that we introduce to each other … We all bonded through this electronic device.—male, 23, vape userA recurring determinant of e-cigarette use was the positive sensory experience it brings. The vast variety of flavors, the “delicious” taste, and the pleasant smell were all perceived to have a major impact on e-cigarettes’ attractiveness.What’s appealing about them is that there are thousands of flavors.—male, 19, e-cigarette userSmell was particularly important among women as it was seen as more acceptable for women to smoke e-cigarettes rather than smoke cigarettes, which emanate an unpleasant smell.… girls they say it’s not nice if her breath smells, it’s not nice if her clothes smell … her nails and fingers get yellow [from cigarette smoking] …—female, 23, cigarette userIn contrast, IQOS products were frequently described as having an unpleasant smell that deterred the participants from using them.… very, very bad. For me, it is worse that a normal cigarette.—male, 27, e-cigarette userE-cigarette use was also seen as entertaining, especially in social settings, and they were seen as more of a social rather than solitary activity.Another type of person who goes to vape, is the type that wants … just to entertain himself for fun.—male, 25, e-cigarette userMost respondents stated that e-cigarettes were used to relieve stress, induce calmness, and/or alleviate boredom. This was reported to have increased during the COVID pandemic. Attempts to quit e-cigarette use were hindered by stress from the pandemic, work, school, and the daily stressors of living especially at the time of a major economic crisis in Lebanon.… the problem is that even though there was awareness [about the harmfulness of vaping], people see vaping … as a way to relieve pressure and anxiety.—male, 27, e-cigarette userBoth e-cigarettes, which were frequently referred to as “mini waterpipes”, and IQOS products were seen as more convenient to use than cigarettes or waterpipes.… [vaping is] like a shortcut, it’s just like something which you can just put it in your pocket and just get it out and smoke it whenever you want, wherever you want.—female, 20, e-cigarette userThe lack of confinement to where and when a person can use vapes/IQOS products was appealing particularly in the context of weakly imposed indoor smoking bans such as those in Lebanon, which in principle include e-cigarette use.Nowadays, we’re not tied to a certain setting … Currently we’re using these devices, small ones, pocket devices, we can use them anywhere, even in some airports … They’re usable inside of restaurants, inside of shopping malls. So, nothing can stop us or make us go outside to the outdoors to have our puffs.—male, 23, e-cigarette userThe novelty of e-cigarettes and IQOS products were mentioned as motivators for experimentation.… That’s why young people are going to these products [vapes], because … they hear that this is yummy and … delicious … So, they have the curiosity to try.—male, 28, e-cigarette userThe main messages of advertisements for e-cigarettes and IQOS products seem to portray those products as healthier alternatives to cigarettes.… media coverage of vaping has brainwashed people into thinking that vaping is not harmful at all and that it doesn’t cause lung cancer …—male, 19, non-user of nicotine and tobacco productsSocial media trends in which influencers would do tricks with vapor/smoke made them be seen as something fun and attractive. The younger population, generally being more impressionable, would see these on social media and emulate this behavior.… they [vapes] are really trendy, especially on social media … Most of the guys that started, started for the trend… that’s mainly how teenagers went into vaping because of the many good tricks …many find these tricks interesting to be watching, to be participating in …—male, 23, e-cigarette userThere are a few vape dealers that are known. Like we search for them on Facebook or Instagram. You find them quickly.—female, 25, e-cigarette userParticipants reported sometimes feeling pressured, whether advertently or inadvertently, by their friends to start using e-cigarettes.… if you want to talk more about preteens and early teen years … so they could be more peer pressured to go into “social norms” …—male, 19, non-user of nicotine and tobacco productsAll the participants reported smoking their first e-cigarette or IQOS products due to someone in their immediate social circle. Moreover, with online delivery, e-cigarettes and IQOS products were easily accessible. Although e-cigarettes were technically illegal in Lebanon and mostly smuggled, this did not impact their availability; it merely made stores more cautious about selling. Most stores sold e-cigarettes in addition to other products  and only took them out upon the customer’s request.… go into a phone shop, you can find the vaping devices inside, hidden under tables …—male, 23, e-cigarette userIQOS products on the other hand, were sold openly in major supermarkets and some minimarkets.[IQOS] is very much available. There are companies or stores that send you SMS: “IQOS plus HEETS for I don’t know how many dollars” … There are stores you can find it, usually online, and [the supermarket] … it is very available.—female, 26, IQOS product userSeveral participants perceived e-cigarettes to be a dying trend, especially with the introduction of IQOS products, which were perceived to be ‘trendy’ and less high maintenance than e-cigarettes.… But I think the vape had a certain period, maybe in 2019 … everyone was smoking vapes. But because the vape needs high maintenance…They have issues that you have to like take care of it and go fix it and do the maintenance and get a new coil this kind of stuff.—female, 25, e-cigarette user… according to what I’m seeing … I feel it’s [vaping] decreased. We’re not seeing it’s widespread like before … maybe because of the economic crisis …—male, 19, non-user of nicotine and tobacco productsIn contrast to social enhancement, which referred to personal acceptance on an individual level, social acceptability was referred to in the context of how e-cigarettes are viewed on a general, societal level. Generally, e-cigarettes were seen to be more socially acceptable than cigarettes and waterpipes. Compared to cigarettes, using e-cigarettes indoors was also seen as more acceptable since the smell and vapor from e-cigarettes were deemed more tolerable.What’s nice about [vaping], it doesn’t bother anyone next to you. No one even notices that you’re vaping … when I was in class I used to vape. … An even in the winter, inside somewhere closed, no one notices, or no one gets bothered.—male, 25, e-cigarette userParents were also seen to be more accepting of their children using e-cigarettes as they were perceived to be healthier than tobacco cigarettes.Although, in general, e-cigarettes were seen as more socially acceptable, there were a handful of participants who mentioned that, in their experience, people they had encountered were opposed to e-cigarettes. This was mainly attributed to the fact that e-cigarettes work on batteries and/or electricity, which were seen as more dangerous since they are artificial as opposed to tobacco, which is “natural”.… [society is] scared of technology … I feel they prefer cigarettes … Not a lot of people accept the vape. Like “What is this? There’s a battery. There’s something wrong. Electricity.” So, yeah, they prefer cigarettes—this is something natural, you grow it.—male, 25, e-cigarette userAlthough many perceived e-cigarettes/IQOS products to be healthier alternatives, a smaller number acknowledged their negative health impacts.All  have harmful diseases. Especially with vaping, it’s directly on the mouth … I heard it causes cancer …—male, 19, non-user of nicotine and tobacco products… after a while, I started feeling its [vaping’s] outcomes … it [vaping] fills up inside like a liquid, in our lungs … I was very athletic; I mean, I go and run, play football and stuff like that. So … I started getting tired due to it.—male, 22, e-cigarette userHealth concerns, although deemed to be less severe than those associated with cigarettes/waterpipe, revolved mainly around the breathing difficulties experienced by e-cigarette/IQOS product smokers. These health concerns were more prominent during the COVID-19 pandemic. The participants who used e-cigarettes and/or smoked IQOS products reported that they reduced or temporarily stopped smoking the products while infected with COVID-19.I had a very mild cough at that time of the corona. It was not … a severe cough but when I use it [the vape], I feel that my body is not accepting it.—male, 27, e-cigarette userAlthough health concerns were mentioned, many viewed the scientific evidence related to the health implications of e-cigarettes/IQOS products to be inconclusive.… cigarettes we know what they do. There is enough research to let us know what’s happening when you smoke … Vaping … there is research but not much … So, it is sort of debatable. –female, 26, IQOS product userFinally, e-cigarettes were seen as more susceptible to manipulation by the retailers to make them more harmful.…the issue is, in Lebanon, there’s a lot [e-cigarettes] that aren’t original … anyone was putting anything [in vapes] and selling it.—female, 21, IQOS product userMany participants regarded e-cigarettes/IQOS products as just as addictive or slightly less addictive than cigarettes.… [IQOS] is addictive. I smoke [IQOS] normally, like my old habits with normal cigarette … I used to smoke 2 packs [per day] of cigarettes … Now I smoke 2 packs of IQOS. It’s the same.—female, 26, IQOS userHowever, since with e-cigarettes/IQOS products a person can control the level of nicotine they consume, these products were seen as a way to reduce people’s nicotine dependency by gradually lowering nicotine levels. This contrasts with the views of participants who believed that even with this control over nicotine levels, one would still be ingesting the same amount of nicotine, perhaps even more, than they would by smoking tobacco cigarettes because of the longer smoking time.… [my brother] got it [vape] so that he can reduce traditional smoking … But no. He went back to the traditional cigarettes. He didn’t decrease.—male, 19, non-user of nicotine and tobacco productsAnother point raised was that while cigarettes had a finite end after a certain number of puffs, e-cigarettes/IQOS products do not have a defined endpoint. A person can smoke as much as they want and whenever they want. Hence, attempts to smoke less, especially in terms of reducing nicotine content, were seen as futile. Some participants mentioned that although a person can put less nicotine in e-cigarettes/IQOS products, they tend to smoke more of it, so in the end they would be consuming the same amount of nicotine as they would have by smoking 20 cigarettes, for example.… the problem with vaping is that it does not have a session like the waterpipe … vaping is portable, available in hand so you can say that it is possible if someone wants to use it 24/7 then he can …—male, 27, e-cigarette userWith the vape … you don’t have a time limit like how you would have with the cigarette … with … [vaping] … you can keep on smoking … as much as possible … So, you get more nicotine than you want, and it feels bad.—female, 26, e-cigarette userBesides the physiological addictiveness of e-cigarettes/IQOS products, participants also mentioned the addictiveness to the behavior or action of smoking, i.e., the habit of holding something in your hands and smoking it.I can tell you that it is by habit and having the device in front of you more than it being a need. I mean I don’t feel the need for nicotine like with a cigarette, but I see the device in front of me, I hold it and start vaping.—male, 27, e-cigarette userAlthough e-cigarettes were seen to be easily accessible and available, following the Lebanese economic crisis and the devaluation of the currency, they were seen as not affordable. In some cases, participants went back to smoking cigarettes due to the increased prices of e-cigarette products.… with the dollar crisis and things like that, people aren’t using vapes a lot. They are using local cigarettes more.—male, 19, non-user of nicotine and tobacco productsThe vape requires this machine with its charger and with its refill. So, there are costs for you to acquire it … not everyone can afford to have access to this, to this product.—female, 29, non-user of nicotine and tobacco productsMoreover, e-cigarettes were said to require a lot of maintenance, and replacement parts are either not available in Lebanon or are too expensive.Comparable to findings in the literature, the results showed highly positive perceptions toward e-cigarette use with most participants reporting favorable outcome expectancies which encouraged initiation and continued use. A recurrent finding was that e-cigarettes are healthier alternatives to cigarettes and waterpipes and thus can be used as smoking cessation tools; the same was mentioned for IQOS products, which were copiously referred to by the participants. The positive sensory experience, such as that provided by the variety of flavors, the pleasant smell, and taste, was one of the most appealing aspects of e-cigarettes and attracted cigarette users as well as non-cigarette users. The ease with which e-cigarettes could be found further facilitated their use.In concurrence with a study conducted by Jiang et al. (2019) on the perceptions of e-cigarettes among young adults in Hong Kong , our stuUsing e-cigarettes as smoking cessation aids was found to be ineffective by some participants. Most participants stated that they or someone they knew continued to smoke cigarettes even after “switching” to e-cigarettes/IQOS products. The ability of e-cigarettes to aid in smoking cessation is a contested topic as there is little to no evidence of their effectiveness . A recenSome participants however acknowledged the negative health impacts of e-cigarettes. These health concerns were heightened for the participants who were infected with COVID-19; the participants either stopped or decreased e-cigarette use during infection. A study on smoking patterns during COVID-19 also found health concerns to be an influential determinant associated with reduced smoking during the pandemic . The perWith regard to addictiveness of e-cigarettes, in contrast to similar studies ,19, our The sensory experience of vaping was another factor which was found to play a prominent role in motivating the use of vaping products. As confirmed by similar studies, a major determinant for using e-cigarettes was their provision of pleasant sensory experiences . Flavor A notable finding was that all the participants mentioned that they were first introduced to e-cigarettes by someone within their immediate social circle. This is not unusual as the most typical social sources of e-cigarettes are members of a person’s peer group . Peer inSome participants merely tried e-cigarettes out of curiosity and interest in the novelty of the devices after seeing friends/family members using them. Experimentation with novel devices was found to be a significant factor in several studies among high school and college students ,21. A loStudies on the social acceptability of e-cigarettes have had mixed results . In our Contrary to Bold et al. (2016) who reported the low cost of e-cigarettes as a predictor of frequent e-cigarette use , e-cigarE-cigarettes and similar products have been frequently found to be used for emotional regulation . ParticiThe goal of this study was to understand the determinants and drivers of e-cigarette use and to generate empirical evidence to inform intervention programs and policies aimed at preventing and controlling the use of ENDS products by young adults. By understanding what drives young adults to start using these products, evidence-based policies, regulations, and intervention programs targeting these drivers, can be put into place to tackle the growing use of e-cigarettes.The findings of this study show the impact of flavoring on vaping initiation. Implementing policies banning flavored tobacco could help tackle this issue. A systematic review of qualitative studies examining the perceptions of and experiences with flavored tobacco products found that flavored products were perceived as less harmful than cigarettes, further supporting the banning of flavored tobacco products, especially as it revolves around curbing smoking initiation among youths . AlthougBanning the advertisement and promotion of e-cigarettes, especially on social media platforms, is also pivotal in decreasing the exposure of these products to youths. Featuring these products in mainstream media and portraying them in a favorable light further strengthens their social acceptability . FurtherRaising cigarette prices has proven to be an effective measure in decreasing their consumption . IncreasThis study is not without its limitations. The first limitation is related to the use of convenience and snowball sampling. Although these methods are cost- and time-efficient, they can result in selection bias . DespiteAnother possible limitation is the use of Zoom (video conferencing) for data collection. Until recently, conducting interviews online has often been seen as a disadvantage, with the main cited challenge being the establishment of a rapport with the participants . HoweverFinally, the possibility of demographic selection bias can be seen as a disadvantage of recruiting through social media, with only younger participants being reached . HoweverWhile this study contributes important data on the determinants of e-cigarette use in Lebanon, more research is needed to investigate the motivations and behavior of e-cigarette users if effective policies and regulations are to be developed and implemented. Moreover, research on e-cigarette and HTP products needs to be conducted separately, since although they share similar determinants and drivers, they are two distinct products that differ in their internal mechanisms—e-cigarettes work by vaporizing e-liquid and HTPs work by heating tobacco. This distinction needs to be made clear during qualitative data collection as some participants may mention both during their discussions when only one or the other is under investigation.Both e-cigarettes and IQOS products were seen as merely other modes of smoking, with the use of both products sometimes sharing similar determinants and drivers. Overall, this study was able to identify the most prominent determinants for the initiation of smoking novel tobacco products. The positive perception toward e-cigarettes raises a lot of public health concerns. These key findings have important implications for tobacco monitoring systems, government policies and regulations, as well as public health initiatives in controlling the marketing and advertising of new and emerging tobacco products.


According to the Convention on the Rights of the Child, all children have the right to health. Since good health is a decisive factor for children’s future, investing in children’s health is important, especially children from vulnerable areas. The purpose of this study was to investigate the perceptions of health among school-aged children from socially vulnerable areas.The study has an explorative mixed-method design with a participatory and inductive approach based on focus group interviews with children and youth leaders, respectively, at Multi-activity Centers in three of the vulnerable areas in Malmö Municipality, as well as results from the Multi-activity Centers’ own questionnaire. The data has been analyzed with inductive and deductive content analysis.The children and the youth leaders described health in terms of well-being, participation, and activity. Well-being included feeling good and safe, having a healthy body, and having fun by doing things together with friends and leaders. Participating in activities was described as having a feeling of involvement, being able to have an influence on the organization of the activities and participating on one’s own terms.The result of this study shows that participating in activities increases the child’s sense of well-being. Children face many pressures and challenges. The social environment of children living in deprived city areas, and having fewer social resources, may easily influence their health and health-related behavior. Furthermore, childhood behaviors can continue into adulthood, affecting issues such as mental health, the development of health complaints, tobacco and alcohol use, diet, and physical activity level.Health Behavior of School-aged Children (HBSC) has noted the importance of the social context and children’s relations with families, peers, and school. The study concludes that a supportive environment could play an important role for a healthy development  were started by the City of Malmö and the neighboring communities against the background of a lack of club activities, low school results, and experiences of insecurity among the residents of vulnerable areas due to safety issues. The MaCs are located at schools of different sizes but are otherwise located in different suburbs of Malmö with similar conditions. The MaCs are an investment that the city has made to increase the opportunities for activities in socially unstable areas, where many families have low incomes and cannot afford or otherwise can participate in leisure activities. A starting point in the MaCs is that it is the participants themselves who decide which activities they want, insofar as they are feasible. Children and young people are also invited to help with various activities and some of the younger adults involved become leaders of the activities. It is the participants’ needs and desires that govern the activities available and the MaCs are living laboratories that can develop and rapidly change related to common wishes and needs. Boxing, street dance, football, help with homework, crafts, music, and gymnastics are some of the activities at the MaCs. The MaCs are available in the school premises during afternoons, evenings, and weekends. One goal is that the parents of the children will have a positive image of the school even after school hours.The especially vulnerable area” , by their teachers.The questionnaires were distributed to children in the schools (The data collection is based on three datasets: (1) the focus group interviews with children, (2) the focus group interviews with leaders, and (3) the MaCs’ own questionnaire.Focus groups are an interview form where a small group of committed people talk about a predetermined topic . The grofocus group interviews with schoolchildren accompanied by leaders. After an introduction round, the participants were asked, in pairs, to discuss and write down their conception of health on Post-it® notes. Thereafter, each pair posted their notes on a flipchart and presented their thoughts about health. After each pair had presented their notes and perceptions, the children were asked to group the Post-it® notes into categories making sense of their perception of health. In all three interviews, the children described health in terms of well-being, activity, and participation. Therefore, the rest of the data collection was based on those three themes. Besides being audio recorded, the interviews were documented by the Post-it® notes and by field notes taken by the participating researchers.The first dataset, about children’s perceptions of health, consists of focus group interviews with leaders at the MaCs. The interviews were scheduled as face-to-face interviews, but because of the Covid-19 pandemic, they were re-scheduled and carried out digitally on Zoom. After an introduction round, the participants were asked to present their experiences about how activities at MaCs can contribute to children’s health, operationalized as well-being, activity, and participation. The interviews were audio recorded and field notes were taken by the participating researcher.The second dataset consists of three MaCs’ own questionnaire about children’s perceptions on activities. The questionnaire contains 15 questions in total and was developed and used by the MaCs to plan their activities for the next semester, and to evaluate the children’s satisfaction with the activities. In the questionnaire, the children reported background data (5 questions) and participation in activities, as well as writing their free comments on the value of different activities and on health, operationalized as well-being, activity, and participation (5 questions). The last five questions are about what the children want to do the next semester .The third dataset consists of the first data analysis was carried out based on the data from Post-it® notes, recorded interviews, and field notes from focus group interviews with children about health. The analysis used was an inductive content and text analysis .interview group consisted of three focus group interviews in total with 21 children aged 10–12 years, all with an immigrant background and the second interview group consisted of three focus group interviews in total with 13 leaders .The third N = 1,473) and 573 (39%) of the children filled out the questionnaire. Out of the children answering the questionnaire, 69% (61–80%/school) had been actively participating in activities at the MaCs  refers to focus groups with children, (Fo gr L) to focus groups with leaders, and (Qu C) to the questionnaire answered by children “I think everything is good” (Qu C)absence of illness and suffering related to the body. Both in the interviews with children and leaders and in the questionnaire, health and well-being were related to physical body functions in connection with activities and outdoor playing.In the focus group interviews, the children also pointed out that health and well-being are an “Not being sick/ Not being in pain” (Fo gr C)“Keep going” (Fo gr L)“Play outside” (Qu C)healthy living, like good and healthy food to make the body function well.Another aspect brought up was the importance of safety for health and well-being. Not having to be afraid was considered important, as was not being alone or not being exposed to fights or conflicts among children, adults, and family members.The children talked a lot about the importance of “Not to be afraid” (Fo gr C)“That you are never alone/No conflicts” (Qu C)Children mentioned examples of places or situations that made them feel safe, such as participating in the girls’ group.“In a girl group it has been safe to just be with girls to avoid all the noisy boys” (Qu C)recognized by the leaders at the MaC. Also, the importance for the child to be recognized in the family at home was mentioned.To have a feeling of health and experience well-being, the children wanted to be seen and “Be there for the child/Pay attention to how you feel at home” (Fo gr L)Having a feeling of health and well-being by being recognized, was often described in terms of small talk or inclusion. But those small recognitions were described as leading to close relations and a feeling of trust.“Just hang out” (Qu C)“Relation/Trust” (Fo gr L)The result of the analysis shows that children describe participating in activities and having fun as an important agent for health, when doing things together with friends and leaders.activities. The most frequent activities the children participated in were divided groups for boys and girls, different kinds of crafts, sports activities, such as football, and sports combined with cooking or baking.In the interviews and in the questionnaire, the children saw health as being related to different “Football, baking/cooking, boys’ group, girls’ group, crafts, games & gaming” (Qu C)more fun and popular to participate in, such as:The children expressed that some activities were “Baking and that we have baked good cakes” (Qu C)“Crafts; to paint, we have beaded, make slime, paint gym bag and backpacks” (Qu C)“Play football” (Qu C)“Boy group because we play games and watch movies” (Qu C)But the preferences changed in relation to what was offered, and in relation to age, gender, and, mainly, friends’ choices.activities they wanted to have more of. Those activities were often the ones where they needed to leave the neighborhood or had to pay an entrance fee, such as:The children also pointed out that there were “Excursions/Go-kart” (Fo gr C)activity needed to be fun. Talking about different activities, the children often stated that they were fun. But they also expressed a feeling of participating in a good activity, leading to emotional expressions.For an activity to lead to a feeling of health the “I think it’s fun/It was good/Laugh” (Qu C)“Be happy” (Fo gr C)The leaders, in turn, mentioned the importance of the children wanting to be present:“They want to go/They come” (Fo gr L)activities together with others, such as friends and adults. The children commented that activities at the MaCs gave them opportunities to meet their friends. Moreover, participating in activities gave the children a chance to make new friends.Children and leaders stressed the importance of giving children the possibility of doing the “You have an activity in your spare time and can hang out with friends at the same time” (Qu C)“What has been good is that I had fun with friends and got many new ones” (Qu C)good relationships. Both children and leaders stated the importance of a good atmosphere and of trustful relationships between children and leaders. The activities were especially valued by children with few friends.Participating in activities also created a good base for “The staff are very nice and fun to hang out with” (Qu C)“Oh, continue to have such a positive spirit every day” (Qu C)“Long-term relationships” (Fo gr L)“Leaders and activities are important for a child who does not have friends” (Fo gr L)spending time with the children.Furthermore, the leaders emphasized the value of being present and available for establishing a trustful relationship and of “Attendance/Time to see children” (Fo gr L)The result of the analysis shows that participating in activities was described by children and leaders as not just being present but having a feeling of involvement, by being able to have an influence and to participate on one’s own terms.able to influence their own situation, with regard to the activities they were participating in. The children described how it was fun to be part of the decision-making. The leaders described how they always invite the children to be part of the planning of activities for the children to be able to make choices.For the children, it was important to be able to be actively involved and to be “We choose what to do at the activities/That it was fun and that we get to decide” (Qu C)“The child is involved in planning” (Fo gr L)wanted to improve, but where their wishes were not being met. The aspects that the children most often mentioned as needing to be improved were the possibilities to choose regarding the activities, both the length, and the design of an activity. Most suggestions for improvements can be considered to be wishes for activities, often the ones requiring traveling and being expensive.But at the same time, the children stated that they wanted to have a greater influence. The children gave examples of aspects and situations they “What I think we can improve is to do some more things we want and get to decide a little more” (Qu C)“Have longer activities/Go to fun and different places” (Qu C)“Water-fight swim at Lindängsbadet [an outdoor swimming pool]” (Qu C)“I want more excursions with our activities with the girl group, then we can go out on the town or go to Tosselilla [an amusement park],” a Zoo or just a café (Qu C)be themselves was also stressed.Both children and leaders pointed out the importance of activities at the MaC being a complement to activities in school, not being compulsory, competitive, or requiring achievements. The children commented that they appreciated the availability of the activities. The importance of letting children “The opposite of school/Voluntary/Not achievement” (Fo gr L)“It has also been good that it’s after school” (Qu C)“The children can come as they are/Unconditional” (Fo gr L)participate equally, regardless of their family’s culture, religion, or economic situation.Moreover, the leaders highlighted the importance of having activities that make all children “The families who have no money, the child can still take part in activities” (Fo gr L)The result of the analysis shows that children and leaders describe participating in activities as a way for the child to gain faith in the future and to learn by trying new things, thus positively influencing the child’s development, and resulting in increased self-confidence and a positive behavior.Both the children and the leaders made statements about how important it is to be able to gain knowledge. The knowledge was gained by trying new activities and by engagement on the part of the leaders. Also, trying new activities could help children find new interests.“Gives me a lot of knowledge/That the leaders help us, teach us new things” (Qu C)“You try new things, which makes you find new interests” (Qu C)Trying new activities can also increase the child’s creative side. For children, finding new interests might even lead to a life-long interest or career.“Creativity in music, art, and crafts” (Fo gr L)“Find geniuses” (Fo gr L)changed behavior if needed. Moreover, the relationship, built on mutual trust between children and leaders, can create more self-confidence in children. Being pointed out as a good friend was also an activity that accelerated the child’s self-confidence.During the focus group interviews with the leaders, they drew attention to the possibility to positively influence the child’s development. Participating in activities and relationships with children and leaders, can influence the child toward a “Friend of the week/Influence the child/Positive reinforcement/Change behavior” (Fo gr L)“Long-term relationship” (Fo gr L)meaningful activities as a way of creating hope for the future. Meaningful activities could be the joy of discovering, such as making crafts to take home and show to parents and siblings or creating.Furthermore, the leaders described “Discover/Create/Creation joy” (Fo gr L)“Have something to take home and show” (Fo gr L)® notes were used as a starting point for the focus group discussions, and the children could present an unlimited number of notes and then sort and discuss the ones of their choice in the focus groups. This gave the children freedom to experiment through play, which they pointed out at the end of the study. Moreover, the Post-it® notes opened for reflections on aspects that were not always obvious to an adult. The smaller number of participating children as well as leaders, in some of the focus groups, is a possible limitation. But it might be easier for children in a focus group to stay focused and be heard when there are only few participants in the group . Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.GI, MR, and KE participated in the design of the study, also participated one or more of the focus groups and in the analysis process, and wrote the manuscript. All authors contributed to the article and approved the submitted version.The current study was carried out as a part of “The Health Promotion Platform in Collaboration” at Malmö University. The platform was funded by VINNOVA from 2016 to 2019 , and by the Faculty of Health and Society at Malmö University from 2020 to 2021. The publication fee was funded by a publication grant by Malmö University.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Dear Readers,Innovative Surgical Sciences on the subject area General and Abdominal Surgery. The Guest Editors believe that they were able to generate an exciting issue. Let us invite you to take your time, to linger on its content and get your own impression.Welcome to the current issue of As you – the reader – may assess and monitor, it is an overwhelming challenge to create an interesting issue of the journal with the given subtitle including the hot topics of the specific surgical subspecialty named General Surgery, which also includes – according to the understanding of the Guest Editors – aspects of abdominal surgery. et al. on “Does intestinal anastomosis in resection of colon cancer have a significant impact onto early postoperative outcome and long-term survival?” on quality assurance in operative medicine - a main range of topics of this issue - is dedicated to Prof. Dr. Hans Lippert (Magdeburg), one of the German protagonists out of this specific field of clinical research on clinical care (see the references list).One of the articles, namely “Hajduk E (i)variable article types such as (Narrative) Review , Original Article  and Case Reports ,(ii)methodological aspects such as Clinical Prospective Observational Studies , rare cases/case constellations  as well as(iii)diverse subtopics, such as rare indication for liver transplantation , conservative therapeutic options in acute appendicitis , “oncosurgery” , colorectal surgery  and prehabilitation  was chosen and favored.Therefore, a representative mixture ofThe various dispositions reflect vividly the broad spectrum of the topics. The topics were mainly suggested by the Guest Editors and were obtained from active clinical researchers and surgical colleagues of the field.As selected commentary:Studies on quality assurance in clinical medicine, in particular, in “oncosurgery”, have a long tradition at the Magdeburg’s Institute of Quality Assurance in Operative Medicine  - see a selection in the reference list , 2], , , 5], , .This issue presents the two latest studies, namely on multivisceral resection (MVR) in colon and rectum cancer (CA), which allows curation by R0 resection with adequate long-term survival. In detail (as an excerpt from the article to arouse the reader’s interest), “MVR tended to be associated with reduced 5-year overall survival rates , as well as, with a significant increase in morbidity rates in both tumor entities. In the overall data, MVR was associated with significant increases in hospital lethality rates, as indicated by the MPA ”.In addition, the variable impact of nutritional aspects  and of anastomosis in colorectal tumor surgery  is demonstrated – see below.In an issue on daily topics of general and abdominal surgery, a (narrative) review on current aspects in an appropriate stage-, finding- and inflammatory severity-adapted management of acute appendicitis may not be lacking. It seems that there are certain characteristics which may allow to decide for a conservative approach  or, in contrast, to set a strict indication for surgery .A great ambition of the Guest Editors is the well-developed collaboration of general and abdominal surgery with other clinical, conservative, surgical or operative disciplines, represented in this issue by topics, such as on “What must the abdominal surgeon need to know on plastic surgery”  and pain therapy .–first, on necessary laparoscopic cholecystectomy for symptomatic cholecystolithiasis (CCL) in case of a Kaposi-like tumor lesion, the Kasabach-Merritt syndrome (KMS), which is characterized by pronounced veins at various regions of the body, which can make the surgical approach very challenging;–ex ano, with an impressive manifestation among the most frequent malignant tumor lesions;second, on the rare colorectal malignant tumor site –third, on a rare indication for liver transplantation due to liver failure caused by heat shock.The illustrative collection of topics and various manuscript types is completed by three case reports , a usually underestimated manuscript category but with a high educational level:Hopefully you will like the meaningful introduction provided by this Editorial and you have already become curious on the current issue’s content. Yes, please, let us know your impressions using reader’s “Letters to the Editor“ or “Short Communication“ as appropriate.We would be glad if you have a great time in reading the favored articles chosen and presented.Many thanks to the Editor-in-Chief, Prof. Jähne, for the magnificent opportunity in arranging this colorful collection of articles as well as for favoring our attitude, ideas and guest editing as well as selections of authors, topics and written papers. Many thanks also to the Managing Editor, Dr. S. Sporn, for support in the manuscript processing, galley proofs and final version of the journal‘s issue.Last but not least, we are grateful for the great input of all authors.Karsten Ridwelski and Frank MeyerGuest Editors.