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Challenges and Enablers to Smoking Cessation for Young Pregnant Australian Women: A Qualitative Study Yvonne Hauck, BScN, MSc, PhD, Fiona Ronchi, BScN, PGradDip Midwifery, Barbara Lourey, RN, RM, BApp Sc (Nursing), and Lucy Lewis, BSc (Health Sciences), MN, PhD ABSTRACT: Background: Western Australian (WA) perinatal statistics indicate an 8 percent decrease in smoking by pregnant women from 1999 to 2009. Despite the success of cessation interventions, the incidence of tobacco smokers among young pregnant women remains a cause for concern. To inform development of an appropriate suite of interventions, a qualitative study was undertaken to gain insight into the perceived challenges and enablers young pregnant women encounter when attempting to modify their smoking. Method: A hypothetical scenario and interview questions were used: if a young pregnant woman decided to decrease or stop her smoking 1) what could assist her, and 2) what are the challenges that she would need to overcome? Thematic analysis was conducted. Our sample included English-speaking pregnant women recorded as a smoker, 16 to 24 years of age, and attending antenatal services at a public maternity hospital. Results: Thirty-six women participated in an interview. “Habit” was noted as the key theme under perceived challenges and incorporated three subthemes: learn to deal with stress; the urge for a smoke; and not being left out. Concern over the health of their baby emerged as the main theme and enabler to change behavior. Four subthemes were extracted around keeping their baby healthy: getting the facts; you need someone; something you can take to help; and keeping your mind off it. Conclusions: Our findings highlight the complex issues around smoking for young pregnant WA women. Insight into these challenges and enablers may inform development of more suitable interventions to address the unique needs of this group of pregnant women. (BIRTH 40:3 September 2013)
Key words: pregnancy, qualitative, smoking cessation, tobacco smoking
The harmful maternal and fetal effects of tobacco smoking during pregnancy are well documented and include the following: miscarriage; placental dysfunction (abruption and previa); antepartum hemorrhage; preterm birth; premature rupture of membranes; preterm labor; and stillbirth (1–3). Adverse neonatal outcomes
include the following: low birthweight; intrauterine growth restriction; behavioral problems; and sudden infant death syndrome (4,5). Given these effects, ideally no pregnant woman would smoke. Australian antenatal smoking cessation interventions advocate the 5 A’s model (6–8). This model
Yvonne Hauck is a Professor of Midwifery, Curtin University and King Edward Memorial Hospital, Curtin Health Innovation Research Institute, Perth, WA, Australia; Fiona Ronchi is a Midwifery Research Assistant, King Edward Memorial Hospital, Perth, WA, Australia; Barbara Lourey is a Clinical Midwifery Nurse Manager, Ambulatory Services, King Edward Memorial Hospital, Perth, WA, Australia; Lucy Lewis is a Midwifery Research Fellow, Curtin University and King Edward Memorial Hospital, Curtin Health Innovation Research Institute, Perth, WA, Australia.
Address correspondence to Yvonne Hauck, BScN, MSc, PhD, Department of Nursing and Midwifery Education and Research, King Edward Memorial Hospital, Bagot Road, Subiaco, WA 6008, Australia. Accepted July 16, 2013 © 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.
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recommends the following: asking about smoking status: assessing willingness to quit, advising quitting, assisting with quit attempts, and arranging follow-up. Women exposed to the 5A steps express greater satisfaction with support and advice (4). Use of the 5 A’s is recommended for Western Australian (WA) women and their partners who can also be offered a referral to a national Quitline (9). Furthermore, cessation strategies noted in the literature include the following: Providing information on the effects tobacco smoking has on the fetus (1); using motivational interviewing (3) or resources such as booklets, videos and computer-based systems combined with counseling (8); using video advice coupled with a cueing sheet (10); and providing incentives (1,3). Western Australian perinatal statistics have revealed a promising downward trend in smoking cessation with 22.6 percent of pregnant women smoking tobacco in 1999, 15.4 percent in 2008 (11), and 14.5 percent in 2009 (12). However in 2009, 35.4 percent of WA women ≤ 19 years of age and 25.5 percent of women 20 to 24 years of age continued to smoke tobacco during pregnancy (12). The 2010 smoking statistics from the only tertiary maternity hospital in WA raises concern as data confirm that 1,047 out of 1,927 (54.3%) young women aged 16 to 24 years attending antenatal care were recorded as smoking tobacco. Thus, despite the success of generic smoking cessation interventions the incidence of tobacco smokers among young pregnant WA women remains a public health issue. Tailoring antenatal smoking cessation interventions to “high risk” women with comorbidities has been advocated (13). Comorbidities associated with tobacco smoking include the following: low socioeconomic status, low levels of education, poor social support, depression, psychological illness, and high parity (3,13). International evidence confirms adolescence as the maternal age group most likely to smoke (2) with Australian research acknowledging adolescents and Indigenous women as two cohorts of pregnant women least likely to quit smoking (14). Although evidence guiding generic smoking cessation programs for pregnant women is available, their suitability and effectiveness for young pregnant women could be questioned, given the higher smoking rates in this population (2). In fact, pregnant smokers and adolescents are viewed as special subpopulations not considered within a proposed algorithm for clinicians to assess and select cessation strategies (15). Addressing the needs of young pregnant smokers must consider their developmental requirements, other substance use such as alcohol, mental health issues, and social circumstances (16). Therefore, potential interventions must incorporate multiple components to acknowledge the complexity of young pregnant women’s lives (16). To inform
development of an appropriate suite of interventions for young pregnant WA women, a qualitative study was undertaken to gain insight into their perceptions of the challenges and enablers they encounter when attempting to modify smoking behavior.
Methods Design, Participants, and Setting A qualitative design was used to explore young pregnant women’s perceptions around the challenges and enablers around decreasing or ceasing smoking. Qualitative research is ideally suited to provide insight into complex issues where further in-depth knowledge is required (17). King Edward Memorial Hospital (KEMH) has approximately 6,000 births annually, is the only public tertiary obstetric hospital in WA and provides care to high-risk populations. KEMH guidelines for nicotine dependence, assessment, and intervention recommend use of verbal and written information by health professionals to highlight the effect tobacco smoking has on pregnancy and the newborn (18). Our sample included English-speaking pregnant women, 16 to 24 years of age, who were attending KEMH antenatal services, and recorded as pregnant smokers.
Recruitment and Data Collection While attending an antenatal clinic appointment, women were approached and invited to participate by a research assistant (RA). An information letter was offered accompanied by a verbal explanation. The RA, a young midwife not in uniform and not involved in care provision, introduced herself as a researcher to avoid potential coercion. The qualitative interviewer is the key data gathering “instrument” and it was essential that participants were able to develop rapport and trust in her (19). A hypothetical scenario was used to remove any personal link to the woman’s current smoking and provide a nonjudgemental, safe environment to discuss smoking issues. The following hypothetical scenario and corresponding questions were used: if a young pregnant woman decided to decrease or stop her smoking 1) what could assist her, and 2) what are the challenges that she would need to overcome? Women participated in a brief face-to-face interview around the hypothetical scenario as the RA made field notes. To obtain additional data women were also offered an opportunity to participate in a further audiorecorded telephone interview if they felt they wanted more time to expand on the issues discussed.
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204 Between July 2011 and June 2012, 40 women were approached with 36 agreeing to participate in a face-toface interview that lasted between 5 and 15 minutes. Although seven women agreed to a telephone interview, only two were contactable and were interviewed for 20 minutes. Ethical approval was obtained from the Women and Newborn Health Service Human Research Ethics Committee (1913/EW). Verbatim transcripts and field notes were stored on a password protected computer in accordance with the National Health and Medical Research Council guidelines (20).
Data Analysis Thematic analysis was conducted to extract common themes, patterns, and similarities around the perceived challenges and enablers to change smoking behavior (21). Qualitative data analysis commenced with initial interview data (22). Analysis was a continual process in which data were deconstructed and reconstructed to find the links between the peripheral and central themes through repeated patterns and meaning. Explicit themes evolved from direct words or sentences. Team members analyzed a cross-section of transcripts and field notes ensuring each data source was reviewed by at least two members. Team meetings were used to clarify, negotiate and refine the findings. Any disagreements on interpretation were negotiated by referring back to the data. Once data saturation was achieved, data collection and analysis ceased (21). Our research team comprised the four midwives, authors of this publication with YH and LL developing the research topic and proposal, BL facilitating the recruitment and data collection and FR conducting the interviews. YH, LL, and FR analyzed the data and all four authors contributed to the final manuscript.
Findings A total of 36 women (16–24 yr of age) provided data around the challenges and enablers faced by young pregnant smokers. Half (n = 18, 50%) of the respondents were 16 to 17 years old, with the majority (n = 28, 78%) in their first pregnancy. Five women (14%) identified themselves as being an Aboriginal or Torres Strait Islander. Direct quotes supportive of the themes and subthemes are provided in italics and coded (P1 to P36) to ensure participant confidentiality.
The Challenges to Decrease or Cease Smoking Exploration of the challenges young pregnant women faced to stop or reduce smoking provided insight to
their smoking behavior and reaffirmed the addictive nature of smoking. “Habit” was noted as the key theme under perceived challenges and incorporated three subthemes: learn to deal with stress; the urge for a smoke; and not being left out.
Habit Young women recognized that the “old habit to smoke” (P13) needed to be addressed to change their smoking behavior. Dependence on smoking was perceived as “a habit, part of an everyday thing. I am used to having a cigarette in my hand and putting it to my mouth every hour” (P18). The words addiction and habit were used interchangeably, offering insight into the perceived difficulties of quitting; “it is a habit and addiction. I want to stop but cannot” (P4) and “there should be rehab for smoking, it is an addiction” (P36). It was noted that women had to “want to quit and have the determination to actually do it” (P12). Some felt they could break the habit/addiction and quit “cold turkey when they were aware of the pregnancy” (P27), whereas others found it “easier to cut down than stop completely” (P35).
Learn to Deal with Stress Smoking was perceived as a potential buffer against “stressful situations such as running late or something bad happening…smoking relaxes you” (P7). Stress was a reoccurring reason for smoking, with P32 stating “stress, that is the reason people smoke, because they are stressed.” She went on to share that stress triggered her need for a cigarette and to stop smoking she would have to “learn to deal with stress” and “remove myself from stressful situations to avoid conflict” (P32). It was suggested that some women did not know “how to deal with things other than having a cigarette” (P35). These stories illustrate how smoking was used to mediate stress levels and how alternate ways to deal with stress would be needed for smoking cessation to be successful.
The Urge for a Smoke Being around smokers increased temptation and the “urge for a smoke” (P26). Many women shared how their perceived addiction to tobacco resulted in difficulty controlling their cravings, particularly when exposed to other smokers. It was suggested that “being around smoking makes you want one—I end up smoking” (P36). One woman actively avoided being around smokers; “disconnecting from friends that smoke”
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(P12) as another shared how it was “difficult to ask them [smokers] to stop or go away” (P25). This move was difficult for women whose exposure extended into their personal living spaces where “everyone around smoked, mum, brothers and cousins” (P26). For one, giving up smoking was “really not possible as everyone in the house has some [cigarettes]. I did not have any which is different to not buying them” (P22). Another felt that her quit attempts would be easier “if everyone in the house stopped smoking and did not smoke around me” (P7). These women recognized that the smoking behavior of others had a negative impact on their resolve to quit.
Not Being Left Out Young women identified the importance of not being left out of their social sphere; being a smoker enabled them to fit in with their peers “my friends smoke…I would feel left out if I was not smoking. I do not smoke when I am at home alone” (P28). The social aspect of smoking was reinforced: “you form a bond with your friends when you smoke—you do not have to speak, just smoke together”(P6) and “it is a social thing, it is hard where you sit there and they are smoking, we all just sit there and have a smoke” (P31). One woman noted how her smoking behavior changed depending on the social situation: “Being around people who are relaxing and having a cigarette—I want to have a cigarette as well. I also hang around some people that have stopped and when I am around them I do not smoke” (P20). For these young women smoking behavior was influenced by peer relationships that enabled them to feel socially included.
Table 1. What Challenges and Enables Young Pregnant Women to Reduce or Stop Smoking: Themes and Subthemes
Challenges Habit Learn to deal with stress The urge for a smoke Not being left out Enablers Health of the baby Getting the facts You need someone Something you can take to help Keeping your mind off it
their decision to stop: “was easy to stop as I was getting headaches from smoking and the health of the baby was at risk” (P26) whereas another stated: “stopped smoking when 6 weeks pregnant [previously smoked a pack a day]. Stopped as I felt sick when smelt smoke while pregnant” (P18). For most just “thinking about the baby…scared me into giving up” (P32) and “thinking of the baby…puts more pressure on yourself” (P17). Information around the potential harm on their baby’s health prompted some to attempt quitting: “I stopped when I was 2 months, because of information about what smoking does to the baby” (P9). However, achieving this goal required focus “you have to be strong minded and realize baby’s health is more important” (P25).
Getting the Facts The Enablers to Decrease or Cease Smoking Women were asked what could assist them to overcome the “habit” of smoking. Concern over the health of their baby emerged as the main theme and motivation to change their behavior. Four subthemes were extracted around keeping their baby healthy: getting the facts; you need someone; something you can take to help; and keeping your mind off it (Table 1).
Information was essential to appreciate the consequences of smoking behavior on the health of their baby. Participants wanted “hard facts on what it [smoking] could do to your baby, realistic, harsh information that is straight to the point” (P35). Providing information in a visual form also appeared to be preferable: “Showing actual photos/videos of what happens when you smoke” (P11) even “seeing graphic pictures on the cigarette box helps” (P5).
Health of the Baby You Need Someone For most participants “pregnancy was the motivation to stop smoking” (P8) with “the health of the baby being the main factor in quitting” (P19) as women were aware that “smoking was bad for the baby” (P21). For some women the physical impact of smoking supported
These young pregnant women identified how a supportive relationship with someone sensitive to their smoking goals could have a positive impact on being able to sustain their quit attempts. “Having someone to talk
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206 through cravings and talk to day to day” (P23) was repeatedly noted. Trying to quit alone was hard “you need someone…I tried to quit before but doing it by yourself stresses you out. I got lonely and kept smoking” (P36). These comments highlight the importance of social support mechanisms in achieving a positive impact on smoking cessation.
Something You Could Take Women were aware of the range of smoking cessation medications available through friends, family and the media. One young woman felt “…it would be easier if there was something you could take” (P1). Another identified that she had wanted “more help with medications; they tell you about patches—that they work but they do not tell you about other things. I ended up buying Champix” [non nicotine drug] (P36). These varied comments highlight the importance of tailoring interventions to address individual preferences.
Keeping Your Mind Off It The importance of having “something to keep your hands busy” (P25) and “something to keep you occupied” (P4) were seen as positive distractions to the cravings women experienced. Other activities to keep their minds off smoking included the following: “Watching a movie” (P12); “going for walks” (P30); “eating something” (P21); and “reading a book” (P27). Young women were able to identify strategies they employed to keep their cravings at bay.
Discussion The findings from this qualitative study represent a small group of predominantly young nulliparous Australian women and their perceptions of the challenges and enablers encountered by young women attempting to change their smoking behavior. Although first-time mothers are more likely to be smoking before pregnancy, they are also more likely to quit during pregnancy (24). Therefore, targeting nulliparous women with smoking cessation interventions can be an effective strategy in making a difference to smoking rates. Although smoking prevalence over the past 10 years has decreased for most pregnant women in WA, this is not the case with young pregnant women (12). Interventions appropriate for all women do not account for development needs across different age groups. Erikson’s development theory argues that young adults and specifically adolescents are involved in a period of
change during their transition to adulthood where peer relationships are a focus (25,26). Although the timing and pace of this developmental transition is subject to variation, the importance of peers to young women must be acknowledged (23). For example, adolescents and young adults prefer web-based information (27). “S.M.A.S.H. Out Cigarettes,” a recently developed web page specifically targets adolescents and is advocated for use in conjunction with counseling or motivational interviewing (2). Although, no evaluation of the website has been published to date, it does provide ageappropriate information on the impact of smoking on their bodies, babies, finances and relationships and is expected to eliminate the fear of self-disappointment or being judged (8). This visual presentation of online information is supportive of our participants’ recommendation of how they wanted to get the facts. Another suggested intervention that addresses the desire to receive visual facts and feedback involves use of carbon monoxide (CO) monitors with either a numeric or colored display in a traffic light format (red, yellow or green). The National Institute for Health and Clinical Excellence (28) suggests that CO testing allows the pregnant women to see a physical measure of her smoking and passive smoke exposure with assistance to interpret the CO reading. Participants acknowledged that smoking is a habit and that attempts to change behavior can extenuate the urge for tobacco. Given that the urge for a smoke may be stronger during pregnancy as physiological adaptations increase nicotine clearance and lower nicotine levels (29,30), these concerns are warranted and must be recognized by professionals assisting pregnant women attempting to quit. Adding these physiological changes with other challenges, such as learning to deal with stress without tobacco and not being socially left out highlight the complex obstacles faced by young pregnant women. Beliefs around smoking reducing stress were supported by another WA study with Indigenous women who did not regard smoking cessation, even in pregnancy, as a priority given their other social and economic stressors (31). In fact, the complexity of issues for young women who smoke suggests that a suite of interventions may be more appropriate for young pregnant women attempting to change their smoking behavior. It is essential that young pregnant women’s perceptions are used to inform development of appropriate components within a suite of cessation interventions. Our participants reinforced how important it was to have someone to support their efforts to change behavior. The social support from partner, family, and friends does influence a woman’s intention to change her behavior (32) and can be either a positive “driver” or a barrier as reported in another qualitative study with
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first-time Canadian mothers (33). Although, a potential father may be willing to support his partner’s attempts to quit, another Australian study suggests if he continues to smoke, misconceptions around the “protection” an unborn child has against passive smoking must be corrected with facts (34). Our Australian participants and men in a British study corroborate concerns around dealing with stress during cigarette withdrawal as being foremost in their minds (34). Becoming a new parent is exciting albeit stressful and attempting to change behavior during this time may amplify this stress. It is therefore important to assist young women and their partners or significant others to develop healthier strategies to deal with stress if we want to increase their chance of successfully ceasing smoking. In fact, a model of resilience in relation to stress and smoking has been recently introduced for people diagnosed with depression (35). It is suggested that smoking is adopted by individuals with perceived high levels of stress and therefore building resilience to stress is an important aspect of the model. Multiple sessions of motivational interviewing (36) as a counseling technique combined with assistance to try alternate strategies to deal with stress may be a potential component for smoking cessations interventions targeting young pregnant women. A further enabler noted in this study was the health of the baby. A summary of qualitative studies cited in a review on adolescent pregnancy (37) suggest that many adolescents view parenting as important to their lives and reinforce their aspiration to be a good parent able to meet their child’s needs. Similar to our findings, a Canadian study also reported concern about the baby’s health as being central to the reason pregnant women reported for changing their smoking behavior (33). In contrast, another review of qualitative studies exploring barriers to quitting smoking during pregnancy for women of all ages concluded that although aware of potential health risks to the fetus, this effort was not sufficient motivation to change smoking behavior (38). Once the baby is born it is important to capitalize on the mother’s motivation to be a good parent by promoting and encouraging her to sustain her smoking reduction or cessation while breastfeeding (39). An American qualitative study of postpartum mothers’ intention to smoke found that although most women did not intend to resume smoking, perceptions around passive smoke and overconfidence in their control over smoking could threaten good intentions (40). The review of qualitative studies also revealed how cessation interventions by health professionals were negatively viewed by women (38) highlighting the importance of tailoring interventions to the unique needs of target groups. A didactic approach to change
smoking behavior during antenatal visits can compromise the trusting relationship needed between the woman and her caregiver (41). Social stigma and negative social attitudes associated with smoking in pregnancy have resulted in women denying or hiding their smoking (42). Therefore to facilitate behavior change, the ideal relationship involves a supportive caregiver and a woman demonstrating transparency, trust, and congruent expectations that positively builds on the woman’s capabilities (41). Finally, having something you can take to help was regarded as an enabler by the young women in this study. However, clinical guidelines at the study setting note that smoking cessation in pregnancy should ideally occur independent of nicotine replacement therapy (NRT) (18), while acknowledging that NRT has fewer adverse effects on the fetus than tobacco smoking (6). If a woman wishes to use NRT, intermittent dosing products such as gum, lozenges, or aerosols are recommended. The efficacy of NRT in pregnancy continues to be debated because of minimal evidence around safe use; and for further research to address this gap, inquiry is needed to explore pregnant women’s perceptions of using NRT (43) in collaboration with other strategies such as motivational interviewing, CO monitoring, and peer support. This Australian study has limitations. Qualitative research findings must be viewed within the context the study was conducted. The perceptions of this predominantly white sample of young pregnant smokers may not reflect the issues faced by other young women in different cultural and geographic locations. The context of this Australian study was outlined to allow the reader to determine the transferability of the findings to their setting.
Conclusions The findings from this study highlight the complex issues around smoking behavior for young pregnant WA women. Sharing their perceptions of the challenges and enablers to changing smoking behavior may be used to inform development of a suite of cessation interventions more appropriate in targeting the unique needs of this group of women.
Acknowledgments Funding support was received from the Women and Infants Research Foundation (WIRF). We acknowledge the young pregnant women who were gracious in sharing their thoughts and feelings on a controversial yet important topic.
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Challenges and Enablers to Smoking Cessation for Young Pregnant Australian Women: A Qualitative Study Yvonne Hauck, BScN, MSc, PhD, Fiona Ronchi, BScN, PGradDip Midwifery, Barbara Lourey, RN, RM, BApp Sc (Nursing), and Lucy Lewis, BSc (Health Sciences), MN, PhD ABSTRACT: Background: Western Australian (WA) perinatal statistics indicate an 8 percent decrease in smoking by pregnant women from 1999 to 2009. Despite the success of cessation interventions, the incidence of tobacco smokers among young pregnant women remains a cause for concern. To inform development of an appropriate suite of interventions, a qualitative study was undertaken to gain insight into the perceived challenges and enablers young pregnant women encounter when attempting to modify their smoking. Method: A hypothetical scenario and interview questions were used: if a young pregnant woman decided to decrease or stop her smoking 1) what could assist her, and 2) what are the challenges that she would need to overcome? Thematic analysis was conducted. Our sample included English-speaking pregnant women recorded as a smoker, 16 to 24 years of age, and attending antenatal services at a public maternity hospital. Results: Thirty-six women participated in an interview. “Habit” was noted as the key theme under perceived challenges and incorporated three subthemes: learn to deal with stress; the urge for a smoke; and not being left out. Concern over the health of their baby emerged as the main theme and enabler to change behavior. Four subthemes were extracted around keeping their baby healthy: getting the facts; you need someone; something you can take to help; and keeping your mind off it. Conclusions: Our findings highlight the complex issues around smoking for young pregnant WA women. Insight into these challenges and enablers may inform development of more suitable interventions to address the unique needs of this group of pregnant women. (BIRTH 40:3 September 2013)
Key words: pregnancy, qualitative, smoking cessation, tobacco smoking
The harmful maternal and fetal effects of tobacco smoking during pregnancy are well documented and include the following: miscarriage; placental dysfunction (abruption and previa); antepartum hemorrhage; preterm birth; premature rupture of membranes; preterm labor; and stillbirth (1–3). Adverse neonatal outcomes
include the following: low birthweight; intrauterine growth restriction; behavioral problems; and sudden infant death syndrome (4,5). Given these effects, ideally no pregnant woman would smoke. Australian antenatal smoking cessation interventions advocate the 5 A’s model (6–8). This model
Yvonne Hauck is a Professor of Midwifery, Curtin University and King Edward Memorial Hospital, Curtin Health Innovation Research Institute, Perth, WA, Australia; Fiona Ronchi is a Midwifery Research Assistant, King Edward Memorial Hospital, Perth, WA, Australia; Barbara Lourey is a Clinical Midwifery Nurse Manager, Ambulatory Services, King Edward Memorial Hospital, Perth, WA, Australia; Lucy Lewis is a Midwifery Research Fellow, Curtin University and King Edward Memorial Hospital, Curtin Health Innovation Research Institute, Perth, WA, Australia.
Address correspondence to Yvonne Hauck, BScN, MSc, PhD, Department of Nursing and Midwifery Education and Research, King Edward Memorial Hospital, Bagot Road, Subiaco, WA 6008, Australia. Accepted July 16, 2013 © 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.
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recommends the following: asking about smoking status: assessing willingness to quit, advising quitting, assisting with quit attempts, and arranging follow-up. Women exposed to the 5A steps express greater satisfaction with support and advice (4). Use of the 5 A’s is recommended for Western Australian (WA) women and their partners who can also be offered a referral to a national Quitline (9). Furthermore, cessation strategies noted in the literature include the following: Providing information on the effects tobacco smoking has on the fetus (1); using motivational interviewing (3) or resources such as booklets, videos and computer-based systems combined with counseling (8); using video advice coupled with a cueing sheet (10); and providing incentives (1,3). Western Australian perinatal statistics have revealed a promising downward trend in smoking cessation with 22.6 percent of pregnant women smoking tobacco in 1999, 15.4 percent in 2008 (11), and 14.5 percent in 2009 (12). However in 2009, 35.4 percent of WA women ≤ 19 years of age and 25.5 percent of women 20 to 24 years of age continued to smoke tobacco during pregnancy (12). The 2010 smoking statistics from the only tertiary maternity hospital in WA raises concern as data confirm that 1,047 out of 1,927 (54.3%) young women aged 16 to 24 years attending antenatal care were recorded as smoking tobacco. Thus, despite the success of generic smoking cessation interventions the incidence of tobacco smokers among young pregnant WA women remains a public health issue. Tailoring antenatal smoking cessation interventions to “high risk” women with comorbidities has been advocated (13). Comorbidities associated with tobacco smoking include the following: low socioeconomic status, low levels of education, poor social support, depression, psychological illness, and high parity (3,13). International evidence confirms adolescence as the maternal age group most likely to smoke (2) with Australian research acknowledging adolescents and Indigenous women as two cohorts of pregnant women least likely to quit smoking (14). Although evidence guiding generic smoking cessation programs for pregnant women is available, their suitability and effectiveness for young pregnant women could be questioned, given the higher smoking rates in this population (2). In fact, pregnant smokers and adolescents are viewed as special subpopulations not considered within a proposed algorithm for clinicians to assess and select cessation strategies (15). Addressing the needs of young pregnant smokers must consider their developmental requirements, other substance use such as alcohol, mental health issues, and social circumstances (16). Therefore, potential interventions must incorporate multiple components to acknowledge the complexity of young pregnant women’s lives (16). To inform
development of an appropriate suite of interventions for young pregnant WA women, a qualitative study was undertaken to gain insight into their perceptions of the challenges and enablers they encounter when attempting to modify smoking behavior.
Methods Design, Participants, and Setting A qualitative design was used to explore young pregnant women’s perceptions around the challenges and enablers around decreasing or ceasing smoking. Qualitative research is ideally suited to provide insight into complex issues where further in-depth knowledge is required (17). King Edward Memorial Hospital (KEMH) has approximately 6,000 births annually, is the only public tertiary obstetric hospital in WA and provides care to high-risk populations. KEMH guidelines for nicotine dependence, assessment, and intervention recommend use of verbal and written information by health professionals to highlight the effect tobacco smoking has on pregnancy and the newborn (18). Our sample included English-speaking pregnant women, 16 to 24 years of age, who were attending KEMH antenatal services, and recorded as pregnant smokers.
Recruitment and Data Collection While attending an antenatal clinic appointment, women were approached and invited to participate by a research assistant (RA). An information letter was offered accompanied by a verbal explanation. The RA, a young midwife not in uniform and not involved in care provision, introduced herself as a researcher to avoid potential coercion. The qualitative interviewer is the key data gathering “instrument” and it was essential that participants were able to develop rapport and trust in her (19). A hypothetical scenario was used to remove any personal link to the woman’s current smoking and provide a nonjudgemental, safe environment to discuss smoking issues. The following hypothetical scenario and corresponding questions were used: if a young pregnant woman decided to decrease or stop her smoking 1) what could assist her, and 2) what are the challenges that she would need to overcome? Women participated in a brief face-to-face interview around the hypothetical scenario as the RA made field notes. To obtain additional data women were also offered an opportunity to participate in a further audiorecorded telephone interview if they felt they wanted more time to expand on the issues discussed.
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204 Between July 2011 and June 2012, 40 women were approached with 36 agreeing to participate in a face-toface interview that lasted between 5 and 15 minutes. Although seven women agreed to a telephone interview, only two were contactable and were interviewed for 20 minutes. Ethical approval was obtained from the Women and Newborn Health Service Human Research Ethics Committee (1913/EW). Verbatim transcripts and field notes were stored on a password protected computer in accordance with the National Health and Medical Research Council guidelines (20).
Data Analysis Thematic analysis was conducted to extract common themes, patterns, and similarities around the perceived challenges and enablers to change smoking behavior (21). Qualitative data analysis commenced with initial interview data (22). Analysis was a continual process in which data were deconstructed and reconstructed to find the links between the peripheral and central themes through repeated patterns and meaning. Explicit themes evolved from direct words or sentences. Team members analyzed a cross-section of transcripts and field notes ensuring each data source was reviewed by at least two members. Team meetings were used to clarify, negotiate and refine the findings. Any disagreements on interpretation were negotiated by referring back to the data. Once data saturation was achieved, data collection and analysis ceased (21). Our research team comprised the four midwives, authors of this publication with YH and LL developing the research topic and proposal, BL facilitating the recruitment and data collection and FR conducting the interviews. YH, LL, and FR analyzed the data and all four authors contributed to the final manuscript.
Findings A total of 36 women (16–24 yr of age) provided data around the challenges and enablers faced by young pregnant smokers. Half (n = 18, 50%) of the respondents were 16 to 17 years old, with the majority (n = 28, 78%) in their first pregnancy. Five women (14%) identified themselves as being an Aboriginal or Torres Strait Islander. Direct quotes supportive of the themes and subthemes are provided in italics and coded (P1 to P36) to ensure participant confidentiality.
The Challenges to Decrease or Cease Smoking Exploration of the challenges young pregnant women faced to stop or reduce smoking provided insight to
their smoking behavior and reaffirmed the addictive nature of smoking. “Habit” was noted as the key theme under perceived challenges and incorporated three subthemes: learn to deal with stress; the urge for a smoke; and not being left out.
Habit Young women recognized that the “old habit to smoke” (P13) needed to be addressed to change their smoking behavior. Dependence on smoking was perceived as “a habit, part of an everyday thing. I am used to having a cigarette in my hand and putting it to my mouth every hour” (P18). The words addiction and habit were used interchangeably, offering insight into the perceived difficulties of quitting; “it is a habit and addiction. I want to stop but cannot” (P4) and “there should be rehab for smoking, it is an addiction” (P36). It was noted that women had to “want to quit and have the determination to actually do it” (P12). Some felt they could break the habit/addiction and quit “cold turkey when they were aware of the pregnancy” (P27), whereas others found it “easier to cut down than stop completely” (P35).
Learn to Deal with Stress Smoking was perceived as a potential buffer against “stressful situations such as running late or something bad happening…smoking relaxes you” (P7). Stress was a reoccurring reason for smoking, with P32 stating “stress, that is the reason people smoke, because they are stressed.” She went on to share that stress triggered her need for a cigarette and to stop smoking she would have to “learn to deal with stress” and “remove myself from stressful situations to avoid conflict” (P32). It was suggested that some women did not know “how to deal with things other than having a cigarette” (P35). These stories illustrate how smoking was used to mediate stress levels and how alternate ways to deal with stress would be needed for smoking cessation to be successful.
The Urge for a Smoke Being around smokers increased temptation and the “urge for a smoke” (P26). Many women shared how their perceived addiction to tobacco resulted in difficulty controlling their cravings, particularly when exposed to other smokers. It was suggested that “being around smoking makes you want one—I end up smoking” (P36). One woman actively avoided being around smokers; “disconnecting from friends that smoke”
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(P12) as another shared how it was “difficult to ask them [smokers] to stop or go away” (P25). This move was difficult for women whose exposure extended into their personal living spaces where “everyone around smoked, mum, brothers and cousins” (P26). For one, giving up smoking was “really not possible as everyone in the house has some [cigarettes]. I did not have any which is different to not buying them” (P22). Another felt that her quit attempts would be easier “if everyone in the house stopped smoking and did not smoke around me” (P7). These women recognized that the smoking behavior of others had a negative impact on their resolve to quit.
Not Being Left Out Young women identified the importance of not being left out of their social sphere; being a smoker enabled them to fit in with their peers “my friends smoke…I would feel left out if I was not smoking. I do not smoke when I am at home alone” (P28). The social aspect of smoking was reinforced: “you form a bond with your friends when you smoke—you do not have to speak, just smoke together”(P6) and “it is a social thing, it is hard where you sit there and they are smoking, we all just sit there and have a smoke” (P31). One woman noted how her smoking behavior changed depending on the social situation: “Being around people who are relaxing and having a cigarette—I want to have a cigarette as well. I also hang around some people that have stopped and when I am around them I do not smoke” (P20). For these young women smoking behavior was influenced by peer relationships that enabled them to feel socially included.
Table 1. What Challenges and Enables Young Pregnant Women to Reduce or Stop Smoking: Themes and Subthemes
Challenges Habit Learn to deal with stress The urge for a smoke Not being left out Enablers Health of the baby Getting the facts You need someone Something you can take to help Keeping your mind off it
their decision to stop: “was easy to stop as I was getting headaches from smoking and the health of the baby was at risk” (P26) whereas another stated: “stopped smoking when 6 weeks pregnant [previously smoked a pack a day]. Stopped as I felt sick when smelt smoke while pregnant” (P18). For most just “thinking about the baby…scared me into giving up” (P32) and “thinking of the baby…puts more pressure on yourself” (P17). Information around the potential harm on their baby’s health prompted some to attempt quitting: “I stopped when I was 2 months, because of information about what smoking does to the baby” (P9). However, achieving this goal required focus “you have to be strong minded and realize baby’s health is more important” (P25).
Getting the Facts The Enablers to Decrease or Cease Smoking Women were asked what could assist them to overcome the “habit” of smoking. Concern over the health of their baby emerged as the main theme and motivation to change their behavior. Four subthemes were extracted around keeping their baby healthy: getting the facts; you need someone; something you can take to help; and keeping your mind off it (Table 1).
Information was essential to appreciate the consequences of smoking behavior on the health of their baby. Participants wanted “hard facts on what it [smoking] could do to your baby, realistic, harsh information that is straight to the point” (P35). Providing information in a visual form also appeared to be preferable: “Showing actual photos/videos of what happens when you smoke” (P11) even “seeing graphic pictures on the cigarette box helps” (P5).
Health of the Baby You Need Someone For most participants “pregnancy was the motivation to stop smoking” (P8) with “the health of the baby being the main factor in quitting” (P19) as women were aware that “smoking was bad for the baby” (P21). For some women the physical impact of smoking supported
These young pregnant women identified how a supportive relationship with someone sensitive to their smoking goals could have a positive impact on being able to sustain their quit attempts. “Having someone to talk
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206 through cravings and talk to day to day” (P23) was repeatedly noted. Trying to quit alone was hard “you need someone…I tried to quit before but doing it by yourself stresses you out. I got lonely and kept smoking” (P36). These comments highlight the importance of social support mechanisms in achieving a positive impact on smoking cessation.
Something You Could Take Women were aware of the range of smoking cessation medications available through friends, family and the media. One young woman felt “…it would be easier if there was something you could take” (P1). Another identified that she had wanted “more help with medications; they tell you about patches—that they work but they do not tell you about other things. I ended up buying Champix” [non nicotine drug] (P36). These varied comments highlight the importance of tailoring interventions to address individual preferences.
Keeping Your Mind Off It The importance of having “something to keep your hands busy” (P25) and “something to keep you occupied” (P4) were seen as positive distractions to the cravings women experienced. Other activities to keep their minds off smoking included the following: “Watching a movie” (P12); “going for walks” (P30); “eating something” (P21); and “reading a book” (P27). Young women were able to identify strategies they employed to keep their cravings at bay.
Discussion The findings from this qualitative study represent a small group of predominantly young nulliparous Australian women and their perceptions of the challenges and enablers encountered by young women attempting to change their smoking behavior. Although first-time mothers are more likely to be smoking before pregnancy, they are also more likely to quit during pregnancy (24). Therefore, targeting nulliparous women with smoking cessation interventions can be an effective strategy in making a difference to smoking rates. Although smoking prevalence over the past 10 years has decreased for most pregnant women in WA, this is not the case with young pregnant women (12). Interventions appropriate for all women do not account for development needs across different age groups. Erikson’s development theory argues that young adults and specifically adolescents are involved in a period of
change during their transition to adulthood where peer relationships are a focus (25,26). Although the timing and pace of this developmental transition is subject to variation, the importance of peers to young women must be acknowledged (23). For example, adolescents and young adults prefer web-based information (27). “S.M.A.S.H. Out Cigarettes,” a recently developed web page specifically targets adolescents and is advocated for use in conjunction with counseling or motivational interviewing (2). Although, no evaluation of the website has been published to date, it does provide ageappropriate information on the impact of smoking on their bodies, babies, finances and relationships and is expected to eliminate the fear of self-disappointment or being judged (8). This visual presentation of online information is supportive of our participants’ recommendation of how they wanted to get the facts. Another suggested intervention that addresses the desire to receive visual facts and feedback involves use of carbon monoxide (CO) monitors with either a numeric or colored display in a traffic light format (red, yellow or green). The National Institute for Health and Clinical Excellence (28) suggests that CO testing allows the pregnant women to see a physical measure of her smoking and passive smoke exposure with assistance to interpret the CO reading. Participants acknowledged that smoking is a habit and that attempts to change behavior can extenuate the urge for tobacco. Given that the urge for a smoke may be stronger during pregnancy as physiological adaptations increase nicotine clearance and lower nicotine levels (29,30), these concerns are warranted and must be recognized by professionals assisting pregnant women attempting to quit. Adding these physiological changes with other challenges, such as learning to deal with stress without tobacco and not being socially left out highlight the complex obstacles faced by young pregnant women. Beliefs around smoking reducing stress were supported by another WA study with Indigenous women who did not regard smoking cessation, even in pregnancy, as a priority given their other social and economic stressors (31). In fact, the complexity of issues for young women who smoke suggests that a suite of interventions may be more appropriate for young pregnant women attempting to change their smoking behavior. It is essential that young pregnant women’s perceptions are used to inform development of appropriate components within a suite of cessation interventions. Our participants reinforced how important it was to have someone to support their efforts to change behavior. The social support from partner, family, and friends does influence a woman’s intention to change her behavior (32) and can be either a positive “driver” or a barrier as reported in another qualitative study with
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first-time Canadian mothers (33). Although, a potential father may be willing to support his partner’s attempts to quit, another Australian study suggests if he continues to smoke, misconceptions around the “protection” an unborn child has against passive smoking must be corrected with facts (34). Our Australian participants and men in a British study corroborate concerns around dealing with stress during cigarette withdrawal as being foremost in their minds (34). Becoming a new parent is exciting albeit stressful and attempting to change behavior during this time may amplify this stress. It is therefore important to assist young women and their partners or significant others to develop healthier strategies to deal with stress if we want to increase their chance of successfully ceasing smoking. In fact, a model of resilience in relation to stress and smoking has been recently introduced for people diagnosed with depression (35). It is suggested that smoking is adopted by individuals with perceived high levels of stress and therefore building resilience to stress is an important aspect of the model. Multiple sessions of motivational interviewing (36) as a counseling technique combined with assistance to try alternate strategies to deal with stress may be a potential component for smoking cessations interventions targeting young pregnant women. A further enabler noted in this study was the health of the baby. A summary of qualitative studies cited in a review on adolescent pregnancy (37) suggest that many adolescents view parenting as important to their lives and reinforce their aspiration to be a good parent able to meet their child’s needs. Similar to our findings, a Canadian study also reported concern about the baby’s health as being central to the reason pregnant women reported for changing their smoking behavior (33). In contrast, another review of qualitative studies exploring barriers to quitting smoking during pregnancy for women of all ages concluded that although aware of potential health risks to the fetus, this effort was not sufficient motivation to change smoking behavior (38). Once the baby is born it is important to capitalize on the mother’s motivation to be a good parent by promoting and encouraging her to sustain her smoking reduction or cessation while breastfeeding (39). An American qualitative study of postpartum mothers’ intention to smoke found that although most women did not intend to resume smoking, perceptions around passive smoke and overconfidence in their control over smoking could threaten good intentions (40). The review of qualitative studies also revealed how cessation interventions by health professionals were negatively viewed by women (38) highlighting the importance of tailoring interventions to the unique needs of target groups. A didactic approach to change
smoking behavior during antenatal visits can compromise the trusting relationship needed between the woman and her caregiver (41). Social stigma and negative social attitudes associated with smoking in pregnancy have resulted in women denying or hiding their smoking (42). Therefore to facilitate behavior change, the ideal relationship involves a supportive caregiver and a woman demonstrating transparency, trust, and congruent expectations that positively builds on the woman’s capabilities (41). Finally, having something you can take to help was regarded as an enabler by the young women in this study. However, clinical guidelines at the study setting note that smoking cessation in pregnancy should ideally occur independent of nicotine replacement therapy (NRT) (18), while acknowledging that NRT has fewer adverse effects on the fetus than tobacco smoking (6). If a woman wishes to use NRT, intermittent dosing products such as gum, lozenges, or aerosols are recommended. The efficacy of NRT in pregnancy continues to be debated because of minimal evidence around safe use; and for further research to address this gap, inquiry is needed to explore pregnant women’s perceptions of using NRT (43) in collaboration with other strategies such as motivational interviewing, CO monitoring, and peer support. This Australian study has limitations. Qualitative research findings must be viewed within the context the study was conducted. The perceptions of this predominantly white sample of young pregnant smokers may not reflect the issues faced by other young women in different cultural and geographic locations. The context of this Australian study was outlined to allow the reader to determine the transferability of the findings to their setting.
Conclusions The findings from this study highlight the complex issues around smoking behavior for young pregnant WA women. Sharing their perceptions of the challenges and enablers to changing smoking behavior may be used to inform development of a suite of cessation interventions more appropriate in targeting the unique needs of this group of women.
Acknowledgments Funding support was received from the Women and Infants Research Foundation (WIRF). We acknowledge the young pregnant women who were gracious in sharing their thoughts and feelings on a controversial yet important topic.
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