Introduction: Community retail pharmacists are experiencing unsafe levels of stress and excessive demands within the workplace. One aspect of workload stress that has been overlooked among pharmacists is occupational fatigue. Occupational fatigue is a characteristic of excessive workload including increased work demands and reduced capacity and resources to complete the work. The goal of this study is to describe the subjective perceptions of occupational fatigue in community pharmacists by using (Aim 1) a previously developed Pharmacist Fatigue Instrument and (Aim 2) semi-structured interviews. Methods: Wisconsin community pharmacists were eligible to participate in the study and recruited via a practice-based research network. Participants were asked to complete a demographic questionnaire, a Pharmacist Fatigue Instrument, and semi-structured interview. Survey data were analyzed using descriptive statistics. Interview transcripts were analyzed using qualitative deductive content analysis. Results: Totally, 39 pharmacists participated in the study. From the Pharmacist Fatigue Instrument, 50% of the participants stated they had times where they were not able to go above and beyond standard patient care on more than half of the days they worked. A total of 30% of the participants reported that they found it necessary to take short-cuts when providing patient care on more than half of the days they worked. Pharmacist interviews were separated into overarching themes including mental fatigue, physical fatigue, active fatigue, and passive fatigue. Conclusions: The findings highlighted the pharmacists’ feelings of despair and mental fatigue, fatigue’s connectedness to interpersonal relationships, and the complex nature of pharmacy work systems. Interventions aimed at improving occupational fatigue in community pharmacies should consider key themes of fatigue that pharmacists are experiencing. Community retail pharmacists are experiencing unsafe levels of stress and excessive demands within the workplace ,5,6,7,8.Occupational fatigue is a characteristic of excessive workload—both increased work demands and reduced capacity and resources to complete the work ,12,13,14Consistent with other health care professionals, the well-being of pharmacists has often been overlooked ,6,7,8,24The COVID-19 pandemic thrust pharmacist work and well-being to the forefront of public media. As a major access site for COVID-19 testing and vaccinations, pharmacies were required to adjust and reprioritize work. Subsequently, patients were exposed to systematic changes including longer wait times, staffing shortages, and policy adjustments . Articles in the New York Times have included catchy titles such as, “How Chaos at Chain Pharmacies is Putting Patients at Risk” and “Angry Customers, More Work and Longer Hours Strain Pharmacists” ,27,28,29Recently, pharmacists on social media have taken to use the tag “#PizzaIsNotWorking” to highlight pharmacy working conditions. The hashtag, a tongue-in-cheek reference to organizational support in the form of pizza as opposed to bonuses or staffing, has garnered public attention as pharmacists “band together to raise awareness about working conditions” ,31,32,33Research literature and pharmacists themselves via social media are alluding to the significant imbalances between work demands and capacity. Given the unique and complex nature of community pharmacist work, a tailored, adapted, and context-specific instrument may be necessary to completely capture this multidimensional phenomenon ,34,35. SThe goal of this study is to describe community pharmacist subjective perceptions of occupational fatigue using (Aim 1) a previously developed Pharmacist Fatigue Instrument and (Aim 2) semi-structured interviews.The study was approved by the Health Sciences Institutional Review Board (IRB) at the University of Wisconsin-Madison (ID 2021-0174-CP001 on 25 May 2021) prior to study recruitment. The study aimed to recruit 60 Wisconsin licensed community pharmacists to participate in the study. Individuals who participated in a previous pilot study (n = 20) were not eligible to participate. The original sample size of 60 was chosen as an appropriate estimate to ensure results and saturation of findings. The final sample was limited due to financial and time restrictions for this project.Subjects were identified based on their voluntary enrollment in the PearlRx (Pharmacy Practice Enhancement and Action Research Link) practice-based research network. To join PearlRx, individuals give permission to share their contact information with researchers from Wisconsin schools of pharmacy and indicate that they are willing to be contacted about possible research study participation. PearlRx is a statewide research network based in the Sonderegger Research Center of over 200 community, clinic, and hospital pharmacists. During the recruitment process, the PearlRx Program Administrator sent four emails to all PearlRx members, alerting them of a new study opportunity for community pharmacists. Pharmacists were also encouraged to forward and share the email newsletter to other interested pharmacists. The call for participation was also placed on PearlRx’s “Current Projects” page. Interested participants were screened for eligibility and asked to meet the researcher at a time and location that was convenient. Participants were instructed to document the days and times they worked the following 14 days on a provided calendar. The calendar was used to anchor the respondent’s recall period . At the Demographic information collected included age, gender, title, years working as a pharmacist, years working in the current position, number of adults and minors in the household, and amount of caffeine consumed per day. The Pharmacist Fatigue Instrument was previously developed and tested to assess occupational fatigue in Wisconsin pharmacists . The 12-Individuals participated in a 30-min semi-structured virtual interview. The purpose of this interview was to explore factors related to fatigue during the 14-day recall period, including workload, work system characteristics, scheduling, and personal factors.The Pharmacist Fatigue Instrument and demographic responses were entered into a secure electronic platform and double-verified. Descriptive statistics, response frequency, and data visualizations were created using R Version 4.0.3 and R Studio . All interviews were audio recorded and transcribed verbatim. The transcripts were analyzed using qualitative deductive content analysis using concepts from the literature to explore pharmacist perceptions and experiences of the various dimensions of occupational fatigue (QSR NVivo). The deductive codes aligned with the domains of mental fatigue, physical fatigue, and general lack of energy, as well as active fatigue and passive fatigue from the Adaptation Model of Stress and Performance ,44. The During data collection, from July 2021 to March 2022, 49 individuals expressed interest in participating in the study and completed the initial recruitment survey. Of those individuals, 39 participants participated in data collection. No Pharmacist Fatigue Instrument data were missing.Participant pharmacist and pharmacy demographic characteristics are summarized in The Pharmacist Fatigue Instrument asked respondents to report the frequency they experienced fatigue-related events over the previous 14 days. Response distributions are represented in In addition to feelings of decreased energy, increased tiredness, and general fatigue, 52% of pharmacists reported they had times where they felt that they could not keep with their work on more than half or all the days they worked . A total of 50% of the participants stated they had times where they were not able to go above and beyond standard patient care on more than half or all the days they worked . Overall, 37.5% of the participants stated that they had trouble thinking clearly at work on more than half of the days they worked. In addition, 37.5% had times where they felt they were not performing at their best on more than half or all the days they worked, while 32.5% had times where they forgot whether they had completed a task on more than half or all the days they worked. Finally, 30% of the pharmacist participants reported they found it necessary to take short-cuts when providing patient care on more than half or all the days they worked .Pharmacist interviews shed light on subjective experiences of fatigue. Their experiences were separated into several overarching themes, correlating to fatigue domains found in the literature: mental fatigue, physical fatigue, active fatigue, and passive fatigue. The key fatigue characteristics are represented in Mental fatigue is often described as feelings of lack of motivation  and sleepiness . ParticiYou can see a difference in the beginning of the day how we treat customers to the end of the day, which is sad. I don’t ever want to get cranky at customers, but, understandably, they’re losing patience with us since everything’s taking longer, but we’re also losing patience with the fact that they don’t have patience with us. So, admittedly, I’ve been getting a lot more cranky at work, especially these last few weeks.Pharmacist 9Another pharmacist indicated that on days with heavier workloads, the staff members are more likely to get irritated with each other:Throughout the day, I can tell we all become a little more irritated with each other. It also depends how the workflow is going, you have your days where nothing is going right, and then you have days where everything’s a cake walk. But, if we’re all caught up and things are going great, we all are like joking around, laughing with each other. But if things are just rough, we’re just snippy with each other, and it’s not fun.Pharmacist 11Pharmacists also described their fatigue as changes to their overall mental states. Many pharmacists described their fatigue as feeling exhausted and worn out after a long day of work or as a general desire for rest. This fatigue had potential implications for relationships once they were home with family members. One pharmacist stated:And that does wear me out by the end to the day, I don’t want to talk to anybody. I just want to sit down and be quiet for a while. That fatigue. Not fall asleep fatigue, but just … I need rest.Pharmacist 1Other pharmacists described their mental fatigue and changed mental states as feeling overwhelmed or feeling that they were unable to keep up with their work tasks.I definitely feel, it’s fatigue, but it’s also just almost more of a mental … despair sounds dramatic. It’s not despair. But, ‘oh, there’s so much to do, and I’m not going to get it done,’ kind of a feeling until it starts to slow down.Pharmacist 4Pharmacists also described a “hazy” or “foggy” feeling that would occur later during the workday. Often participants would describe forgetting whether they had completed tasks such as checking prescriptions or what information they told patients during prescription counseling. Participants stated that they would verify the “same prescription” multiple times because they had trouble concentrating or would get distracted from the singular task. One participant described this feeling of mental fatigue as:As I start to get towards that end of the day, that foggy hazy feeling. Most of the time I am doing the vaccines, so it’s okay. But, I’ll start to get that foggy, hazy feeling, and I’ll be like, ‘wait, what did I just say? What was I just working on?’Pharmacist 1In the literature, physical fatigue includes physical exertion and physical discomfort ,22. CommPharmacists mentioned low back pain that developed over the course of the day, potentially attributable to standing in the same location for long shifts. Some pharmacists stated this pain was exacerbated by age or previous injuries. One pharmacist described their experience with low back pain as:Sometimes I do get low back pain. And I don’t know if it’s just from standing for ten hours straight in the same spot for most of the day.Pharmacist 11Additionally, pharmacists also described lower leg or foot pain arising over the course of the day. Some participants detailed personal efforts to mitigate this pain by wearing more expensive shoes, arch support, and insoles.Usually, my feet will start to hurt. I’ll be walking back from the flu room or something, and I’ll just notice my feet are sore. I even got these better shoes, and that seemed to work for a little while. But now I’m like ‘ugh.’Pharmacist 20Some pharmacists reported that the headaches were associated with certain tasks or simply the result of prolonged shifts without opportunities for food or rest.And especially if [the patient] is going to come yell at you, or you recognize the name and you know it’s a script you have to refuse, and it’s going to probably start an issue, and you have to keep smiling through the whole thing. That does make me get headaches by the end of the day.Pharmacist 1The Adaptation Model of Stress and Performance states that active fatigue results from conditions of high cognitive overload with continuous and prolonged work . PharmacIt’s just mentally exhausting helping person after person after person, running back and forth between trying to keep up on product checking. Just physically, mentally, it’s exhausting. And then by the end of the day, my brain just doesn’t, I don’t feel as clear. It’s hard to think.Pharmacist 12Commonly, pharmacists stated they would not notice these feelings of fatigue “in the moment” but rather once they had a moment to pause or stop. Pharmacists stated this was most prevalent when patient load decreased when the pharmacy was close to closing or when they got in their cars to drive home.I think for me, one of the signs that I’ll usually pick up on that makes me realize that I’m more tired is usually once I have a chance to actually sit down, I’ll be like, ‘oh, my God, this actually feels really good right now.’ Especially with those long days where I’m working 7:30 a.m. to 8 p.m. I have a lunch break in there, but you’re just continuously working. And then after a while, I sit in my car for a minute, and ‘wow, it’s been a long day.’Pharmacist 8In comparison to active fatigue, the Adaptation Model of Stress and Performance states that passive fatigue is indicative of low cognitive work and under stimulation . PharmacBecause days that we’re super busy, your brain doesn’t have a chance to slow down and stop, whereas a day where you’re slow, it’s hard because your brain’s not constantly stimulated. And then I feel like when you do have the sudden person come in, you’re like, ‘oh, I have to check.’ I’m one of those ones, I function better on a day where we’re consistently busy. I like where it’s like not overwhelming, but yet it’s busy enough where I never actually check out of what I’m doing to have to check back in. I think, when you are having a slow day, and there isn’t a lot going on it’s hard to keep engaged with what’s going on.Pharmacist 35Even when the pharmacy was not “slow,” pharmacists described instances of passive fatigue as working on “autopilot” while completing tasks. Pharmacists noticed these feelings when they recovered and returned to focus or forgetting the details of a prescription they recently verified. Two pharmacists described their experiences with this type of passive fatigue in the following exemplar quotes:The scripts start to run into each other. And that’s also when you’re supposed to be checking them against other medications and stuff, and I just notice that I start to really zone out in what I’m doing. And I really have to snap myself and be like, ‘okay, you have to focus. You got to make sure this is correct.’Pharmacist 9Autopilot, I think is the way I would describe it. Because, there’s been times where once I’ve checked the prescription and I’ll pull it back up, I’ll be like ‘I literally don’t even remember looking at those pills or seeing that prescription.’ Or I guess I’d compare it to the times where I’ve driven home and I’m like ‘how did I just get home? I don’t remember turning here.’ It just goes by, and I’m like ‘what happened?’Pharmacist 11Overall, the Pharmacist Fatigue Instrument and interviews presented similar findings regarding subjective perceptions of fatigue in pharmacists. Specifically, the findings highlighted three themes related to pharmacist fatigue: feelings of mental fatigue, connection to interpersonal relationships, and complex work systems with both active and passive fatigue. The survey instrument and interviews shed light on pharmacists’ perceptions of the mental fatigue they experienced at work. More than 60% of participants stated that their energy decreased, and they felt more tired over the course of their shifts most of the days they worked. Instrument respondents also shared their trouble thinking clearly and taking longer to complete tasks. These results are similar to the previous study, which identified mental fatigue as a key domain of pharmacist occupational fatigue .The objective instrument results align with the interview findings where participants described feeling exhausted, worn out, overwhelmed, hazy, or foggy. This is similar to findings in other healthcare professionals ,46. A 20Exploring pharmacist work through an occupational fatigue lens helps to describe this complex and multidimensional experience. With a tailored and context-specific instrument, researchers and organizations can further study community pharmacist occupational fatigue as well as the impact of intervention over time. During the pharmacist interviews, participants stated they knew they were fatigued when they became more irritable with team members or cranky with patients. Within the Pharmacist Fatigue Instrument, over 30% of pharmacists stated that on more than half of the days they worked, they felt more impatient later in the day than they did at the beginning. Similarly, 50% of pharmacists stated that on more than half of the days they worked, they felt they were unable to go above and beyond when providing patient care. The instrument and interview findings help to conceptualize the interpersonal nature of occupational fatigue. Within the literature, fatigue is often considered a “personal” phenomenon that an “individual” experiences—the body’s biological desire for rest and recovery. Efforts to address fatigue are often directed at the individual level, such as proper sleep hygiene or promoting mental health, well-being, and resiliency in the face of stress. While this individualized definition is correct, fatigue must also be considered within the larger social system ,48. A 20The results also shared the connection between occupational fatigue and relationships with patients. Research studies provide demonstrable evidence to the increased risk to patients when health care workers are fatigued ,52,53,54This research study demonstrated that fatigue is related to pharmacist interpersonal relationships with family, team members, and patients. In a study of emergency medicine consultants, one-third of participants reported that stress at work caused them to be irritable with patients, colleagues, or reduce their standard of care at least monthly . AddressOccupational fatigue dimensions are not mutually exclusive. Fatigue may be mental or physical while also occurring acutely or chronically over time ,20. AddiWithin the Pharmacist Fatigue Instrument, 52% of pharmacists reported they had feelings where they could not keep up with their work most days. This may relate to the feelings of active fatigue expressed during the interviews where participants stated they were fatigued after helping “person after person”. Similarly, over 32% of pharmacists reported forgetting whether they had completed tasks on most of the days they worked. This may align with feelings of passive fatigue in the interviews or pharmacists that stated they felt they were working on “autopilot.”The Adaptation Model of Stress and Performance, including active and passive fatigue, help to explain unique scenarios of fatigue, namely why under-stimulating work can be just as exhausting as over-stimulating work. A study by Saxby et. al. identified that when simulating active and passive fatigue in drivers (wind gusts inducing active fatigue and full vehicle automation inducing passive fatigue), only passive fatigue reduced alertness, speed of braking, and steering responses to an emergency event . The pharmacists in this study highlighted the fine balance between staying busy enough to stay engaged in work while also being too busy to slow down or recover between patients. This idea of balance can be challenging in community pharmacy, and other retail professions, especially because they are unable to control their rate of work . PatientUltimately, pharmacist occupational fatigue is a complex multidimensional phenomenon. Solutions to address occupational fatigue must consider how to address the mental, interpersonal, as well as work system components of pharmacist experiences.This study faces potential selection bias, in that individuals experiencing high levels of fatigue may be more interested in participating. Conversely, pharmacists who feel overwhelmed and unable to keep up with work may not have the time or energy to participate in a multi-week study. Recruitment mainly included pharmacists engaged in the PearlRx practice-based research network, which may limit generalizability of findings.There are inherent limitations to the Pharmacist Fatigue Instrument in that it assigns a continuous value to a non-continuous/categorical response variable, potentially inflating the results. However, this approach has been used in other fatigue instruments, including the Swedish Occupational Fatigue Inventory and follows the assumption that normally distributed, continuous variables underly the categorical variables of the Likert-scale ,60,61. The Pharmacist Fatigue Instrument has been shown to demonstrate the mental and physical domains of occupational fatigue—it has not explicitly been tested to capture interpersonal relationships or components of active and passive fatigue. Therefore, researchers should be cautious in using this instrument alone to distinguish discrete fatigue domains. The Pharmacist Fatigue Instrument may be paired with other validated fatigue instruments such as the Swedish Occupational Fatigue Inventory or the Occupational Fatigue Exhaustion/Recovery Scale to isolate specific fatigue domains or compare fatigue in pharmacists or generalize to other professions. However, the Instrument presents a holistic survey to capture experiences of occupational fatigue tailored specifically to community pharmacists. Future research may be done to expand the use of the Pharmacist Fatigue Instrument to pharmacists in setting outside of community pharmacy as well as pharmacy technicians or student interns. Future studies may also explore the validity of the Pharmacist Fatigue Instrument at comparing fatigue before and after the implementation of interventions aimed at improving pharmacist fatigue.The goal of this study was to describe Wisconsin community pharmacists’ experiences with occupational fatigue. This study is valuable in that it took a multimodal approach of a tailored Pharmacist Fatigue Instrument and semi-structured interviews. The Pharmacist Fatigue Instrument may be useful for researchers or organizations wishing to capture a holistic picture of community pharmacist fatigue. Interventions aimed at improving occupational fatigue in community pharmacies should consider key themes of fatigue that pharmacists are experiencing including mental fatigue, interpersonal connections and relationships, as well as the complex work system impact of active and passive fatigue.


Contraceptive choice is central to reproductive autonomy. The internet, including social networking sites like Reddit, is an important resource for people seeking contraceptive information and support. A subreddit dedicated to contraception, r/birthcontrol, provides a platform for people to post about contraception.This study explored the use of r/birthcontrol, from the inception of the subreddit through the end of 2020. We describe the web-based community, identify distinctive interests and themes based upon the textual content of posts, and explore the content of posts with the most user engagement .Data were obtained from the PushShift Reddit application programming interface from the establishment of r/birthcontrol to the start date of analysis . User interactions within the subreddit were analyzed to describe community use over time, specifically the commonality of use based on the volume of posts, the length of posts (character count), and the proportion of posts with any and each flair applied. “Popular” posts on r/birthcontrol were determined based on the number of comments and “scores,” or upvotes minus downvotes; popular posts had 9 comments and a score of ≥3. Term Frequency-Inverse Document Frequency (TF-IDF) analyses were run on all posts with flairs applied, posts within each flair group, and popular posts within each flair group to characterize and compare the distinctive language used in each group.There were 105,485 posts to r/birthcontrol during the study period, with the volume of posts increasing over time. Within the time frame for which flairs were available on r/birthcontrol , users applied flairs to 78%  of posts. Most posts contained exclusively textual content , had comments , and had a score . Posts averaged 731 characters in length (median 555). “SideEffects!?” was the most frequently used flair overall , while “Experience”  and “SideEffects!?”  were most common among popular posts. TF-IDF analyses of all posts showed interest in contraceptive methods, menstrual experiences, timing, feelings, and unprotected sex. While TF-IDF results for posts with each flair varied, the contraceptive pill, menstrual experiences, and timing were discussed across flair groups. Among popular posts, intrauterine devices and contraceptive use experiences were often discussed.People commonly wrote about contraceptive side effects and experiences using methods, highlighting the value of r/birthcontrol as a space to post about aspects of contraceptive use that are not well addressed by clinical contraceptive counseling. The value of real-time, open-access data on contraceptive users’ interests is especially high given the shifting landscape of and increasing constraints on reproductive health care in the United States. Contraceptive use is widespread in the United States, with approximately 65% of reproductive-age individuals (ages 15-49 years) using a form of contraception based on the 2017-2019 National Survey of Family Growth. Overall the use of contraception is relatively stable in the United States, with similar proportions of women using a method from 2008 to 2016 . While tInformed contraceptive choice, or the ability to freely access and choose from among the range of methods of fertility control, is recognized as a necessary component of reproductive autonomy, understood as people being able to control and decide if, when, and how to have children . ContracWhile patient-centered contraceptive counseling approaches can provide information to anticipate contraceptive use experiences, they have been found to have limited effects on method continuation . ContracSocial networking sites, or web-based platforms designed to build social relationships, allow people to share experiences, ask questions, and seek support from others within a web-based community. Some scientists and experts argue that the anonymous nature of certain platforms makes them uniquely appealing to individuals who are seeking information about sensitive or stigmatized concerns like contraception -35 and mReddit is a social media platform that houses web-based communities of anonymous users called “Redditors.” It is one of the most popular websites in the United States, largely because of its user-driven aggregation and community-based curation of web-based content ,46. ReddThis study focuses on the subreddit r/birthcontrol. In 2017, this subreddit consisted of 20,107 members, and 2.9% of its members identified as male, while 97.1% of them identified as female . This stThe use of machine learning, and natural language processing (NLP) specifically, presents an opportunity for contraception researchers to work efficiently with big data from social networking sites to generate knowledge about how people are using language across an entire body of text rather than a subset. Additionally, the use of NLP expands beyond traditional qualitative analyses of textual data from Reddit, like those presented by recent research on the use of social networking sites for reproductive health ,49-51, tPushShift.io API Wrapper package in Python (version 3). The PushShift Reddit API team noted that PushShift has a greater size limit for downloaded content and better facilitates researchers’ use of Reddit data than the official Reddit API [The subreddit r/birthcontrol was established on July 21, 2011, as a “place to discuss birth control methods.” This subreddit has 2 moderators who uphold the following moderators-created and enforced rules for contributing to the community: (1) not doctors, (2) be welcoming, (3) tact, (4) respect, (5) Reddiquette, (6) no selling, advertising, or surveys, and (7) factual comments. We extracted data from r/birthcontrol for this analysis using the PushShift Reddit API (application programming interface). PushShift is a data platform for social networking sites that started to collect Reddit data in 2015 . This stddit API .Data were pulled from July 21, 2011, the establishment of r/birthcontrol, to December 31, 2020, when this analysis began. On Reddit, “posts” are descriptive information generated and shared by a community member with no word limit and the option to share images, links, videos, and text. For each post, there is an option to apply 1 of any of the available pre-established “flairs” for that subreddit to each post. On Reddit, a user can apply a flair or a “tag” to their post before sharing within a subreddit. Users can choose the flair they think most accurately describes their post, designating the informational “group” for that post. Flairs are determined and set by subreddit moderators and operate as content “tags” for Reddit posts. Flairs for r/birthcontrol include “Experience,” “SideEffects!?,” “WhichMethod?,” “MistakeorRisk?,” “Howto?,” and “Educational.” Users can either select a single predefined flair per post or not apply a flair.“Comments” are any response to a post from a community member. Community members also have the option to “upvote” or “downvote” posts and comments, indicating approval or disapproval of that content and contributing to the ranking of that content on the subreddit’s home page, with posts having more upvotes being raised closer to the top where other community members are more likely to view it. Comments and likes are 2 strong indicators showing user interactions on social media platforms. Usually, the more comments and likes, the more popular the post is. In the PushShift API, a “score” is presented as a proxy for the popularity of each post in this community, which is calculated as upvotes minus downvotes. User interactions within the subreddit—including the number of characters per post and comment, the contents of posts and comments, and the upvotes, downvotes, and “scores” of the Reddit posts—are compiled in the API.Before exploring the textual data, we did some necessary preprocessing of the text, including cleaning stop words and lemmatization using the Natural Language Toolkit package . We alsPandas package. Then, we narrowed the data to only the time period for which flairs were active on r/birthcontrol . Flairs were used as a foundation for coding categories of posts. First, duplicative flairs were consolidated, for example, some flairs share the same meaning but are slightly different in their text, as with missing punctuation. After this process, we were left with the previously described 5 main flairs on r/birthcontrol. After excluding posts with flairs that did not have text in the body of the post, we also calculated the volume of posts to which flairs were applied and the proportion of posts with each flair over time to explore how users were indexing their own posts, which can be understood as indicative of posters’ interest in communicating about common themes within this community. From the number of posts tagged with each flair by year, a proportional bar chart was generated to present the frequency with which each flair was applied to posts across years (2016-2020).To describe the use of r/birthcontrol over time, we counted the number of posts by month, calculated the average length of the text per post, and determined the log of text length through the sklearn package to convert the corpus text  into vectors, a matrix of TF-IDF features (SciKitLearn). Within the TfidfVectorizer function, there is a parameter called ngram_range, which decides n-grams to be extracted. For example, for ngram_range of , it is unigrams, and ngram_range of  indicates unigrams and bigrams. In our setting, we used both  and .To show the most distinctive words and phrases (2-word phrases) in all textual content of posts to r/birthcontrol, we used Term Frequency-Inverse Document Frequency (TF-IDF). TF is term frequency, meaning the number of times the term appears in a document, similar to the bag-of-words approach, and it allowed us to determine how frequently words were used in the text of posts. IDF is the inverse document frequency, weighing words by how prevalent or rare they are in the entire corpus . This apUsing findings from the TF-IDF analysis, we investigated the most distinctive words and phrases (“terms”) in a sample of r/birthcontrol posts with flairs applied (starting in 2016 with the introduction of flairs) and compiled a ranking of the top 10 unigrams and bigrams. Finally, the same process for determining top-ranked unigrams and bigrams was replicated for posts within each flair group since the introduction of flairs.To examine the posts with the greatest or most user engagement in the subreddit, we explored the number of comments and “scores,” calculated by subtracting the down-vote counts from the up-vote counts. We were interested in focusing analyses on approximately 10% of posts that constituted the most popular content on this subreddit. After exploring the number of comments and the “scores” of posts (upvote count minus downvote count), we decided to select posts with more than 9 comments and a score of 3 or higher, categorized as “popular posts” for this analysis . Among “As this research was conducted using public internet posting, rather than data from private forums or conversations, and no other nonpublic information was used, this study team operated following previously described approaches where ethics approvals were not deemed necessary .Since its establishment in 2011, there were 105,485 total posts to r/birthcontrol. The number of monthly posts largely increased over time , with alWithin the timeframe for which flairs were available on r/birthcontrol , users applied flairs in this analysis to 78%  of posts. Applying exclusions to these posts, 1619 did not contain any text, 2746 were deleted by users, and 267 were removed. This left us with an analytic sample of 68,824 posts. The majority of posts were exclusively textual content , with only 4% (n=2753) including images. Posts averaged 731 characters in length, with a median of 555 characters. Overall, 86%  of posts had comments, with a median of 3 comments, and only 10% (n=6882) of posts with 10 or more comments. In total, 96%  of posts had a score, with only 2% (n=1376) having a score of more than 10.The absolute number of posts to which each flair was applied increased over time, paralleling the increasing number of posts in this community between 2016 and 2020. The proportion of posts from each year to which each flair was applied is presented in The top 10 unigrams and bigrams among all r/birthcontrol posts with flairs  are presented in The top 10 unigrams and bigrams for posts with each flair applied are presented in There were 2318 popular posts, for this research defined as posts with 9 or more comments and a score of 3 or more (Methods section), on r/birthcontrol posts since the introduction of flairs. “Experience” was the most commonly applied flair among top posts , followed by “SideEffects!?” , “WhichMethod?” , “MistakeorRisk?” , and “Howto?” . Compared to all posts, “Experience” and “WhichMethod?” were more common among popular posts.The top 10 unigrams and bigrams for popular posts with each flair applied are presented in For “SideEffects!?,” top n-grams were also commonly related to IUDs , birth control pills (“pill” and “control pill”), specific side effects , and timing .For “MistakeorRisk?,” popular posts often discussed contraceptive methods , unprotected sex and pregnancy risk , and timing .Among popular “Experience” posts, physical experience phrases were common , as were discussions of IUDs (“get IUD” and “copper IUD”). “Horror story,” “sex drive,” and “get pregnant” were the other top bigrams for “Experience” posts.For “Howto?,” popular posts were similar to those for “MistakeorRisk” but with more common discussion of IUDs and action or experience .For popular posts in “WhichMethod?,” similar to all posts different methods were discussed , along with efficacy, side effects, and risk words .This descriptive analysis of posts on the r/birthcontrol subreddit revealed several findings of interest. First, posts on r/birthcontrol have increased over time since the establishment of the subreddit in 2011, with a notable increase in the volume of posts in the last 5 years. Our findings show that r/birthcontrol was used to seek information about contraception, which aligns with past research demonstrating that the internet is a source of contraceptive information ,39,41,42Second, leveraging the opportunity presented by user-applied flairs as a tool for categorizing the topical content of Reddit posts, we found that the use of flairs on r/birthcontrol has increased over time in parallel to the progressively increasing volume of posts. Of the 6 flairs explored, “SideEffects!?” was most frequently applied to posts across years, while among popular posts “Experience” and “SideEffects!?” were the most frequently applied flairs. This suggests that a high proportion of members of this subreddit were engaging with it to discuss side effects and contraceptive experiences, as they self-selected to apply these flairs to their posts. Knowledge about potential side effects is a key consideration for users who seek contraceptive information -8,27, anThird, findings from the TF-IDF analyses shed additional light on distinctive interests posted in this community, including contraceptive methods, menstrual experiences, timing, feelings, and unprotected sex. While n-gram results for posts with each flair varied somewhat, topics including the contraceptive pill, menstrual experiences, and timing were discussed across flair groups. Based on TF-IDF results, IUDs and language related to experience using contraception  were more often discussed among popular posts than the entire sample of posts. Popular posts are presented at the top of the subreddit, and therefore, most seen by people engaging with this community—meaning that this content has the greatest potential to impact both community members and people “lurking” (or reading without actively engaging) on a subreddit. While IUD use has been increasing steadily over the past 15 years (with use among contraceptive users increasing from less than 3% in 2002 to 14% in 2018)  and IUDsReddit and data from health topic-specific subreddits not only serve as resources for individuals navigating health experiences and concerns but also present novel opportunities for researchers. This analysis of data from r/birthcontrol serves as a case study of how public health researchers can use NLP to explore the use of Reddit to communicate about health needs. NLP presents powerful tools for efficient and reproducible analysis of textual data, which allowed us to explore a large corpus of text across the history of a subreddit, but NLP does not provide the nuanced and contextualized insights gained from qualitative analytic approaches  and can Additionally, while using user-applied flairs as a categorization tool allowed us to explore broader interests across posts and differences in post content between flair groups, the available flairs for each subreddit are determined by moderators, and the application of flairs is highly subjective. As such, these findings are limited by the flairs made available in r/birthcontrol and the level of consistency with which flairs were applied by posters. Future research could explore how flairs are applied more deeply to provide additional insights into their power as a categorization tool. Despite this limitation, our research approach provides an accessible method to categorize content shared on Reddit.It is important to understand not just how web-based communities are used by posters, but how they impact community members and their health. While our analysis focused exclusively on posts to r/birthcontrol, analysis of comments shared in this community could provide additional insights into the impacts of this community on contraceptive outcomes as well as the dynamics of communication within the community. Furthermore, estimates indicate that as much as 98% of Reddit users only observe and never post or comment (“lurkers” ), meaninAs a pseudo-anonymous platform where users are not required to create profiles and are only identified by usernames, Reddit provides a space where users feel comfortable discussing sensitive and stigmatized topics -36,40. WFinally, while this research established the range of contraceptive interests and concerns across posts to r/birthcontrol, it did not explore the presence and content of misconceptions and misinformation in the community. Future research on the use of r/birthcontrol and social networking sites for contraception more generally should explore what misconceptions are commonly described and how they diffuse within communities. For prospective users, misinformation and misconceptions about contraceptive methods are known to be widespread, including those relating to the perceived safety and efficacy of certain methods -71,79. WThis study presents an analysis of post data from r/birthcontrol, providing insights into how this digitally facilitated web-based community was used from 2011 to 2020. We found that people commonly wrote about contraceptive side effects and experiences using methods, highlighting the value of this subreddit as a space to post about aspects of contraceptive use that are not well addressed by clinical contraceptive counseling. The value of real-time, open-access data on contraceptive users' interests is especially high given the shifting landscape of and increasing constraints on reproductive health care in the United States, creating opportunities to understand population interests and current needs for contraceptive support.


Preventing smoking among young Aboriginal people is important for reducing health inequities. Multiple factors were associated with adolescent smoking in the SEARCH baseline survey (2009–12) and discussed in a follow-up qualitative study that aimed to inform prevention programs. Twelve yarning circles were facilitated by Aboriginal research staff at two NSW sites in 2019 with 32 existing SEARCH participants aged 12–28 . Open discussion around tobacco was followed by a card sorting activity, prioritising risk and protective factors and program ideas. The age of initiation varied by generation. Older participants had established smoking in their early adolescence, whereas the current younger teens had little exposure. Some smoking commenced around high school (from Year 7), and social smoking increased at age 18. Mental and physical health, smoke-free spaces and strong connections to family, community and culture promoted non-smoking. The key themes were (1) drawing strength from culture and community; (2) how the smoking environment shapes attitudes and intentions; (3) non-smoking as a sign of good physical, social and emotional wellbeing; and (4) the importance of individual empowerment and engagement for being smoke-free. Programs promoting good mental health and strengthening cultural and community connections were identified as a priority for prevention. Tobacco use continues to be a major cause of preventable ill health for Aboriginal and Torres Strait Islander peoples accounting for half of all deaths in people aged 45 years and older, and is the largest contributing modifiable risk factor to the gap in disease burden between Aboriginal and Torres Strait Islander people and non-Indigenous Australians ,2. WhileGenerally, the drivers of smoking initiation and tobacco use among Aboriginal and Torres Strait Islander people are similar to those of other populations. These include normalisation and exposure to peer or family smoking, concurrent use with alcohol and cannabis, as well as life stress and poor mental health ,14. SmokThe Study of Environment on Aboriginal Resilience and Child Health (SEARCH) is a community-controlled cohort study of Aboriginal children, young people and their carers from four Aboriginal Community Controlled Health Services (ACCHS) in urban and regional New South Wales (NSW) . It provides a unique insight into the individual, social, environmental and cultural factors associated with the smoking experience of young Aboriginal people in urban areas. Cross-sectional baseline (Phase 1—2008-12) findings from self-reported responses from Aboriginal adolescents (12–17 years) and their carers identified multiple factors that may be associated with adolescent tobacco use, and have the potential to inform policy and community-level programs . These iOther factors identified through a previous systematic review  which haThis study aimed to understand and explore the smoking and non-smoking experiences, attitudes and beliefs of Aboriginal adolescents aged 12 and above in urban and regional settings in NSW, and to triangulate the cross-sectional SEARCH survey findings to develop recommendations for future, contextually relevant, community-based prevention programs. Specifically, this study sought to explore, interpret, confirm and explain the quantitative findings with two generations of SEARCH adolescents (Phase 1 and 2 participants), and through discussion, identify key factors to be leveraged in future community-led tobacco prevention interventions.This is the second stage of an explanatory sequential mixed methods  researchPhenomenological methods such as interviews and group discussions are commonly used to understand, describe and interpret behaviours and the meanings attached to experiences, and are particularly useful for exploring perceptions, attitudes and beliefs . Group dOur discussions were underpinned by an Aboriginal research method, yarning. Yarning allows for culturally safe and more relaxed, interactive, collaborative, two-way conversation in Indigenous settings, reducing the formality and power dynamics of traditional research interviews ,33,34. TACCHS staff and Aboriginal researchers have led the design and conduct of this study. Co-authors SS and CC guided the research design, one a SEARCH Aboriginal Research Officer familiar with the study, its partners and participants (SS), the other a senior Aboriginal academic (CC) experienced in qualitative research methods. The senior author (SE), also a senior Aboriginal academic, provided leadership and guidance throughout. Another SEARCH Aboriginal Research Officer (MC) led the yarns, supported by CH  and in some sessions, with other Aboriginal ACCHS staff .Fieldwork was conducted at two ACCHS partner sites in NSW, one regional and one metropolitan. Staff identified suitable spaces in which participants would feel comfortable and safe. At both sites, these were recreational community spaces, separated from dedicated health service buildings and with an informal, relaxed lounge atmosphere. Morning/afternoon tea was provided.AHMRC  approval was granted by amendment to the SEARCH study ethics (568/06) and registered with University of Melbourne HREC (1953833). CEO approval from both sites was received. Additional informed consent protocols were followed with each participant receiving a participant information sheet and consent form (PICF). SEARCH ROs sought caregiver consent for 12–17-year-old participants in advance, with the underage adolescents also providing their own assent when attending. Key points from the PCIF were reinforced prior to each session.ACCHS/SEARCH staff recruited 32 existing study participants (aged 12–28 years) of any smoking experience who had either participated in SEARCH Phase 1 (between 2008-12) or Phase 2 (from 2014) when aged between 12–17 years. Participants were primarily recruited in small groups of 3–4 friends or family within kinships groups. Group composition was determined by ACCHS staff based on their local understanding of relationships and dynamics that would increase participant comfort and familiarity to facilitate discussion. Recruitment continued at Site 2 until saturation was reached, and participants shared similar perspectives. All participants received a Gift Card  and morning/afternoon tea. The gift cards and sharing of food acknowledged the value of their contribution and helped build a reciprocal relationship.Fieldwork was completed in March and June 2019 across the two sites, with a total of 12 yarning circles  of approximately 60 minutes each. Each began with introductions as outlined above, followed by a broad, general discussion about health and specific tobacco knowledge, attitudes and experiences. Participants then completed an interactive card sorting activity of 45 potential risk and protective factors drawn from the SEARCH survey items ,37 and AThe primary purpose of the card sorting activity was to validate  the findThis is an effective method, particularly among young people, vulnerable populations or when discussing sensitive topics . Not onlA short discussion guide was used and revised between Site 1 and Site 2, removing redundant prompts duplicating the discussion. The guides, cards and fieldwork photos are included in The fieldwork team debriefed at the end of each interview. Audio files were transcribed by a third-party contractor with no connection to participants. CH reviewed the transcripts against the recordings for immersion and accuracy, removing identifying information. Redacted transcripts were sent to MC and the other SEARCH ROs for checking. A multi-stage coding process was undertaken in NVivo 12 by CH. Site 1 coding was completed prior to Site 2 fieldwork.Thematic analysis was used as described by Braun and Clarke and Green et al. ,40,41, tThe relationship between the risk and protective factors as identified/described by participants was initially mapped by CH and organised into four overarching categories, loosely guided by the Theory of Triadic Influence. From this, four key analytic themes were developed in collaboration. CC reviewed a visual summary of risk and protective factors and independently organised them into similar themes. Concurrently, MC reviewed a full summary of the analysis with the major themes, sub-themes and illustrative participant quotes, and by teleconference confirmed that they reflected the yarns. Finally, CH compared these agreed findings to those from the Phase 1 quantitative findings .The identification of key themes, findings and recommendations was completed in collaboration with several Aboriginal co-authors . A short summary of the major themes and key findings was presented to the ACCHS partners for feedback. COVID-19 restrictions prevented the research team from presenting findings to participants at a local event, but these were presented to staff via Zoom. A written summary was also made available to participants via the ACCHS. Feedback from the ACCHS staff and participants was incorporated where received. AHMRC and the ACCHS partners provided approval for publication.Overall, 32 participants were recruited for twelve yarning sessions across the two sites, with a diverse range of ages and smoking experiences .Four key themes were generated from the analysis: (1) drawing strength from culture and community; (2) how the smoking environment shapes attitudes and intentions; (3) non-smoking as a sign of good physical, social and emotional wellbeing; and (4) the importance of individual empowerment and engagement in being smoke-free.We briefly discuss general concepts of health and wellbeing and personal experiences of smoking/non-smoking, then detail influences on tobacco use under the four key themes . For all groups, ‘healthy’ was about diet and exercise. Social and emotional wellbeing, poor mental health and some specific diseases  were also mentioned. Some also mentioned broader determinants of health such as education, employment, personal safety (including domestic violence), living in a hygienic environment, social and cultural connections, as well as broader concepts of life balance, motivation and agency to look after themselves and pursue their interests.Participants had a range of tobacco experience , includiThose who had tried or taken up smoking as a teenager reported starting between 10–15 years old, with friends or family (often cousins and siblings) facilitating first attempts. Some only began around age 18–21, when they started working, going out to bars, and were legally able to buy cigarettes.Smoking intensity varied. For the ‘social smokers’, this was dependent on when they were socialising/drinking, and might be ‘1–2 cigarettes every second weekend’. For the current regular smokers, intensity ranged from 8–10 cigarettes a day for some up to 30–40 for others, and varied depending on whether the individual was having a “bad day”.All non-smokers were firm in their intentions not to start smoking in the future. The occasional smokers did not explicitly say they wanted to stop, and although they acknowledged it was not good for them, they rationalised that they did not smoke often. All current regular smokers intended to quit in the future or were actively cutting down. Although they listed a range of barriers to quitting, they passionately described what kind of cessation support they would value.I think I only smoke due to my peace, that’s like my peace. You know. My little getaway from my little one and partner and yeah. And I think I smoke…I really do, I just can’t find myself to quit right now. When I become more stable, when I get my own house that I know I’m not going to get kicked out of. And when I get the kids settled, and like I can start focusing on my health again. I really want to quit, I just can’t right now. I think once I get more stable, and it’d be easier for me to quit.[11.F1]The relationship between the key factors under the four overarching themes  is illusstrong community and cultural connections were important protective factors that were highlighted by all groups as central to supporting young people to stay smoke-free or quit smoking. Community belonging and the non-smoking values of the community were also important. Strong role models, as they are related to community connection, included wanting to be a good role model and contribute to the community as a leader. However, the smoking behaviour of role models also relates to Theme 2.Having I reckon, just like if you’re someone that’s deeply connected with your culture, it gives you like um, I don’t know, just like a sense of belonging, and it just makes you not want to smoke because you’re more interested in, in your culture. But, like, so could be either studying, it could be working with the community. It could be um, studying your culture. Like yeah, and just, I feel that being connected to your culture, it does um make you want to smoke less, just because of wanting to fit in with the, the rest of your community and stuff like that.[11.F2]Role models. Just don’t be a follower, be a leader. And then strong community, ah, connection to my community. So, keep everyone in the community strong, try and quit smoking. Be healthy. Yeah, live longer.[4.M1]Normalisation of smoking through the influence of having friends and family who smoked, which created access to cigarettes, as well as seeing smokers around the community or even on TV/in movies were all seen to contribute to smoking.Participants attitudes to smoking and their own experiences were strongly shaped by the environment and the behaviours of those around them. strong role models had the potential to be an important and positive influence (Theme 1), this is mediated by whether they themselves smoke and what behaviours they model.While Like role model, like it’s in there, but I feel like it can kind of be wrong, cos if your role model smokes, you’re going to kind of want to be like him.[7.F1]smoking friends were a particularly important influence for initiation. Some reported experiencing overt peer pressure to try smoking, or doing so to fit in and belong to the group. For others, it was simply curiosity. Some reported starting with social smoking at parties or on a work break, which then evolved to regular smoking. Current smokers who started socially, expressed regret that their lives had moved on from those social connections but they were still smoking.Almost all participants felt that Yeah, it’s going through your mind “what are they going to think of me if I say no”.[2.F2]Yeah, I’ve tried cigarettes but I don’t smoke, occasionally. Like when I’m around parties and all that, it’s kind of a social thing where you feel pressured to smoke, in front of everyone. And so obviously, I just usually do it at parties I think.[10.F1][RO] Do you think that your main reason for starting was just because of your friends? Yep?And now I’ve got no friends I’ve only got me and my two kids[2.F1][RO] Kids. Yep.It’s nothing to be proud about now.[2.F1]But, when I became an adult and started working and stuff, and started hanging round people that did smoke, I did end up picking it up. So I shouldn’t even have started. I’ve only been smoking for about four or five years, but since I have been smoking, I’ve gotten pretty bad at it.[11.F2][I1] Um, how’d you feel after your first cigarette?I started choking a lot. Like, I couldn’t really handle it, that was then, and then I started a lot. But, um, yeah. I started smoking probably only socially. So I’d go and just have a yarn with the girls, I’d have a smoke. And then soon it started me going out by myself to smoke. And then I just started going again and again, and I just never stopped.[11.F2]trying to be cool, act older and fit in. Other attitudes ranged from smoking being disgusting or ‘gross’ ; a bad habit; wrong (particularly if the smoker is young); silly or stupid; a waste of money; and shameful, embarrassing and uncool.Most non-smokers had very low visibility of smoking among their peers, with their close friends also being non-smokers. While some were aware others their age smoked, they perceived this negatively. Non-smokers held strongly negative attitudes to smoking. They felt smoking peers were doing so for their self-image: Everyone just thinks like they’re wannabees. But, then they think to themselves “oh, we’re top shit” and all that…They think that they’re like seventeen, but they’re like twelve, fifteen[7.F1]permissive smoking environment, and participants estimated that at least half of all students smoked with little consequence, as some teachers also smoked in sight of students. Smoking in the toilets during class time was reportedly common.For some urban participants, even among non-smokers, there was very high visibility of smoking at their schools, and these participants could easily identify key locations within school grounds at which smokers congregate. One school had a very The teacher smokes, so…[8.F2]It can really put an influence on the kids[8.F1]But, the teachers go outside the school gate and, or some of them, or some of them wait until after school.[8.M1]Positive, reverse peer pressure was described by one participant who was worried about losing his friends and about what they would think of him if he started smoking. Although pressure from peers to smoke was reported by many, some felt they could confidently say no and avoid personal exposure. Some non-smokers also reported how smoking created tension in relationships when encouraging friends to stop. These points also relate to self-efficacy and confidence under Theme 4.family members who smoked, and this visibility was perceived to directly contribute to smoking initiation through observation and curiosity or direct encouragement as well as normalisation of smoking. For the older participants, this normalisation created an environment in which smoking was more a collective action, and a behaviour that was transferred generationally as opposed to an individual behavioural choice, with smoking taken up almost unconsciously in this social context. Two participants reported their mothers had first quit when they fell pregnant and continued to be smoke-free.The majority of participants did have My mum’s a big smoker too. She started smoking when she was about twelve. Same with my brother. His father, he started smoking when he was about twelve. And my sister, she started smoking at a young age too. But, because I had health problems, I didn’t start smoking till later in life.[11.F2]Yeah, Mum’s always been a smoker, since a young age, and so was her mother, well now me and my brother and sisters smoke, and my brother’s kids smoke.[11.F2]But, my son, he’s only two, and his nan like came down from [Town2] and she just, she was staying at my house and she kept going out the back smoking. And after she left, he’d get up and be like “mum I want a moke”. That’s what he said…That’s what he said. And I was like “what?”. And then he’s like “I want a moke”. But, see, cos he noticed her smoking. Cos like nobody else in the house smokes, but seeing her kept, keep going outside, and then he probably thought he’d be able to go outside if he smoked. Like that’s, it shocked me when he said that.[1.F1]Whether family members smoked or not did not automatically correspond to the adolescent’s own smoking behaviours. One participant lived in a smoke-free household and reported sneaking out to smoke. For some, smoking family members were motivation for their own smoke-free choices, but others reflected with some irony that although they had been strong non-smoking advocates in their early years, social influences had led them to take it up themselves. These were occasional ‘social’ smokers who felt there was a difference between their smoking and their families’ regular smoking.[I1] What were your thoughts though when you seen your mum and that smoking?Oh, I thought well “like, why do you smoke? Don’t do that, I don’t want you to die” or something, you know what I mean? And then now I’m doing it. Only when I drink though but still, I don’t reckon I should do it, cos, it’s not a healthy thing.[4.M1][I1] How does that make you feel, like having a night out with cigarettes?I feel normal. It’s gross. They are, they’re gross. Um, most of my family smokes, not any more. My Nan used to smoke, she got cancer from it. Um, I used to hide her smokes from her. She used to get really angry. It was really funny. You know, it was a good thing. I used to, cos she had cancer, she wasn’t supposed to smoke. So. Yeah.[10.F1][I1] So knowing that Nan had cancer, what made, what made you want to smoke?Mostly just people around me. I don’t do it all the time, you know, just mostly when I’m around people.[10.F1]smoke-free home and anti-smoking rules (parents’ expectations or designated smoke-free spaces) were identified as key to preventing smoking. Several participants lived in households with very strong anti-smoking expectations, which translated to their own smoke-free intentions.Having a No participants reported living in homes where smoking was allowed inside, and many said visitors were respectful of this expectation and would ask permission to go outside and smoke. Some also noted that ‘outside’ was understood to mean far away from the door and out by the fence.second-hand smoke (SHS) exposure away from home was still a concern for some. One young mother felt that not all community members were aware or concerned about the harms of SHS, and that did not think to move away from a pram in public places, but that she was unable to say anything. One young participant reported feeling upset by being involuntarily exposed to smoking by their peers.While there have been important changes in the home environment, reducing Knowledge of the harms of smoking was high among all participants. They described several physical health impacts including death, cancer, damage to lungs or breathing problems as well as being unhealthy in general, impact on fitness and more cosmetic impacts to teeth, smell, and skin. Many had first-hand experience of the harms of smoking, with family members who were sick or had passed away from smoking-related illnesses, including SHS exposure.Financial and social costs due to high cigarette prices and loss of future opportunities or time with family were also mentioned, alongside harms to others from SHS and being a burden to family. Occasional ‘social’ smokers perceived different levels of harm from lower smoking intensity, and felt that was an important distinction between them and regular smokers.Although knowledge of the harms of smoking was high, information sources were unclear or uncommon. Some groups reported learning about them at school; however, overall, this seemed infrequent, and a lower order issue behind mental health. Awareness of campaigns was low, with most reporting that they had seen fewer advertisements in recent years other than posters at the AMS. However, some were able to recall and describe specific ads  and calls to action , and one participant said that these ads were the main reason they did not smoke.Many were able to refer to specific graphic health warnings on packets (and to even describe the “Brian” execution). However, some questioned the impact of warning labels and campaigns, as many people still smoked. This relates to a recurring sub-theme that knowledge of harms was not enough to prevent smoking, particularly when smoking facilitated bonding or social cohesion. This was not discussed as a positive perception of smoking, but more as an explanation for why participants had started or continued to smoke socially, despite knowing the harms of smoking and holding negative views on it.I think that’s the main reason I don’t do it. Cos you know, you see ads and that on TV. Um, yes. My biggest turnoff. Lung cancer and that’s a big thing. Don’t want to do it. Cos you put your family through a lot and that.[5.M1]Yeah, I see ads and that, like quit smoking, call smoke line, or help line or whatever it is. I don’t know what it is. I seen it on ads.[4.M1][AHW] Do you see much though?No I hardly see stuff about smoking to be honest. Only thing I see is all the stuff from the packets of people like dying and yeah. That stuff. That’s the main thing I see on the smokes.[4.M1][I1] What do you think when you see those?It’s horrible.[4.M1][I1] Makes you not want to smoke.Yeah, it does. It does. I don’t want to end up like that. Know what I mean? I don’t want anyone to end up like that.[4.M1]Younger participants had little awareness of the changes in tobacco control over the past two decades, and of how the formerly pro-smoking environment had contributed to the long-term dependency they saw in their families. Older participants who smoked were acutely aware of these changes over time, and reflected that when they started, it was common to be around smoking inside cars, homes, restaurants and bars. They expressed regret at starting, noting that it was becoming harder to smoke, with increasing prices and restrictions making it ‘not worth it’.You had more freedom back then. And the smokes were cheaper back then. They were cheaper and you were allowed to smoke in more places. You know, there weren’t that many rules, but now there’s so many rules around it, and they’re so expensive, and it’s just, it’s starting to feel like it’s not worth it anymore, but it’s really hard to quit.[11.F2]historical introduction of tobacco to Aboriginal people. MC provided some tobacco education as part of the yarning circles on the history of use in Australia; this was of particular interest to younger participants, and demonstrated an opportunity to incorporate this history into formal tobacco education programs.There was also very little knowledge of the So, the laws we have now and that, do you, like wish they were there when you were little?[9.F2][I1] Yeah, definitely. Yes I do, yeah… But, these are things that I sit back actually, and think on, if all these things that are part of your generation now, the laws, and restrictions, if that was in place when I was younger, then yeah. Cos, you know, when I look back on it now, um, majority of my Elders have all passed away from cancer, from cigarettes. So, very preventable diseases. Um, if the laws had changed many, many years ago, then a lot of my Elders would still be alive today. I know that for sure. And the fact that cigarettes and alcohol was an introduced thing to our people you know, makes it even, um, makes it more upsetting in a way. There was no need for our people to have these influences given to us.vaping (e-cigarettes) and three had direct experience or exposure. One had observed vapers in public but generally dismissed it as embarrassing behaviour. One participant asked if it was for quitting and described a friend who switched from smoking and continues to vape at a similar intensity.Only four groups spontaneously mentioned A group of urban secondary students reported high levels of vaping among their peers, particularly the use of ‘JUULs’ and ‘vape pens’ that look like USB sticks and pens. They reported the devices being brought to school and used in the classroom, describing large clouds of vapor, attempts to blow smoke rings and a range of flavours. Generally, there was little or no knowledge of their contents or potential harms; the participants stated that their peers believed that they contained no nicotine (just water or air), and that vaping was less harmful than smoking.Vaping’s stupid. What’s the point of that? [Mimes cloud of smoke][6.F1][I2] Maybe they think they look like a magician or something.Yeah, like, they reckon they’re mad. They make themselves shame. So shame. Dumbest thing ever created…I see someone what an idiot, how stupid is that. How stupid is it to just stand there, inhale some smoke and blow it out? “Oh because it tastes nice.” It’s so stupid.[6.F1]Vaping. Lot of that around now.[9.M2]And Shisha as well… A lot of people at night go do shisha.[9.M4]There’s a lot of that [vaping] going around.[9.F2]Yeah, they all try to blow circles.[9.M4]They even do it in class.[9.M3]The teacher will be writing on the board and they’ll go and then put it in their bag. It’s funny.[9.M2]Alcohol and other drug use were seen as particularly important for adolescent smoking initiation. Many reported only smoking when they drank, or that initiation occurs at the same time as drinking begins, when going to parties and licensed venues; established smokers reported that their smoking increased when they drank. Mixing tobacco with cannabis was understood to be common practice which then contributed to nicotine addiction.sport and fitness was seen as protective against smoking, through keeping fit and active more broadly, maintaining a healthy mindset, not being bored and drifting into other activities (relates to Theme 4), as well as not wanting to risk impairing performance.Participation in And if you’re, for sport, if you’re in a rep team, or if you want to be big in a particular sport, sporting, ah, smoking. Won’t help you. It’ll just make you go down track, and it’ll just be bad for you, in anywhere you want to be.[7.M1]For many, smoking was a symptom of greater concerns, and it was acknowledged that good health and social and emotional wellbeing was important for being a non-smoker. One participant said he would see newly commenced smoking in friends as an indicator of what else may be going on in their lives, underlying drivers at home or in their relationships, and an opportunity to check-in.I’d worry about what’s going on with their family and stuff. Start asking questions and that…there’s always a reason they’re doing it. Starting smoking. There’s always a reason.[5.M1]Poor mental health and stress were seen as key drivers of smoking. Stress was discussed widely, and while there were general descriptions of “stress”, many specific factors were seen to contribute to stress which then increased the risk of smoking. These included having seriously ill family members and grief if they had passed away, moving house frequently, experiences of bullying, being in trouble at school or with the police, and being expelled or going to youth detention (which relates to Theme 4).It was rare for smoking to be discussed positively, except for use as a stress management tool, a form of self-medication and an opportunity for a time-out. Particularly for participants that had small children and had made their homes smoke-free, smoking provided an opportunity to step outside and have a break, as their children knew to stay away when someone was smoking. Smoking was also described as a way of practicing mindfulness, as an activity that forced them to slow down and focus on breathing.A bit of both. Like I know the kids can’t come near me if I’m having a smoke. Cos I go outside and smoke, like “you stay inside, I’m out here smoking, leave me alone”. That’s why, five minutes for me to sit down and what I’ve been told, to have a smoke, you literally physically have to calm down because if you’re running, or if you’re walking around, you can’t smoke as well. Because your lungs are working to help you breathe. So, you’ve got to sit down, relax so then you can inhale the cigarette. It is forcing you to sit still and to relax, just so you can smoke a cigarette. That’s, yeah, so to have a cigarette you need to relax yourself, and yeah. I use that a lot.[11.F2]Cos I’ve moved houses quite a lot too, since I was about eighteen. And I felt like it did worry me sometimes cos I didn’t know where I was go…I was couch hopping. I moved probably ten, fifteen times in the last couple of years. And right now, I’m in a transitional house, so I’m going to be moving again in a few weeks. Maybe, or it could be a month, or it could be two. I don’t know. So, it’s always the, the fear of not knowing where I’m going to be able to set up a permanent house for me and the kids, yeah, cos we haven’t had stability, we’ve moved, I’ve had the kids for about a year and a half now, and I’ve moved house three times. And we’ve got to move again, and again, and it’s just like, it stresses me out knowing that we can’t unpack all our stuff, just because we know that we’re going to be packing up again in a few months. And the kids, it’s not fair for the kids. They don’t get a chance to set up their rooms and they don’t feel like they’ve got a stable home. Hmm. So that does stress me out as well…That’s why I need my smokes.[11.F2]nicotine addiction to stress, in that smoking was used initially to manage stress and over time developed into an addiction.Many tied It comes under stress and, as well, because once you smoke, it, that’s a way that it could make your stress go away. And once you have that, like…[7.M1]Once you start smoking…[7.M2]Yeah, you get heaps addicted to it because it takes away the stress.[7.M1]It could be like depressed. Like, feel like you harm yourself or whatever. And you need a smoke to calm you down or something. For example like yarndi. And then same thing, like if you’re stressed out, like going through court, family members in hospital crook. Just want to smoke, try and relax yourself. And then addicted, since you started, you’re just addicted. Ever since you started.[4.M1]serious illness in the family was seen as a stress that could be managed by smoking, if it was a smoking-related illness, non-smokers found this reinforced their decisions not to smoke. However, for some established smokers, stress outweighed knowledge of the harms of smoking (related to Theme 2).While a If you have a family member that’s sick and you see like, the pain and the stage that they’re going through. You feel like upset because you don’t want them to be like in that, in that stage, and it will help you not want to be like them, in the bed.[7.M1]Like yes it would turn me off smoking, cos obviously all the bad stuff instilled into your body and stuff, but it would also make me want to smoke, just because of the stress factor involved. So, my family member’s dying, like there’s nothing I can do, it’s just it’s gotta stress me out and it’s my family’s all stressing. Like, we’re going to bury somebody, they’re dying. Um, it would just like put my stress levels right up. So I’d be smoking because of the stress, but I’d also be thinking like I need to quit because look what it’s done. I know that it’s doing more harm than good. Yeah. But, just at that time, you feel like you just need to have a smoke just to catch your breath, catch your thoughts, just stop for a second.[11.F2]The role of family relationships and friendships was unclear. These relationships were perceived to be a potential source of strength for preventing smoking or supporting quitting, but very much depended on the quality of the relationship and whether they were supportive of non-smoking (relates to Theme 2).…if you feeling stressed your family can help you instead of smoking. Cos when people are stressed they smoke, or if other people are stressed, then their family can help them.[7.M2]Cos if you have a strong family, they’re behind you, you know, make you quit. Or you have a bad family that doesn’t give a shit, you know, they just keep lending you.[9.M3]personal choice, different experiences and attitudes informed those choices. Young people who were bored and disengaged (which includes getting in trouble at school or with the police) were seen to be at higher risk of smoking, being short-term focused and interested in cultivating the rebellious or ‘cool smoker’ image, and rejecting the harms of smoking by rationalising infrequent, low levels of consumption while they were young (related to Theme 2).While many believed there was no particular reason behind smoking, and that it was simply a I think it’s also to do with trying to look cool. Um, I think you shouldn’t have to wreck your body to try and look cool.[9.F1]They’re all doing it because they think it won’t happen to them, till like a couple of years…Yeah, they’re not worried about the long term, they worry about short term…they’re like you know, “I’ll quit after school”. When school finishes, they’ll quit, but they just keep going.[9.M2]engaged with their community and culture (Theme 1) and future focused, including at school and in thinking about their life post school, were more empowered to resist smoking even when in high smoking environments (Theme 2). They displayed the self-efficacy to navigate smoking environments, and were very comfortable and confident in rejecting offers, removing themselves, publicly advocating against smoking and advising others not to smoke. For them, their long-term career and family goals were directly tied to their short-term smoking behaviours.Young people who were more positively [I1] And you’ll be a non-smoker?Yeah, I got a future career I’ve got to focus on. Can’t do that shit.[12.F2]At parties. Do it a lot at parties when they’re drinking. They decide to smoke. I don’t really like it. I just walk away from them. Cos I don’t really like even seeing them doing that…I like being different. And I like, you have to be your own person, you don’t have to follow other people. I’d rather be a leader than a follower.[5.M1][I1] What makes you think “oh, I don’t want to do that”?Just your future.[3.M3]Ask them what their dreams are. And then if they say whatever, then you say you’re not going to get it by smoking.[3.M1]Participants provided their thoughts on potential programs to reduce smoking in their communities in relation to core objectives, target audience, settings, key features and timing.Participants agreed that there is a need for general smoking prevention that provides information and education to young people prior to initiation. However, it is also important to encourage quitting attempts and offer cessation support to young people who are already smoking regularly and have developed a nicotine dependence. Broader healthy lifestyle and skills programs that include a focus on nutrition, mental health and stress management, other substance use, and managing peer pressure (for smoking and other behaviours) and that promote a general positive life and future focus would be valued.There is a need for tobacco prevention to reach young people across the total period of adolescence and young adulthood. The early teenage years/when starting high school (aged 12–13 years) are a particularly important period for experimentation. Thus, it was felt that education should begin in primary school (students in Year 5 or 6 and from age 8–10 years) so that students are primed with knowledge of the harms of smoking before they entered high school, at which time access and exposure increases. Others noted that this needed to be sustained throughout high school years, as information provided at age 12 was likely forgotten by the age of 16–17 years. Further, with turning 18 (another key period for initiation), it was thought that programs needed to continue to reach people into their twenties.While some felt there was an opportunity for a whole of community program that reached smokers of all ages, others felt there had been a focus on supporting Elders to quit, and it was now time to focus on the youth. It was noted that selection of age groups must be managed carefully, as some young people would not want to participate with adults (approximately 26 and over), whereas others felt it was important to allow younger children in because they often feel excluded. There was no real distinction made by sex or gender.A range of settings and approaches were discussed. More advertising and social marketing was suggested, including the development of a TV show featuring young people talking about their own smoking experiences.There was an expectation that health professionals would continue to raise quitting with patients, but greater follow-up may be needed, as people may resist the first attempts to discuss smoking.Schools were expected to be a place in which students could learn about the harms of smoking, and for those attending high-prevalence schools, it was strongly felt that it was important to address these harms in that setting. Sporting clubs were also an avenue to offer advice/education, and Aboriginal community spaces were seen as a key setting for all programs, particularly those with a broader health and wellbeing focus.Younger participants were not supportive of any program that was delivered as a straight health education exercise. They felt attendance would need to be compulsory and was unlikely to impact existing smokers. Participants requested hands-on interactive learning (such as a model diseased lung they could handle) and personal stories from role models, Elders and cancer survivors who could share the realities of smoking. It was important for the program to be fun and interesting.Be like, if they can get something like chemicals here, like I don’t know. Like show like how smoking works. Like you know how they have that one lung and the other lung, and how you press it and how slow the air released out of the smoked lung?[7.M2]I reckon we should get some Elders that’s like grew up smoking and quit…Sit around and tell you how much, tell the young ‘uns you know, how it ruined them, and how they felt to inspire the little kids not to do it.[9.M2]Young mothers requested a women’s group, and were interested in opportunities to quit as a group while also making new friends, being supported socially and engaged in regular cultural activities .Because there are a lot of young mums around here, that smoke, well not just mums, single people too. Um, but yeah. Because there’s been a bit of talk about wanting, I’ve asked a few girls about the women’s group, and a lot of them want the women’s group back. I do. I’ve been saying that for years.[11.F2]Key incentives to promote attendance and participation were the provision of good food, and some Koori-designed apparel (such as a t-shirt) only available to program participants.Well, like T-shirts are a very big deal around here. So if there was a deadly designed T-shirt at the end of it, that you get to keep, or maybe um, like a bag or something, that’s covered in Koori designs, that’d, that’d be a real eye catcher.[11.F2]A range of diversional activities were suggested that would help keep young people to be active and engaged with community and subsequently help protect them against smoking and other risk behaviours. These included providing computer access, game nights, movie nights, a disco, a music festival, sports, and non-team based physical activities . There was also demand for a large range of cultural activities: art classes, camps, cooking classes with traditional recipes, cultural awareness through dancing, games, music (including learning how to make and play a didge), and Aboriginal women’s, men’s and youth groups. There was a desire and an expectation that a key part of any program would be improving wellbeing through greater cultural and community connections.Suggestions for timing varied by the type of program suggested. For regular youth diversion activities, a weekly/twice weekly schedule was recommended. It was expected that quit support groups would run for at least nine months to allow people to relapse and re-join as needed, and to be supported in the longer term to stay quit and build relationships. For regular youth-targeted community events that might include a small health messaging component, it was also suggested that these could occur at the end of each term.At least nine [months], yeah. Cos if I want to quit smoking, I know my behaviour’s going to change and I want her there with me, cos if she’s quitting too, she’s going to want me, and it’s just going to be like, we know we’ve got another couple of months to go together, and like. So by the time we full on quit, you know, it’d be good to make new friends too. Like there are other people who I don’t really talk to, but I’m pretty sure if we like go through this program, and meet up, and we’ll have something in common about quitting smoking … Just something constant over the next few weeks that we know is going to be in place. So like I’m not going to go cold turkey and then start smoking in a month or two, you know what I mean?[11.F2]In this study, smoking attitudes and experiences varied by age. Older regular smokers established smoking in early adolescence, whereas most teenage participants had little to no personal experience or exposure (depending on their school environment). Early high school was a key period for experimentation. ‘Social smoking’ increased around 16–18 years. Most had family members who smoked, but none reported living in houses where smoking was allowed inside. Mental health, stress, addiction, other smokers and substance use were key risk factors. A strong connection to community and culture, physical and mental wellbeing, social relationships and non-smoking environments were protective. Hands-on, interactive programs with personal stories and age-relevant cessation support were recommended, with broader diversional, community-based cultural activities. Young people who were strong anti-smoking advocates and were able to confidently reject offers of cigarettes even in high-prevalence smoking environments were engaged at school, socially and in sports, and were future-focused and well supported by family.Drawing strength from culture and community;How the smoking environment shapes attitudes and intentions;Non-smoking as a sign of good physical, social and emotional wellbeing;The importance of individual empowerment and engagement in being smoke-free.Four major themes were developed:The discussions mostly confirmed the quantitative findings from the SEARCH baseline survey , in partStress was a key reason for smoking in this study. Although the survey measure of ‘stressful life events’ was not significant, several individual measures were also identified as important by participants. These included being in trouble at school, and the unintended consequence of school exclusions facilitating smoking and increasing disengagement. Participants agreed that family arguments could create a stressful home environment that increased risk of smoking . Sick family members also contributed to stress that some managed with smoking, but this increased the salience of the harms of smoking for others. Moving house frequently increased instability and life stress, which may also contribute to smoking. Although criminal justice interactions showed a strong association in the quantitative analysis and participants broadly agreed this would contribute to life stress, it was not an obvious relationship in the qualitative study. Some younger non-smokers avoided smoking to reduce the risk of being picked up by police. Others noted that you could no longer smoke in prison/detention.Although not a significant survey finding, smoking was understood to increase with age; however, it was noted that it could still begin in the early years, as a way for younger people to try to act older. While participants were perplexed by the reported strong relationship between smoking and being sexually active in the survey, some felt this also related to a life stage of experimentation and acting older.Although not statistically significant in the survey, non-smoking parents and smoke-free homes were identified by participants as clear non-smoking influences. Similarly, a strong sense of community or knowledge of Aboriginal culture and history were not significantly associated with smoking behaviour in the survey results, but factors related to community and cultural connection were identified in this study as vital for supporting young people to be smoke-free and make quit attempts (the exception being where community members were smoking and encouraged uptake). While many of our participants felt this connection was important for prevention, few stated that this was their own reason for being smoke-free, but that it was an asset they would like to access more.Satisfaction with available leisure activities was thought to be important, as many felt boredom was a key risk factor and that keeping active and engaged was a protective factor. Higher household income was inconclusive, as it could both increase the affordability of cigarettes and support other activities for avoiding boredom and disengagement.A systematic review  of influOur findings support previous qualitative work with Aboriginal adolescents and adults in other settings ,45,46,47A high level of awareness of the harms of smoking has been reported by others; this included the perception that harms were not relevant to short-term ‘social smokers’ who did not identify as ‘real smokers’ ,47, despIn line with program preferences in our study and findings on future-focused aspirational non-smokers, Passey et al. emphasised culture and identity as a source of empowerment, but also that marginalisation of young Aboriginal people contributed to a short-term focus and smoking risk . The recPrevention programs must build cultural and community connections, empower young people and draw on community strengths. This essential approach is operationalised nationally in both the Australian Government’s ‘My Life My Lead report and Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023′ (the Implementation Plan) [on Plan) . Three oYoung community members must lead the development of prevention programs to build youth engagement and empowerment. Many study participants demonstrated they were eager and ready for such an opportunity. A potential model would see centralised decision making by an independent youth committee supported by and embedded within existing community-controlled organisational structures, providing leadership opportunities and enhancing self-determination while ensuring the program’s appeal and relevance.Interactive education about the harms of tobacco use is needed and should incorporate storytelling alongside youth-specific cessation support. It is important to counter the perception of safer, ‘light’ levels of smoking among ‘occasional’ or ‘social smokers’, as even lower levels of consumption increases cardiovascular disease risk [ase risk . The lowActivities should be provided to address the broader underlying drivers of smoking and other risk behaviours, reducing stress and promoting good mental health and wellbeing. Although the previous iteration of the Tackling Indigenous Smoking program included a Healthy Lifestyles component with a focus on nutrition and physical activity and some relevant activities such as cooking classes, sport and cultural games [al games , programCommunity-level activities should be reinforced with strong national, mainstream tobacco control measures, including smoke-free legislation and social marketing campaigns, to continue the de-normalisation of smoking. Social marketing campaigns can play a key role in building knowledge of non-smoking expectations, increasing confidence to reject offers of cigarettes and reducing the appeal and status of cigarettes [garettes ,52. ThesThere are some limitations to this study. This study includes Aboriginal participants from only two sites in regional and urban NSW, and we acknowledge that given the diversity and heterogeneity of Aboriginal and Torres Strait Islander peoples the findings may not reflect the experiences and views of people from other communities, particularly those in remote areas. There is possible sampling bias, as participants were those engaged in a community-controlled study and available during business hours (or whose parents gave them permission to attend during school time). This may have exaggerated the generational differences; however, in some cases, we were able to compare accounts from the same schools and same communities over time, so we are confident in our findings. Finally, all coding and initial analysis was completed by one researcher (CH); however, MC, who facilitated all sessions (with CH), reviewed the transcripts, codes and summaries and confirmed that these reflected the yarns.This study has a number of strengths. Young community members’ engagement in the interpretation of the survey findings has not only validated the analysis, but has also validated international evidence of influences on smoking uptake. By privileging the voices of young Aboriginal people, we have been able to identify key opportunities to design effective smoking prevention programs that will enhance adolescent health and wellbeing. A key strength of this research is the predominantly Aboriginal research team who have developed the major themes and recommendations in a collaborative manner.Through interactive engagement with young Aboriginal people, this study has identified four key themes that can be understood as objectives for programs preventing youth smoking: continue to change the tobacco environment, promote good health and wellbeing more broadly, build on community and cultural strengths, and support the empowerment and engagement of young people. These should be embedded into community-level programs and led by young people themselves. However, large-scale comprehensive tobacco control measures are needed to ensure that the ongoing de-normalisation of smoking is sustained in the broader environment. Programs need to reach people from very early adolescence and into young adulthood to continue to reinforce non-smoking intentions across the key initiation periods of attending early high school, starting to drink and attend parties, turning 18 years old, and starting work.