Midwifery 30 (2014) e64–e71
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The experiences of women who quit smoking during pregnancy and how they dealt with their spouses' continued smoking Chia Yin Wang, RN, CNM, MS (Registered Nurse)a, Hsin-Tzu Li, RN, CNM, MS (Head Nurse for the Labor and Delivery Ward)b, Chi-Ho Hsu, RN, PhD (Assistant Professor)c, Yu-Lan Lin, RN, CNM, MS (Assistant Head Nurse)d, Su-Chen Kuo, RN, CNM, PhD (Professor)e,n a
Outpatient Department at Mennonite Christian Hospital, Hualien County, 44 Min-Chuan Road, Hualien 970, Taiwan Changhua Christian Hospital, Changhua County, 135 Nanxial St., Changhua 500, Taiwan Department of Nursing, National Taipei University of Nursing and Health Sciences, 365 Ming-Te Road, Taipei 112, Taiwan d Taipei Veterans General Hospital, 201, Sec 2, Shipai Rd., Taipei 11217, Taiwan e College of Nursing, National Taipei University of Nursing and Health Sciences, No. 365 Ming-Te Road, Taipei 11219, Taiwan b c
art ic l e i nf o
a b s t r a c t
Article history: Received 22 March 2013 Received in revised form 3 September 2013 Accepted 21 October 2013
Objective: to explore how pregnant women in Taiwan dealt with their spouses who continued to smoke and with passive smoking during their own process of quitting and abstaining. Design: a qualitative study using an oral history approach. Data were collected via tape-recorded openended interviews. All interviews were transcribed verbatim. Data were analysed using narrative analysis. Setting: the homes of the participant women living in the district of a regional hospital of eastern Taiwan. Participants: a purposive sample of 10 Taiwanese women who had quit smoking while pregnant was recruited at 1–3 months following the birth of their infants. Findings: five major themes emerged: (1) the women coping with tobacco addiction on their own, (2) creating a non-smoking section or environment at home, (3) dealing with passive smoking, (4) conflict over the wife's sensitivity to her spouse's residual tobacco smell, and (5) allowing the husband to continue smoking to avoid conflicts. Key conclusions: the pregnant women were expected by their spouses to quit smoking, yet the husbands continued to smoke. Women had to struggle to quit smoking on their own. The findings from this study support the need to listen to pregnant women's stories, as this is paramount to understanding their experiences of tobacco-use reduction and cessation, and for developing gender appropriate interventions to support their efforts. Implications for practice: health care providers should encourage and help pregnant women who are willing to quit smoking. This help could be more family-centred instead of focusing on the pregnant women alone, and therefore involve educating the spouse to support his wife. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Smoking cessation Passive smoking Pregnancy
Introduction Smoking during pregnancy may readily lead to premature birth and the slow growth of the fetus in uterus; the more a pregnant woman smokes, the greater the influence will be (Hammoud et al., 2005; Vardavas et al., 2010). Various studies have shown that half of pregnant women who smoked intended to quit smoking during pregnancy, especially in the first trimester, and that as soon as they found themselves pregnant, they intended to do so. This is
n
Corresponding author. E-mail addresses: [email protected] (C.Y. Wang), [email protected] (H.-T. Li), [email protected] (C.-H. Hsu), [email protected] (Y.-L. Lin), [email protected] (S.-C. Kuo). 0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.10.016
because they wanted the fetus to be healthy and not affected by smoking (Thompson et al., 2004; Näsman and Ortendahl, 2007). In Taiwan, about 4–5% of pregnant women smoke cigarettes, about 60% of the pregnant women's spouses also smoke, and almost all of smoking women's spouses smoke. Even though the women may actively quit smoking during pregnancy, they will still encounter secondary smoke (passive smoking) at home (Shih et al., 2008). If the pregnant woman does not smoke cigarettes herself but is exposed to the surroundings of such secondary smoke, the fetus will be influenced, being smaller than the normal gestation age (SGA) and easily become a low birth weight infant (Hammoud et al., 2005; Aagaard-Tillery et al., 2008). The difficulties confronted by pregnant women intending to quit smoking have been shown to be associated with having spouses who smoke (Ma et al., 2005; Schneider et al., 2010). Also, the strongest
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predictable factor for a pregnant woman who has quit smoking to resume the practice of smoking after birth is that of her spouse smoking (Moffatt and Whip, 2004). For pregnant woman who quits smoking, the symptoms of withdrawal such as unstable emotions, insomnia and thirst will decrease the longer she abstains from smoking. These withdrawal symptoms may be ignored because of the strong nausea and vomiting during the early stage of pregnancy (Thompson et al., 2004). However, when the woman sees her spouse smoking or the cigarettes at home, this could undermine her determination to quit smoking (Tod, 2003; Moffatt and Whip, 2004). On the other hand, the pregnant woman able to quit smoking during pregnancy may encounter her spouse's encouragement and supporting acts and therefore feel she is not alone in facing the challenge of quitting (Koshy et al., 2010). Therefore, when health care providers help a pregnant woman quit smoking, they are advised to invite and teach her spouse to support her. This will lead to a more significant rate of smoking cessation than simply helping only the pregnant woman quit smoking (McBride et al., 2004). Once a pregnant woman quits, she may like to change those situations that might entice her to resume the practice, and she may also expect her spouse to reduce or quit smoking, or at least not to smoke in her presence. However, although the spouse who smokes may expect the pregnant woman to quit smoking, he does not always provide her with real support, or himself quit (Thompson et al., 2004), possibly giving only a verbal promise that remains unfulfilled (Bottorff et al., 2010). Although the husbands may know the expectation of their wives and accept some pressure, they may also think the fetus is protected in the womb and therefore passive smoking should not affect the fetus (Wakefield et al., 1998). When the secondary smoke of the spouse becomes the focus of conflict for the couple, threatening their relationship, the pregnant woman more often than not is faced with great psychological pressure (Bottorff et al., 2006). Accordingly, after the pregnant woman quits smoking, her attitude towards her spouse's smoking may change; she not only has to face her spouse's secondary smoke, but also face a change in the relationship with her husband. In Taiwan, the population of smoking females has gradually increased. Women's smoking rate was 2.3–3.8% between 1986 and1996, which increased to 4.1–5.3% between 1999 and 2007 (Bureau of Health Promotion, 2008); thus, quitting smoking by pregnant women has become an important issue. However, in Taiwanese culture males seldom change their lifestyle or habits for their wives, and this includes few Taiwanese males quitting smoking during their wives' pregnancy (Chen et al., 2002). Given that nearly all spouses of smoking females smoke, it is not surprising that 80% of women continue to smoke during their pregnancy. Those who do quit have a relapse rate of 69.2% after the birth of the first child and 91.7% after the second child within one year after the birth of their child (Shih et al., 2008). In 2004 the Taiwan government began promoting ‘smoke-free families’. According to an evaluation report for this program, the cessation rate for participants one year after joining the program was 21–22%, (Bureau of Health Promotion, 2006). However, there has been no further follow-up evaluation for this program. Although health care providers advise smoking pregnant women to quit, they encounter not only this significant percentage of women who continue to smoke during pregnancy but also neglect the passive smoking that pregnant women have to face after quitting. Those who successfully quit may face their spouses' secondary smoke, and have to avoid or otherwise deal with passive smoking. When their spouses do not accept their advice or requests to quit smoking, they may feel disappointed. Research related to these aspects of quitting is limited. By knowing the pressures and difficulties confronted by pregnant woman in
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having to deal with passive smoking, and helping the pregnant woman herself to quit smoking, we can better know how to reduce those pressures. We can learn how to offer the pregnant woman adequate support and help, and how to develop communication with the spouse to encourage him also to quit or, in the least, to reduce the number of cigarettes smoked. Therefore, the aim of this qualitative research was to explore how pregnant women dealt with their spouses who continued to smoke and with passive smoking during their own process of quitting and abstaining.
Methodology Study design This study used an oral history method to capture personal stories and construct new evidence and avenues for future research. It explored the individual and, thematically, the collective experience of pregnant women who encountered their spouse's secondary smoke, thereby generating evidence where little other documentation exists (Thompson, 2000). We considered oral history as more attuned to compiling short narratives about people and particular events, as in this case (Feldstein, 2004). As a research methodology, it allows the individuals to be central to the empirical data, giving voice to those who have arguably been ignored, marginalised or silenced within particular contexts. As our study was focused on a particular event in the women's lives, with practical implications, rather than a more philosophical understanding of what this meant for them, we opted for oral history rather than a phenomenological approach. Our interview style encouraged the participants to recall and convey their spouses' secondary smoke issues and what it meant to be pregnant and a mother, or how the situation strained relationships, or how it was done and how the participants felt about doing it, etc. Using the oral history approach vis-à-vis two to three times deep interviews provided an opportunity for participants to articulate their own situations and feelings, memories were understood in new ways, and the self story is both confirmed and recreated. This oral history method has been considered appropriate in the verbalisation of different beliefs and particular experiences, allowing for the exploration and elaboration of lives, or aspects of life, in particular (Thompson, 2000; Banks-Wallace, 2002). Ethical considerations This study was approved by the ethics committee of the hospital. Written informed consent was obtained from each participant before the interviews. Confidentiality and the right of refusal at anytime were stressed. The data disclosed in the interviews were confidential. To preserve the participants' anonymity, pseudonyms for all persons were used throughout the research. Participants Inclusion criteria for participation in this research were (1) the female and her spouse were older than 20; (2) each spouse was a current smoker (defined as one who had smoked at least 100 cigarettes in their entire life and was currently smoking every day or some days) (Centre for Disease Control and Prevention USA, 2011); (3) the pregnant woman was in her third trimester, had quit smoking in the first trimester of pregnancy, and had not smoked until after she gave birth; (4) both the pregnant woman and the fetus had no major obstetrical or medical complications according to the antenatal check chart, and had a singleton pregnancy.
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Participants were recruited through an antenatal clinical service in a regional hospital of eastern Taiwan. Women who met the selection criteria were directly approached by the first researcher when they received antenatal health education. Willing participants were asked to sign a letter of consent for the study. Because there were few women who had quit smoking in the first trimester and continued their abstinence until after they had given birth, only a final 10 participants were able to be included in the study. Data collection The semi-structured interviews were conducted by the first author in the participants' homes. A short questionnaire was used to record demographics such as age, marital status, parity, education level, and smoking duration. In consultation with colleagues, the interviewer formulated the guiding questions, and to be as value-free as possible. Although literature was utilised to inform what areas might be covered in the interviews, no specific questions specifically relied on the literature, as it was believed that the questions were more of a guidance than specific, and the method of oral history, like anthropology, lent itself more to exploring issues and asking guiding questions as they arose in each situation, rather than stick to a structured regimen. Also, little literature specifically on this issue provided precise guidance on questions to be asked, and thus we took the opportunity through oral history and guided questions to allow participants to raise issues important to them and perhaps that we had not thought of, which were then developed in subsequent interviews. Using these questions as a base, the interviewer guided the participants to describe their experiences regarding the subject of interest. Commonly, an initial question was, ‘Tell me of your experience when you quit smoking during pregnancy and had to deal with your spouse's secondary smoke.’ Probes such as, ‘How did you set the non-smoking area at home?’ encouraged the participants to add depth in describing their experiences. Investigator field notes were taken during each interview and were included as data in the analysis. All the interviews took place in the absence of the spouse. The interviews were conducted from June 2007 to February 2009. Six participants were interviewed three times, and four were interviewed twice. Each interview took 1.5–2 hours. The interview time was one to three months after the participants had given birth, at which time they had maintained abstinence. However, all of the participants' spouses had continued to smoke. No new themes emerged after 10 participants had been interviewed. These provided sufficient data to account for several aspects of how the pregnant women dealt with their smoking/non-smoking situations. Apart from interviews, we also used observation, field notes, and participant checks to cover a wide variety of situations and narratives. In addition, an acceptable interpretative framework was constructed after the tenth interview. A four-step process was used in this project. First, the 10 participants were interviewed and their responses, in Chinese, tape-recorded. Second, we transcribed the Chinese and typed verbatim drafts from the tapes. Third, we let the participants read and check the meanings from the verbatim drafts, and amended them accordingly. Four, ‘back-translations’ followed, with the Chinese themes being translated back into English by an independent bilingual midwife. The meaning of each translated version was then compared by another bilingual midwife. Results showed high reliability of the translated version. This procedure ensured a semantically and conceptually equivalent translation of the themes. Three Chinese-English bilingual nurse-midwives on the panel committee were involved in reaching final agreement on the translations.
Data analysis After establishing all of the original data, we read each interview to discern the narrative logic of the participants and sort out the life experiences of the participants and the issues for discussion and analysis, keeping in mind during the research process that the women's views and voices should be a priority (Riessman, 1993). We immersed ourselves in the data to understand the participant's point of view from an empathetic rather than a sympathetic position. Next, each transcript was read through again several times with a view to identifying narrative segments and categories within it. As part of this process analytical memos were also made. Following this, preliminary and tentative connections were made to theoretical concepts related to issues emerging within each participant's story. This process, along with the analytical memos, helped shape the questions asked and the themes explored at the next interview as part of a cyclical process. As the interviews progressed and data were accumulated, connections were sought across narrative segments and themes in an attempt to identify patterns and meanings constructed both within and between the stories told by the participants in order to facilitate a comparative analysis of their narrative maps (Thompson, 2000; Miller-Rosser et al., 2009). We then integrated and summarised those stories.
Study rigour Several practices were employed throughout the study that aimed to establish methodological rigour. The qualitative data were analysed by two research members, checking the validation of themes, guided by the data analysis suggestions of Miles and Huberman (1994). Preliminary raw data analysis occurred during data collection. The accuracy of checking the tapes against the transcribed data provided the evolution of themes that were later checked in the process by research members checking the analysis; this provided a validation of themes. Data were extracted as concepts and categories that identified specific experiences. Recurrent experiences were marked through several readings of the material and collected into thematic clusters. A codebook was created so that reliability could be maximised from the researchers' input. The codebook included statements that could be included in identified concepts and categories. The identified and validated categories were then taken to a greater level of abstraction by placing them all on a blackboard for discussion in order to centralise the categories. Weekly research meetings facilitated reflection on the data and enabled discussion of emerging themes arising from the analysis. These formal meetings provided us with opportunities to test the validity of the themes and to reach a consensus. It should also be noted that none of the authors condone smoking, and agree that smoking and passive smoking are harmful to one's own health and also that of an unborn child. The experience of smoking as ‘pleasurable’ is purely the subjective assessment by and responses of the participants. However, the integrity of the participants' perspective was maintained in several ways, to ensure the researchers' view of smoking did not affect our methodology or analysis, and hence validate experiences of the participants. We provided each participant with the opportunity to check and amend her narrative as we transcribed it, and our research group, consisting of experienced nurses, had regular meetings that significantly enhanced our ability to be reflexive about what we were doing when we were in the thick of our research. We reflected on and recorded our interpretations, and were self-conscious and articulate about our role in the research process and outcomes. We listened to the data repeatedly, with a
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focus on meanings, letting the data and the participants speak for themselves, discussing all issues in order to arrive at a consensus.
Findings Ten women were interviewed. The ages of the participants were between 23 and 33 years, and all of them were married. Nine had graduated from senior high school, whereas one was a graduate of junior high school. Seven of the women were pregnant for the first time, whereas three women had borne at least two children. Most of them had begun smoking cigarettes when they were adolescents; only one woman had begun at the age of 10. Their smoking behaviour covered 3—19 years. Half of them had previously tried to quit smoking but failed to do so; three of these had had a previous child, whereas two were first-time mothers. The other five participants had never tried to quit. In this study 10 women quit smoking in their first trimester of pregnancy and continued abstinence until they gave birth. They put in a lot of effort to deal with the problems arising from their spouse's secondary smoke. From their perspective, five major themes emerged from the analysis of interview data. Coping with tobacco addiction on their own When the participants learned that they were pregnant, they decided to quit smoking. All were also asked by their husbands to quit smoking mainly because they did not want the fetus to be harmed. Smoking cigarettes had been the participants' habit for many years, which was developed when they were adolescents. Quitting smoking meant sacrificing a part of their life's pleasure and enduring the withdrawal symptoms of quitting. However, although a child belongs to a couple and it is the couple who are responsible for the child's health, the husband continued to smoke, ignoring not only the psychological struggle of his partner in some cases, but also the effect of passive smoking on an unborn child (Lin, 2009). This situation made some participants feel disheartened: I felt very painful when I saw him smoking cigarettes… Although I was pregnant, I could do nothing about it. Indeed, I was not willing to be pregnant! [because it meant having to quit smoking]. (Mary) This participant felt that this situation was not fair. From the beginning, her husband showed no sympathy for her quitting, and he did not think that he had any responsibilities or obligations. Genny, another participant, said that what made her feel most helpless was that her husband told her that ‘the foetus is in your womb.’ It seemed that the mother was fully responsible for the health of the fetus, which had nothing to do with the father, and that because the fetus was protected by the womb of the mother it would not be affected by passive smoking. Babara said that when she asked her husband not to smoke in the car her husband surprisingly said, ‘Isn't the foetus safe and healthy in your womb?’ This made Babara very angry. She also had to face the struggle and temptation alone while she was quitting, especially in the first week. She had to keep herself from seeing others smoking or keep herself from scenarios that attracted her to smoking. All the expectant fathers wanted their pregnant wives to give up smoking, but they themselves did not stop smoking. The fact that the pregnant women were alone in having to give up the ‘enjoyment’ of smoking cigarettes made them unwilling to do so. Although it was the couple who was responsible for the health of the fetus, it now seemed that it was the pregnant women who were solely responsible, as noted above. Although the husbands felt that the pregnant women were obliged to quit smoking, they
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did not think that passive smoking would harm the fetus or that that it would affect their wives if the men kept smoking. That the wives saw their husbands continue to enjoy the pleasure of smoking and that husbands did not understand the pains the women experienced in quitting made the pregnant women feel isolated and at times angry or depressed. Creating a non-smoking section or environment at home Having quit smoking, the pregnant women used various strategies to limit their desire to smoke and to avoid passive smoking. They would try to keep themselves from smelling cigarette smoke or seeing cigarettes and related paraphernalia, and changed their previous daily routines. The participants initially separated off certain sections at home as non-smoking, limiting the space where their husbands could smoke, or insisted that their husbands go outside to smoke. In the past both wife and husband had smoked cigarettes, so for convenience cigarettes, ashtrays and lighters were available in the bedrooms and elsewhere. Carol, for example, said that she took away the articles for smoking in the bedroom to prevent her from seeing them. Thus she actively changed the arrangements in the bedroom, telling her husband that the re-arrangement was for the purpose of quitting smoking. Certainly this caused inconvenience when her husband wanted to smoke, which helped Carol to achieve another purpose, that of reducing the frequency of her husband's smoking at home: I thought that what I did was for the foetus. And after I quit smoking, I did not want to encounter his smell of cigarettes because when I smelled it, I would like to smoke cigarettes again. (Carol) When the pregnant women used various means to clean and refurbish the bedroom, they had to make their husbands understand that getting rid of the smell of secondary smoke would take a lot of time and energy, and even cost money to replace some of the décor in the bedroom. When the furnishings were changed and all traces of smoking were extinguished, the husbands clearly understood that they were not allowed to smoke in the bedroom. Although the smell could float into the bedroom from other parts of the house, this would be better than smoking in the bedroom. If the couple agreed that smoking was not permitted indoors at all, then all the smoking paraphernalia and some of the furnishings were removed, so that there was nothing that would evoke the women's desire to smoke. This also prevented the pregnant women from being affected by passive smoking indoors. However, for women who lived with parents-in-law and whose father-inlaw smoked, it was difficult to make the house a smoke-free zone. Only five of the couples agreed that smoking was not permitted anywhere in the house, and so the other couples compromised by excluding smoking only from the bedroom. Dona, for example, said that the couple made an agreement that the husband could smoke only outside of the bedroom. Dealing with passive smoking The period of pregnancy is not merely a few days or even weeks, but long months. During this long period the participants had to constantly remind their husbands about passive smoking, which the husbands thought as bothersome. As Babara and Ida put it, ‘This is the privilege of pregnant women, for pregnant women are first!’ Even though their husbands thought them bothersome, as mothers these women defended their position of addressing passive smoking as seriously as possible.
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One month after quitting, most of the participants had no impulse to smoke when they saw their spouses smoking, but even after the first trimester they still did not like to encounter secondary smoke or like the residual smell of smoking left by their husbands. Therefore, the participants would explain the situation to their husbands, letting their husbands know that they were responsible for producing secondary smoke, which was as harmful to the fetus as directly as smoking cigarettes. Sometimes the women escaped from these conditions by going to the bedroom, which was smoke-free. For Carol, Dona, Genny, Jenny and Mary, five participants whose non-smoking section at home was the bedroom only, their husbands had reduced their frequency of smoking in the living room, but had not completely abstained from smoking there. Thus, if these women wanted to totally avoid passive smoking they had to go to the bedroom:
for smoking; however, that smell simultaneously made some of them disgusted and they worried about the health of the fetus. Those wives who had banned smoking in the house commonly asked their husbands not to go into the house immediately after they had smoked, but to wait until the smell had faded. In some cases the husband had to wash his hands, take a shower, or change clothes before he could approach his wife:
He went outside to smoke cigarettes, which showed he was in a good mood. However, he was not always in a good mood. It was me that needed to escape him. And sometimes, when it was cold, he did not want to go outside. Anyway, it depended on his mood. (Genny)
My husband said that I was too sensitive. However, when I smoked before, I did not have the feeling, even not smelling the odour of his body. After I quit smoking, I felt that his smell of cigarettes was very strong and smelly. (Ida)
Although Genny constantly reminded her husband not to smoke wherever and whenever she was present, sometimes her husband would forget, or he would think that as the air outdoors was moving he could still smoke if the wind did not blow towards her. At such times the pregnant woman not only needed to remind her husband in words, but also needed to take some action. Ida, for example, said that she had a close relationship with her husband, telling him many times not to smoke cigarettes in her presence. If her husband did smoke in her presence, she would simply take away his cigarette. Apart from the husband, visiting relatives and friends also smoked cigarettes in the smoking sections of the home. If relatives and friends paid a visit to the home and smoked, then the pregnant woman could do nothing other than leave the scene: They did not care whether I was pregnant or not. So, I had to escape. (Elizabeth) Thus, if a woman encountered her husband smoking in her presence, she would leave the scene or advise their husbands not to smoke. However, dealing with guests at home, or in visiting friends and relatives in their homes, had other, wider, socio-cultural implications. Although the pregnant woman may have been compelled to leave her guests, this in itself may have been considered culturally inappropriate, and thus could put the woman in a dilemma. If, on the other hand, she herself was a guest at another's house, there was little she could do than to try to escape passive smoking. Given that Taiwan society is largely male dominated, as previously noted, and that there are cultural prescriptions about public behaviour, such a dilemma is indicative of how little consideration may be given by men, and others, to (pregnant) women in Taiwanese society. It is thus suggestive that health workers must focus not only on women who are or may become pregnant, but also on her friends and relatives, in addition to their husbands. Conflict over the wife's sensitivity to her spouse's residual tobacco smell For several weeks after the pregnant women quit smoking, they would feel different, physically and psychologically, and slowly they became more capable of controlling the impulse to smoke. However, the participants had not anticipated that their sense of smell would become more acute. Thus, when they could detect the residual smell of their husbands' smoking they would be reminded of the scenarios
When my husband smoked, he would wait outside for a long time. After the smell faded, he could come in. Otherwise, when he came in, I would feel uncomfortable and want to vomit because of the smell of smoking. (Babara) Jenny decided to use her own quilt instead of sharing a quilt with her husband. Ida and Amy mentioned that when they chatted with their husbands, or even when their husbands opened their mouths to breath, the bad odour of their breath was evident:
All participants indicated that they could judge whether their husband had smoked when he came near. Some of the couples had arguments several times because the smell of cigarettes was so strong. Although their husbands' residual smoke odour was obvious, the pregnant women did their best to tolerate it, but only if the smell was not too strong. However, it was difficult to set an objective standard for judging whether or not the odour was smelly. Sometimes the husbands thought there was little or no smell, whereas the pregnant women would feel that the smell was very strong. Under such circumstances arguments between couples could erupt. Allowing the husband to continue smoking to avoid conflicts As mothers, the participants thought that they should never be exposed to passive smoking because of their husbands smoking, and hoped their husbands would also quit. However, as wives, they did not insist that their husbands should not smoke. Firstly, they knew that quitting smoking was not easy, for the process entailed endurance and pain from the withdrawal symptoms. Secondly, the participants felt that forcing their husbands to quit smoking could damage their relationship, and that their husbands had to be willing to quit smoking by themselves. The participants thought that smoking cigarettes was a personal choice, and a way of entertainment and amusement. Although for the expectant mother quitting as soon as possible was paramount for the health of her baby, this immediacy was not the case for her husband to quit smoking. The participants said that their husbands had ‘good’ reasons for smoking, such as that they needed cigarettes to gain ‘inspiration’ while working, and cigarettes were a means and necessity in their social life. Men could not work or make friends without cigarettes. In addition, the participants indicated that their husbands had indulged in smoking longer than them, so quitting smoking would be a difficult process: It's difficult for him to quit smoking. You see, I have had the habit of smoking cigarettes for about three years. Three years is short, but I still had difficulty in quitting smoking. He has had the habit of smoking cigarettes for over ten years. So, quitting smoking must be very difficult for him. (Amy) Dona said: If he wants to quit smoking, he would do that. If he has no intention, it would harm mutual feelings to force him to quit smoking. (Dona)
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The participants thus suggested that cigarettes were a ‘companion’ when their husbands worked or which they enjoyed during entertainment or socialising. Even though they asked their husbands to smoke elsewhere or to quit, they also reflected on how they themselves had been addicted to tobacco, and therefore saw no grounds for strongly pursuing the issue. Thus, in order to maintain harmonious relations, the participants unanimously said that it was up to their husbands as to whether or not they should quit smoking. While the logic of the participants, and also most likely of their husbands, is spurious and stands more as a legitimation, it is what they believed and said, and by which they justified the strategy of allowing husbands to continue smoking. As an aside, it should also be noted that, although the women were concerned about the effects of smoking and passive smoking on the fetus, some of the women participants resumed smoking, and/or perhaps tolerated more pervasive passive smoking, after birth, but failed to acknowledge the health effects of this on the newborn child.
Discussion This study set out to explore how pregnant women in Taiwan dealt with their spouses who continued to smoke and with passive smoking, while they endured their own process of quitting and abstaining from smoking. Several themes emerged, as noted in the results and analysis. Quitting smoking was constructed as part of the process of engaging in motherhood. Their spouses expected the pregnant women to quit smoking, yet the husbands continued to smoke. Women had to struggle to quit smoking on their own, set aside a non-smoking area in the home, and put a lot of effort into avoiding passive smoking and the residual odour of smoking, which could at times create conflict between couples. In addition, in order to avoid any strained relationship with their husbands, the women allowed them to continue smoking. The spouse's encouragement was helpful at times for the pregnant woman's act of quitting smoking; however, several of the participants thought that quitting during pregnancy was to sacrifice their own enjoyment, so at the initial stage of quitting they would tend to smoke cigarettes again when they saw or thought of their spouses smoking cigarettes, as Thompson et al. (2004) and Bailey et al. (2008) also note. Although a woman might like to smoke cigarettes, she also thought that she should quit for the fetus. This unfairness that some pregnant women felt could make them feel isolated. Hence, as the partner's smoking habits have a great effect on the motivation for the woman to change her behaviour, he also should be offered help (McBride et al., 1998). As our findings reveal, similar to the study by Bottorff et al. (2010), the pregnant women tried to control the place and time for their spouses to smoke cigarettes. As the husbands certainly thought that pregnant women should not smoke, they abided by only the minimal rule that bedrooms were non-smoking sections in support of their spouse, but they themselves continued to smoke, as Thompson et al. (2004) also found in their study. In common with other studies (e.g. Lee, 2008; Yang et al., 2010), pregnant women in China who tried to manage their spouses' smoking to protect the fetus' physical development faced great challenges; they imposed various degrees of restrictions on smoking in the home, but few asked family smokers to quit or to reduce their frequency of smoking. Through the experiences of the participants in this study we can see how the women tried hard to avoid or otherwise deal with passive smoking situations every day, for almost nine months. Certainly this would affect the way the couple lived with each other. It was also revealed that husbands did not think that passive smoking would hurt the fetus or their wives, and thus their
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smoking did not matter to the pregnant women, which is consistent with the findings by Wakefield et al. (1998). Despite these conflicting views, the participants expected or at least hoped that their husbands would also quit smoking, but they lacked convincing reasons, and certainly they did not expect that their relationship could be strained by different needs and views. These findings accord with limited studies in other Asian countries. Many Cambodian women had tried to advise or persuade their husbands not to smoke in the home, with very few convincing their husbands to actually quit; men in Vietnam, Malaysia and Indonesia ignored their wives' persuasion to reduce or stop smoking (Efroymson and Velasco, 2007; Nichter et al., 2010). In this study, it was never expected that after a few weeks of quitting the wife might feel very disgusted towards the residual smell of smoking that her spouse left on his clothing and body. This left the husbands very surprised, and they thought that the women were over-reacting. This often became a starting point for conflict between them. The pregnant woman had not anticipated her sense of smell to be so keen, whereas the husband considered the pregnant woman's complaints as verbal attacks, which he defended, and maintained his right to continue smoking, as Bottorff et al. (2006) also found in their study. Another condition which could easily give rise to conflicts occurred whenever the husband smoked in the woman's presence; she would reiterate that she should not experience passive smoking, but if she complained too many times, her spouse would feel that she was very bothersome, as Greaves et al. (2007) similarly reported: although men used power and control to force their partners to stop smoking, they themselves continued and found their wives' complaints unreasonable. However, in our study, the pregnant women worried that to criticise their husbands for their odour would affect mutual feelings of affection, which was a concern that Bottorff et al. (2010) also noted in their study. Bottorff et al. (2006) pointed out that if a pregnant woman expected or asked her spouse to quit smoking, this could spark a conflict between the couple; our study supports this issue of potential conflict amongst couples. This possibility or reality made the women feel lonely and at times helpless. It is therefore of utmost importance that nurses, midwives and doctors are aware of this. In Taiwan society, and which this study confirms, it is a common and traditional idea that a woman who smokes is not a ‘good’ woman (Chang and Wang, 2004). As a mother is expected to make sacrifices for her children, and to ensure the health of the next generation, she is expected to quit smoking during pregnancy. On the other hand, in terms of a man's social life and work, it seems that he cannot help but smoke cigarettes. Although the Tobacco Hazards Prevention Act (2009) suggests that pregnant women should not smoke in Taiwan, it fails to take into account that pregnant women who do quit may be confronted by passive smoking, particularly from their husbands. This information was instrumental in developing more effective measures for helping women who smoked during their pregnancy to quit. However, more attention must be paid to the damaging effects of passive smoking (Chen et al., 2002; Aagaard-Tillery et al., 2008).
Limitations Limitations of this study are acknowledged as focusing on only 10 women from one regional hospital in eastern Taiwan, and that the sample was self-selecting. In view of the socio-cultural influences upon women's smoking behaviour, generalisation to other parts of Taiwan and other countries may, therefore, be limited. We have no information regarding the women who chose not to quit smoking, nor the first-hand views of the women's husbands.
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Also, this study was completed four years ago; since then the Taiwan government has provided a comprehensive support environment to encourage people to quit smoking (Bureau of Health Promotion, 2010). Such a policy might effect a different response if the study were to be conducted today. In addition, conducting an interview one to three months post birth could have resulted in recall bias, although this was somewhat mitigated by conducting several interviews with each participant and providing them with transcripts, which allowed them to reflect on and amend their thoughts and feelings. Although various biases may intrude into interviewing, as a method, we feel confident that, over a period of time and with the building of rapport with participants, much of what was revealed by these women reflected their situation. Although it is always difficult to control for these features of research and bias by both participants and researchers, such as telling and hearing what wants to be said, the consistency across the 10 participants' experiences lends validity to the narrative results (Sarantakos, 1998). Despite these limitations, one of the strengths of this study design was that oral history, as a method, enabled women to talk about the various ways by which they dealt with their spouses' continued smoking, through which they revealed the stress and problems confronted by them in having to deal with passive smoking, as clearly articulated in the results and their quotations. Thus, overall, despite some limitations, certain issues emerged that others may find useful. Implications for practice This study highlights several strategies to address identified issues. First, when a pregnant woman with the habit of smoking cigarettes attends her first antenatal check, she should be afforded help to quit smoking. In addition, if her spouse smokes then health care providers may need to help the pregnant woman address passive smoking. This help could be more family-centred instead of focusing only on the pregnant woman, and therefore involve educating the spouse to support his wife. However, few health care providers currently know how to help the pregnant woman, or her husband, in this endeavour. Implications for research Future research based on our study of women's strategies is warranted. Such research could focus on spousal interactions when a pregnant woman is attempting to quit smoking; moreover, it could consider the development of guidelines and methods for health care providers to support such pregnant women and their spouses. Serendipitously, such research and education may also lead to a lower recidivist rate.
Conclusion Our results support the view that understanding spousal influences on pregnant women's smoking behaviour is necessary to enrich our understanding of their smoking and attempts at quitting, and to provide a foundation for developing interventions. Interventions that aim to encourage expectant fathers' tobacco reduction or cessation have the clear potential to decrease relationship tensions and reduce pressure on pregnant women to be solely responsible for regulating expectant fathers' smoking. Continuing to listen to pregnant women's stories is paramount to understanding their experiences of tobacco cessation, and for developing gender appropriate interventions to support their efforts.
This study therefore represents the perspective of women and a challenge to the development of appropriate health services, which should be needs-oriented, and health promotion campaigns. If we affirm a family-centred philosophy, then antenatal education should include consideration of expectant fathers along with the traditional attention provided to expectant mothers who wish to quit smoking.
Conflict of interest The authors confirm and prove the study without any conflict of interest. There is no funding for this research.
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Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
The experiences of women who quit smoking during pregnancy and how they dealt with their spouses' continued smoking Chia Yin Wang, RN, CNM, MS (Registered Nurse)a, Hsin-Tzu Li, RN, CNM, MS (Head Nurse for the Labor and Delivery Ward)b, Chi-Ho Hsu, RN, PhD (Assistant Professor)c, Yu-Lan Lin, RN, CNM, MS (Assistant Head Nurse)d, Su-Chen Kuo, RN, CNM, PhD (Professor)e,n a
Outpatient Department at Mennonite Christian Hospital, Hualien County, 44 Min-Chuan Road, Hualien 970, Taiwan Changhua Christian Hospital, Changhua County, 135 Nanxial St., Changhua 500, Taiwan Department of Nursing, National Taipei University of Nursing and Health Sciences, 365 Ming-Te Road, Taipei 112, Taiwan d Taipei Veterans General Hospital, 201, Sec 2, Shipai Rd., Taipei 11217, Taiwan e College of Nursing, National Taipei University of Nursing and Health Sciences, No. 365 Ming-Te Road, Taipei 11219, Taiwan b c
art ic l e i nf o
a b s t r a c t
Article history: Received 22 March 2013 Received in revised form 3 September 2013 Accepted 21 October 2013
Objective: to explore how pregnant women in Taiwan dealt with their spouses who continued to smoke and with passive smoking during their own process of quitting and abstaining. Design: a qualitative study using an oral history approach. Data were collected via tape-recorded openended interviews. All interviews were transcribed verbatim. Data were analysed using narrative analysis. Setting: the homes of the participant women living in the district of a regional hospital of eastern Taiwan. Participants: a purposive sample of 10 Taiwanese women who had quit smoking while pregnant was recruited at 1–3 months following the birth of their infants. Findings: five major themes emerged: (1) the women coping with tobacco addiction on their own, (2) creating a non-smoking section or environment at home, (3) dealing with passive smoking, (4) conflict over the wife's sensitivity to her spouse's residual tobacco smell, and (5) allowing the husband to continue smoking to avoid conflicts. Key conclusions: the pregnant women were expected by their spouses to quit smoking, yet the husbands continued to smoke. Women had to struggle to quit smoking on their own. The findings from this study support the need to listen to pregnant women's stories, as this is paramount to understanding their experiences of tobacco-use reduction and cessation, and for developing gender appropriate interventions to support their efforts. Implications for practice: health care providers should encourage and help pregnant women who are willing to quit smoking. This help could be more family-centred instead of focusing on the pregnant women alone, and therefore involve educating the spouse to support his wife. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Smoking cessation Passive smoking Pregnancy
Introduction Smoking during pregnancy may readily lead to premature birth and the slow growth of the fetus in uterus; the more a pregnant woman smokes, the greater the influence will be (Hammoud et al., 2005; Vardavas et al., 2010). Various studies have shown that half of pregnant women who smoked intended to quit smoking during pregnancy, especially in the first trimester, and that as soon as they found themselves pregnant, they intended to do so. This is
n
Corresponding author. E-mail addresses: [email protected] (C.Y. Wang), [email protected] (H.-T. Li), [email protected] (C.-H. Hsu), [email protected] (Y.-L. Lin), [email protected] (S.-C. Kuo). 0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.10.016
because they wanted the fetus to be healthy and not affected by smoking (Thompson et al., 2004; Näsman and Ortendahl, 2007). In Taiwan, about 4–5% of pregnant women smoke cigarettes, about 60% of the pregnant women's spouses also smoke, and almost all of smoking women's spouses smoke. Even though the women may actively quit smoking during pregnancy, they will still encounter secondary smoke (passive smoking) at home (Shih et al., 2008). If the pregnant woman does not smoke cigarettes herself but is exposed to the surroundings of such secondary smoke, the fetus will be influenced, being smaller than the normal gestation age (SGA) and easily become a low birth weight infant (Hammoud et al., 2005; Aagaard-Tillery et al., 2008). The difficulties confronted by pregnant women intending to quit smoking have been shown to be associated with having spouses who smoke (Ma et al., 2005; Schneider et al., 2010). Also, the strongest
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predictable factor for a pregnant woman who has quit smoking to resume the practice of smoking after birth is that of her spouse smoking (Moffatt and Whip, 2004). For pregnant woman who quits smoking, the symptoms of withdrawal such as unstable emotions, insomnia and thirst will decrease the longer she abstains from smoking. These withdrawal symptoms may be ignored because of the strong nausea and vomiting during the early stage of pregnancy (Thompson et al., 2004). However, when the woman sees her spouse smoking or the cigarettes at home, this could undermine her determination to quit smoking (Tod, 2003; Moffatt and Whip, 2004). On the other hand, the pregnant woman able to quit smoking during pregnancy may encounter her spouse's encouragement and supporting acts and therefore feel she is not alone in facing the challenge of quitting (Koshy et al., 2010). Therefore, when health care providers help a pregnant woman quit smoking, they are advised to invite and teach her spouse to support her. This will lead to a more significant rate of smoking cessation than simply helping only the pregnant woman quit smoking (McBride et al., 2004). Once a pregnant woman quits, she may like to change those situations that might entice her to resume the practice, and she may also expect her spouse to reduce or quit smoking, or at least not to smoke in her presence. However, although the spouse who smokes may expect the pregnant woman to quit smoking, he does not always provide her with real support, or himself quit (Thompson et al., 2004), possibly giving only a verbal promise that remains unfulfilled (Bottorff et al., 2010). Although the husbands may know the expectation of their wives and accept some pressure, they may also think the fetus is protected in the womb and therefore passive smoking should not affect the fetus (Wakefield et al., 1998). When the secondary smoke of the spouse becomes the focus of conflict for the couple, threatening their relationship, the pregnant woman more often than not is faced with great psychological pressure (Bottorff et al., 2006). Accordingly, after the pregnant woman quits smoking, her attitude towards her spouse's smoking may change; she not only has to face her spouse's secondary smoke, but also face a change in the relationship with her husband. In Taiwan, the population of smoking females has gradually increased. Women's smoking rate was 2.3–3.8% between 1986 and1996, which increased to 4.1–5.3% between 1999 and 2007 (Bureau of Health Promotion, 2008); thus, quitting smoking by pregnant women has become an important issue. However, in Taiwanese culture males seldom change their lifestyle or habits for their wives, and this includes few Taiwanese males quitting smoking during their wives' pregnancy (Chen et al., 2002). Given that nearly all spouses of smoking females smoke, it is not surprising that 80% of women continue to smoke during their pregnancy. Those who do quit have a relapse rate of 69.2% after the birth of the first child and 91.7% after the second child within one year after the birth of their child (Shih et al., 2008). In 2004 the Taiwan government began promoting ‘smoke-free families’. According to an evaluation report for this program, the cessation rate for participants one year after joining the program was 21–22%, (Bureau of Health Promotion, 2006). However, there has been no further follow-up evaluation for this program. Although health care providers advise smoking pregnant women to quit, they encounter not only this significant percentage of women who continue to smoke during pregnancy but also neglect the passive smoking that pregnant women have to face after quitting. Those who successfully quit may face their spouses' secondary smoke, and have to avoid or otherwise deal with passive smoking. When their spouses do not accept their advice or requests to quit smoking, they may feel disappointed. Research related to these aspects of quitting is limited. By knowing the pressures and difficulties confronted by pregnant woman in
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having to deal with passive smoking, and helping the pregnant woman herself to quit smoking, we can better know how to reduce those pressures. We can learn how to offer the pregnant woman adequate support and help, and how to develop communication with the spouse to encourage him also to quit or, in the least, to reduce the number of cigarettes smoked. Therefore, the aim of this qualitative research was to explore how pregnant women dealt with their spouses who continued to smoke and with passive smoking during their own process of quitting and abstaining.
Methodology Study design This study used an oral history method to capture personal stories and construct new evidence and avenues for future research. It explored the individual and, thematically, the collective experience of pregnant women who encountered their spouse's secondary smoke, thereby generating evidence where little other documentation exists (Thompson, 2000). We considered oral history as more attuned to compiling short narratives about people and particular events, as in this case (Feldstein, 2004). As a research methodology, it allows the individuals to be central to the empirical data, giving voice to those who have arguably been ignored, marginalised or silenced within particular contexts. As our study was focused on a particular event in the women's lives, with practical implications, rather than a more philosophical understanding of what this meant for them, we opted for oral history rather than a phenomenological approach. Our interview style encouraged the participants to recall and convey their spouses' secondary smoke issues and what it meant to be pregnant and a mother, or how the situation strained relationships, or how it was done and how the participants felt about doing it, etc. Using the oral history approach vis-à-vis two to three times deep interviews provided an opportunity for participants to articulate their own situations and feelings, memories were understood in new ways, and the self story is both confirmed and recreated. This oral history method has been considered appropriate in the verbalisation of different beliefs and particular experiences, allowing for the exploration and elaboration of lives, or aspects of life, in particular (Thompson, 2000; Banks-Wallace, 2002). Ethical considerations This study was approved by the ethics committee of the hospital. Written informed consent was obtained from each participant before the interviews. Confidentiality and the right of refusal at anytime were stressed. The data disclosed in the interviews were confidential. To preserve the participants' anonymity, pseudonyms for all persons were used throughout the research. Participants Inclusion criteria for participation in this research were (1) the female and her spouse were older than 20; (2) each spouse was a current smoker (defined as one who had smoked at least 100 cigarettes in their entire life and was currently smoking every day or some days) (Centre for Disease Control and Prevention USA, 2011); (3) the pregnant woman was in her third trimester, had quit smoking in the first trimester of pregnancy, and had not smoked until after she gave birth; (4) both the pregnant woman and the fetus had no major obstetrical or medical complications according to the antenatal check chart, and had a singleton pregnancy.
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Participants were recruited through an antenatal clinical service in a regional hospital of eastern Taiwan. Women who met the selection criteria were directly approached by the first researcher when they received antenatal health education. Willing participants were asked to sign a letter of consent for the study. Because there were few women who had quit smoking in the first trimester and continued their abstinence until after they had given birth, only a final 10 participants were able to be included in the study. Data collection The semi-structured interviews were conducted by the first author in the participants' homes. A short questionnaire was used to record demographics such as age, marital status, parity, education level, and smoking duration. In consultation with colleagues, the interviewer formulated the guiding questions, and to be as value-free as possible. Although literature was utilised to inform what areas might be covered in the interviews, no specific questions specifically relied on the literature, as it was believed that the questions were more of a guidance than specific, and the method of oral history, like anthropology, lent itself more to exploring issues and asking guiding questions as they arose in each situation, rather than stick to a structured regimen. Also, little literature specifically on this issue provided precise guidance on questions to be asked, and thus we took the opportunity through oral history and guided questions to allow participants to raise issues important to them and perhaps that we had not thought of, which were then developed in subsequent interviews. Using these questions as a base, the interviewer guided the participants to describe their experiences regarding the subject of interest. Commonly, an initial question was, ‘Tell me of your experience when you quit smoking during pregnancy and had to deal with your spouse's secondary smoke.’ Probes such as, ‘How did you set the non-smoking area at home?’ encouraged the participants to add depth in describing their experiences. Investigator field notes were taken during each interview and were included as data in the analysis. All the interviews took place in the absence of the spouse. The interviews were conducted from June 2007 to February 2009. Six participants were interviewed three times, and four were interviewed twice. Each interview took 1.5–2 hours. The interview time was one to three months after the participants had given birth, at which time they had maintained abstinence. However, all of the participants' spouses had continued to smoke. No new themes emerged after 10 participants had been interviewed. These provided sufficient data to account for several aspects of how the pregnant women dealt with their smoking/non-smoking situations. Apart from interviews, we also used observation, field notes, and participant checks to cover a wide variety of situations and narratives. In addition, an acceptable interpretative framework was constructed after the tenth interview. A four-step process was used in this project. First, the 10 participants were interviewed and their responses, in Chinese, tape-recorded. Second, we transcribed the Chinese and typed verbatim drafts from the tapes. Third, we let the participants read and check the meanings from the verbatim drafts, and amended them accordingly. Four, ‘back-translations’ followed, with the Chinese themes being translated back into English by an independent bilingual midwife. The meaning of each translated version was then compared by another bilingual midwife. Results showed high reliability of the translated version. This procedure ensured a semantically and conceptually equivalent translation of the themes. Three Chinese-English bilingual nurse-midwives on the panel committee were involved in reaching final agreement on the translations.
Data analysis After establishing all of the original data, we read each interview to discern the narrative logic of the participants and sort out the life experiences of the participants and the issues for discussion and analysis, keeping in mind during the research process that the women's views and voices should be a priority (Riessman, 1993). We immersed ourselves in the data to understand the participant's point of view from an empathetic rather than a sympathetic position. Next, each transcript was read through again several times with a view to identifying narrative segments and categories within it. As part of this process analytical memos were also made. Following this, preliminary and tentative connections were made to theoretical concepts related to issues emerging within each participant's story. This process, along with the analytical memos, helped shape the questions asked and the themes explored at the next interview as part of a cyclical process. As the interviews progressed and data were accumulated, connections were sought across narrative segments and themes in an attempt to identify patterns and meanings constructed both within and between the stories told by the participants in order to facilitate a comparative analysis of their narrative maps (Thompson, 2000; Miller-Rosser et al., 2009). We then integrated and summarised those stories.
Study rigour Several practices were employed throughout the study that aimed to establish methodological rigour. The qualitative data were analysed by two research members, checking the validation of themes, guided by the data analysis suggestions of Miles and Huberman (1994). Preliminary raw data analysis occurred during data collection. The accuracy of checking the tapes against the transcribed data provided the evolution of themes that were later checked in the process by research members checking the analysis; this provided a validation of themes. Data were extracted as concepts and categories that identified specific experiences. Recurrent experiences were marked through several readings of the material and collected into thematic clusters. A codebook was created so that reliability could be maximised from the researchers' input. The codebook included statements that could be included in identified concepts and categories. The identified and validated categories were then taken to a greater level of abstraction by placing them all on a blackboard for discussion in order to centralise the categories. Weekly research meetings facilitated reflection on the data and enabled discussion of emerging themes arising from the analysis. These formal meetings provided us with opportunities to test the validity of the themes and to reach a consensus. It should also be noted that none of the authors condone smoking, and agree that smoking and passive smoking are harmful to one's own health and also that of an unborn child. The experience of smoking as ‘pleasurable’ is purely the subjective assessment by and responses of the participants. However, the integrity of the participants' perspective was maintained in several ways, to ensure the researchers' view of smoking did not affect our methodology or analysis, and hence validate experiences of the participants. We provided each participant with the opportunity to check and amend her narrative as we transcribed it, and our research group, consisting of experienced nurses, had regular meetings that significantly enhanced our ability to be reflexive about what we were doing when we were in the thick of our research. We reflected on and recorded our interpretations, and were self-conscious and articulate about our role in the research process and outcomes. We listened to the data repeatedly, with a
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focus on meanings, letting the data and the participants speak for themselves, discussing all issues in order to arrive at a consensus.
Findings Ten women were interviewed. The ages of the participants were between 23 and 33 years, and all of them were married. Nine had graduated from senior high school, whereas one was a graduate of junior high school. Seven of the women were pregnant for the first time, whereas three women had borne at least two children. Most of them had begun smoking cigarettes when they were adolescents; only one woman had begun at the age of 10. Their smoking behaviour covered 3—19 years. Half of them had previously tried to quit smoking but failed to do so; three of these had had a previous child, whereas two were first-time mothers. The other five participants had never tried to quit. In this study 10 women quit smoking in their first trimester of pregnancy and continued abstinence until they gave birth. They put in a lot of effort to deal with the problems arising from their spouse's secondary smoke. From their perspective, five major themes emerged from the analysis of interview data. Coping with tobacco addiction on their own When the participants learned that they were pregnant, they decided to quit smoking. All were also asked by their husbands to quit smoking mainly because they did not want the fetus to be harmed. Smoking cigarettes had been the participants' habit for many years, which was developed when they were adolescents. Quitting smoking meant sacrificing a part of their life's pleasure and enduring the withdrawal symptoms of quitting. However, although a child belongs to a couple and it is the couple who are responsible for the child's health, the husband continued to smoke, ignoring not only the psychological struggle of his partner in some cases, but also the effect of passive smoking on an unborn child (Lin, 2009). This situation made some participants feel disheartened: I felt very painful when I saw him smoking cigarettes… Although I was pregnant, I could do nothing about it. Indeed, I was not willing to be pregnant! [because it meant having to quit smoking]. (Mary) This participant felt that this situation was not fair. From the beginning, her husband showed no sympathy for her quitting, and he did not think that he had any responsibilities or obligations. Genny, another participant, said that what made her feel most helpless was that her husband told her that ‘the foetus is in your womb.’ It seemed that the mother was fully responsible for the health of the fetus, which had nothing to do with the father, and that because the fetus was protected by the womb of the mother it would not be affected by passive smoking. Babara said that when she asked her husband not to smoke in the car her husband surprisingly said, ‘Isn't the foetus safe and healthy in your womb?’ This made Babara very angry. She also had to face the struggle and temptation alone while she was quitting, especially in the first week. She had to keep herself from seeing others smoking or keep herself from scenarios that attracted her to smoking. All the expectant fathers wanted their pregnant wives to give up smoking, but they themselves did not stop smoking. The fact that the pregnant women were alone in having to give up the ‘enjoyment’ of smoking cigarettes made them unwilling to do so. Although it was the couple who was responsible for the health of the fetus, it now seemed that it was the pregnant women who were solely responsible, as noted above. Although the husbands felt that the pregnant women were obliged to quit smoking, they
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did not think that passive smoking would harm the fetus or that that it would affect their wives if the men kept smoking. That the wives saw their husbands continue to enjoy the pleasure of smoking and that husbands did not understand the pains the women experienced in quitting made the pregnant women feel isolated and at times angry or depressed. Creating a non-smoking section or environment at home Having quit smoking, the pregnant women used various strategies to limit their desire to smoke and to avoid passive smoking. They would try to keep themselves from smelling cigarette smoke or seeing cigarettes and related paraphernalia, and changed their previous daily routines. The participants initially separated off certain sections at home as non-smoking, limiting the space where their husbands could smoke, or insisted that their husbands go outside to smoke. In the past both wife and husband had smoked cigarettes, so for convenience cigarettes, ashtrays and lighters were available in the bedrooms and elsewhere. Carol, for example, said that she took away the articles for smoking in the bedroom to prevent her from seeing them. Thus she actively changed the arrangements in the bedroom, telling her husband that the re-arrangement was for the purpose of quitting smoking. Certainly this caused inconvenience when her husband wanted to smoke, which helped Carol to achieve another purpose, that of reducing the frequency of her husband's smoking at home: I thought that what I did was for the foetus. And after I quit smoking, I did not want to encounter his smell of cigarettes because when I smelled it, I would like to smoke cigarettes again. (Carol) When the pregnant women used various means to clean and refurbish the bedroom, they had to make their husbands understand that getting rid of the smell of secondary smoke would take a lot of time and energy, and even cost money to replace some of the décor in the bedroom. When the furnishings were changed and all traces of smoking were extinguished, the husbands clearly understood that they were not allowed to smoke in the bedroom. Although the smell could float into the bedroom from other parts of the house, this would be better than smoking in the bedroom. If the couple agreed that smoking was not permitted indoors at all, then all the smoking paraphernalia and some of the furnishings were removed, so that there was nothing that would evoke the women's desire to smoke. This also prevented the pregnant women from being affected by passive smoking indoors. However, for women who lived with parents-in-law and whose father-inlaw smoked, it was difficult to make the house a smoke-free zone. Only five of the couples agreed that smoking was not permitted anywhere in the house, and so the other couples compromised by excluding smoking only from the bedroom. Dona, for example, said that the couple made an agreement that the husband could smoke only outside of the bedroom. Dealing with passive smoking The period of pregnancy is not merely a few days or even weeks, but long months. During this long period the participants had to constantly remind their husbands about passive smoking, which the husbands thought as bothersome. As Babara and Ida put it, ‘This is the privilege of pregnant women, for pregnant women are first!’ Even though their husbands thought them bothersome, as mothers these women defended their position of addressing passive smoking as seriously as possible.
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One month after quitting, most of the participants had no impulse to smoke when they saw their spouses smoking, but even after the first trimester they still did not like to encounter secondary smoke or like the residual smell of smoking left by their husbands. Therefore, the participants would explain the situation to their husbands, letting their husbands know that they were responsible for producing secondary smoke, which was as harmful to the fetus as directly as smoking cigarettes. Sometimes the women escaped from these conditions by going to the bedroom, which was smoke-free. For Carol, Dona, Genny, Jenny and Mary, five participants whose non-smoking section at home was the bedroom only, their husbands had reduced their frequency of smoking in the living room, but had not completely abstained from smoking there. Thus, if these women wanted to totally avoid passive smoking they had to go to the bedroom:
for smoking; however, that smell simultaneously made some of them disgusted and they worried about the health of the fetus. Those wives who had banned smoking in the house commonly asked their husbands not to go into the house immediately after they had smoked, but to wait until the smell had faded. In some cases the husband had to wash his hands, take a shower, or change clothes before he could approach his wife:
He went outside to smoke cigarettes, which showed he was in a good mood. However, he was not always in a good mood. It was me that needed to escape him. And sometimes, when it was cold, he did not want to go outside. Anyway, it depended on his mood. (Genny)
My husband said that I was too sensitive. However, when I smoked before, I did not have the feeling, even not smelling the odour of his body. After I quit smoking, I felt that his smell of cigarettes was very strong and smelly. (Ida)
Although Genny constantly reminded her husband not to smoke wherever and whenever she was present, sometimes her husband would forget, or he would think that as the air outdoors was moving he could still smoke if the wind did not blow towards her. At such times the pregnant woman not only needed to remind her husband in words, but also needed to take some action. Ida, for example, said that she had a close relationship with her husband, telling him many times not to smoke cigarettes in her presence. If her husband did smoke in her presence, she would simply take away his cigarette. Apart from the husband, visiting relatives and friends also smoked cigarettes in the smoking sections of the home. If relatives and friends paid a visit to the home and smoked, then the pregnant woman could do nothing other than leave the scene: They did not care whether I was pregnant or not. So, I had to escape. (Elizabeth) Thus, if a woman encountered her husband smoking in her presence, she would leave the scene or advise their husbands not to smoke. However, dealing with guests at home, or in visiting friends and relatives in their homes, had other, wider, socio-cultural implications. Although the pregnant woman may have been compelled to leave her guests, this in itself may have been considered culturally inappropriate, and thus could put the woman in a dilemma. If, on the other hand, she herself was a guest at another's house, there was little she could do than to try to escape passive smoking. Given that Taiwan society is largely male dominated, as previously noted, and that there are cultural prescriptions about public behaviour, such a dilemma is indicative of how little consideration may be given by men, and others, to (pregnant) women in Taiwanese society. It is thus suggestive that health workers must focus not only on women who are or may become pregnant, but also on her friends and relatives, in addition to their husbands. Conflict over the wife's sensitivity to her spouse's residual tobacco smell For several weeks after the pregnant women quit smoking, they would feel different, physically and psychologically, and slowly they became more capable of controlling the impulse to smoke. However, the participants had not anticipated that their sense of smell would become more acute. Thus, when they could detect the residual smell of their husbands' smoking they would be reminded of the scenarios
When my husband smoked, he would wait outside for a long time. After the smell faded, he could come in. Otherwise, when he came in, I would feel uncomfortable and want to vomit because of the smell of smoking. (Babara) Jenny decided to use her own quilt instead of sharing a quilt with her husband. Ida and Amy mentioned that when they chatted with their husbands, or even when their husbands opened their mouths to breath, the bad odour of their breath was evident:
All participants indicated that they could judge whether their husband had smoked when he came near. Some of the couples had arguments several times because the smell of cigarettes was so strong. Although their husbands' residual smoke odour was obvious, the pregnant women did their best to tolerate it, but only if the smell was not too strong. However, it was difficult to set an objective standard for judging whether or not the odour was smelly. Sometimes the husbands thought there was little or no smell, whereas the pregnant women would feel that the smell was very strong. Under such circumstances arguments between couples could erupt. Allowing the husband to continue smoking to avoid conflicts As mothers, the participants thought that they should never be exposed to passive smoking because of their husbands smoking, and hoped their husbands would also quit. However, as wives, they did not insist that their husbands should not smoke. Firstly, they knew that quitting smoking was not easy, for the process entailed endurance and pain from the withdrawal symptoms. Secondly, the participants felt that forcing their husbands to quit smoking could damage their relationship, and that their husbands had to be willing to quit smoking by themselves. The participants thought that smoking cigarettes was a personal choice, and a way of entertainment and amusement. Although for the expectant mother quitting as soon as possible was paramount for the health of her baby, this immediacy was not the case for her husband to quit smoking. The participants said that their husbands had ‘good’ reasons for smoking, such as that they needed cigarettes to gain ‘inspiration’ while working, and cigarettes were a means and necessity in their social life. Men could not work or make friends without cigarettes. In addition, the participants indicated that their husbands had indulged in smoking longer than them, so quitting smoking would be a difficult process: It's difficult for him to quit smoking. You see, I have had the habit of smoking cigarettes for about three years. Three years is short, but I still had difficulty in quitting smoking. He has had the habit of smoking cigarettes for over ten years. So, quitting smoking must be very difficult for him. (Amy) Dona said: If he wants to quit smoking, he would do that. If he has no intention, it would harm mutual feelings to force him to quit smoking. (Dona)
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The participants thus suggested that cigarettes were a ‘companion’ when their husbands worked or which they enjoyed during entertainment or socialising. Even though they asked their husbands to smoke elsewhere or to quit, they also reflected on how they themselves had been addicted to tobacco, and therefore saw no grounds for strongly pursuing the issue. Thus, in order to maintain harmonious relations, the participants unanimously said that it was up to their husbands as to whether or not they should quit smoking. While the logic of the participants, and also most likely of their husbands, is spurious and stands more as a legitimation, it is what they believed and said, and by which they justified the strategy of allowing husbands to continue smoking. As an aside, it should also be noted that, although the women were concerned about the effects of smoking and passive smoking on the fetus, some of the women participants resumed smoking, and/or perhaps tolerated more pervasive passive smoking, after birth, but failed to acknowledge the health effects of this on the newborn child.
Discussion This study set out to explore how pregnant women in Taiwan dealt with their spouses who continued to smoke and with passive smoking, while they endured their own process of quitting and abstaining from smoking. Several themes emerged, as noted in the results and analysis. Quitting smoking was constructed as part of the process of engaging in motherhood. Their spouses expected the pregnant women to quit smoking, yet the husbands continued to smoke. Women had to struggle to quit smoking on their own, set aside a non-smoking area in the home, and put a lot of effort into avoiding passive smoking and the residual odour of smoking, which could at times create conflict between couples. In addition, in order to avoid any strained relationship with their husbands, the women allowed them to continue smoking. The spouse's encouragement was helpful at times for the pregnant woman's act of quitting smoking; however, several of the participants thought that quitting during pregnancy was to sacrifice their own enjoyment, so at the initial stage of quitting they would tend to smoke cigarettes again when they saw or thought of their spouses smoking cigarettes, as Thompson et al. (2004) and Bailey et al. (2008) also note. Although a woman might like to smoke cigarettes, she also thought that she should quit for the fetus. This unfairness that some pregnant women felt could make them feel isolated. Hence, as the partner's smoking habits have a great effect on the motivation for the woman to change her behaviour, he also should be offered help (McBride et al., 1998). As our findings reveal, similar to the study by Bottorff et al. (2010), the pregnant women tried to control the place and time for their spouses to smoke cigarettes. As the husbands certainly thought that pregnant women should not smoke, they abided by only the minimal rule that bedrooms were non-smoking sections in support of their spouse, but they themselves continued to smoke, as Thompson et al. (2004) also found in their study. In common with other studies (e.g. Lee, 2008; Yang et al., 2010), pregnant women in China who tried to manage their spouses' smoking to protect the fetus' physical development faced great challenges; they imposed various degrees of restrictions on smoking in the home, but few asked family smokers to quit or to reduce their frequency of smoking. Through the experiences of the participants in this study we can see how the women tried hard to avoid or otherwise deal with passive smoking situations every day, for almost nine months. Certainly this would affect the way the couple lived with each other. It was also revealed that husbands did not think that passive smoking would hurt the fetus or their wives, and thus their
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smoking did not matter to the pregnant women, which is consistent with the findings by Wakefield et al. (1998). Despite these conflicting views, the participants expected or at least hoped that their husbands would also quit smoking, but they lacked convincing reasons, and certainly they did not expect that their relationship could be strained by different needs and views. These findings accord with limited studies in other Asian countries. Many Cambodian women had tried to advise or persuade their husbands not to smoke in the home, with very few convincing their husbands to actually quit; men in Vietnam, Malaysia and Indonesia ignored their wives' persuasion to reduce or stop smoking (Efroymson and Velasco, 2007; Nichter et al., 2010). In this study, it was never expected that after a few weeks of quitting the wife might feel very disgusted towards the residual smell of smoking that her spouse left on his clothing and body. This left the husbands very surprised, and they thought that the women were over-reacting. This often became a starting point for conflict between them. The pregnant woman had not anticipated her sense of smell to be so keen, whereas the husband considered the pregnant woman's complaints as verbal attacks, which he defended, and maintained his right to continue smoking, as Bottorff et al. (2006) also found in their study. Another condition which could easily give rise to conflicts occurred whenever the husband smoked in the woman's presence; she would reiterate that she should not experience passive smoking, but if she complained too many times, her spouse would feel that she was very bothersome, as Greaves et al. (2007) similarly reported: although men used power and control to force their partners to stop smoking, they themselves continued and found their wives' complaints unreasonable. However, in our study, the pregnant women worried that to criticise their husbands for their odour would affect mutual feelings of affection, which was a concern that Bottorff et al. (2010) also noted in their study. Bottorff et al. (2006) pointed out that if a pregnant woman expected or asked her spouse to quit smoking, this could spark a conflict between the couple; our study supports this issue of potential conflict amongst couples. This possibility or reality made the women feel lonely and at times helpless. It is therefore of utmost importance that nurses, midwives and doctors are aware of this. In Taiwan society, and which this study confirms, it is a common and traditional idea that a woman who smokes is not a ‘good’ woman (Chang and Wang, 2004). As a mother is expected to make sacrifices for her children, and to ensure the health of the next generation, she is expected to quit smoking during pregnancy. On the other hand, in terms of a man's social life and work, it seems that he cannot help but smoke cigarettes. Although the Tobacco Hazards Prevention Act (2009) suggests that pregnant women should not smoke in Taiwan, it fails to take into account that pregnant women who do quit may be confronted by passive smoking, particularly from their husbands. This information was instrumental in developing more effective measures for helping women who smoked during their pregnancy to quit. However, more attention must be paid to the damaging effects of passive smoking (Chen et al., 2002; Aagaard-Tillery et al., 2008).
Limitations Limitations of this study are acknowledged as focusing on only 10 women from one regional hospital in eastern Taiwan, and that the sample was self-selecting. In view of the socio-cultural influences upon women's smoking behaviour, generalisation to other parts of Taiwan and other countries may, therefore, be limited. We have no information regarding the women who chose not to quit smoking, nor the first-hand views of the women's husbands.
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Also, this study was completed four years ago; since then the Taiwan government has provided a comprehensive support environment to encourage people to quit smoking (Bureau of Health Promotion, 2010). Such a policy might effect a different response if the study were to be conducted today. In addition, conducting an interview one to three months post birth could have resulted in recall bias, although this was somewhat mitigated by conducting several interviews with each participant and providing them with transcripts, which allowed them to reflect on and amend their thoughts and feelings. Although various biases may intrude into interviewing, as a method, we feel confident that, over a period of time and with the building of rapport with participants, much of what was revealed by these women reflected their situation. Although it is always difficult to control for these features of research and bias by both participants and researchers, such as telling and hearing what wants to be said, the consistency across the 10 participants' experiences lends validity to the narrative results (Sarantakos, 1998). Despite these limitations, one of the strengths of this study design was that oral history, as a method, enabled women to talk about the various ways by which they dealt with their spouses' continued smoking, through which they revealed the stress and problems confronted by them in having to deal with passive smoking, as clearly articulated in the results and their quotations. Thus, overall, despite some limitations, certain issues emerged that others may find useful. Implications for practice This study highlights several strategies to address identified issues. First, when a pregnant woman with the habit of smoking cigarettes attends her first antenatal check, she should be afforded help to quit smoking. In addition, if her spouse smokes then health care providers may need to help the pregnant woman address passive smoking. This help could be more family-centred instead of focusing only on the pregnant woman, and therefore involve educating the spouse to support his wife. However, few health care providers currently know how to help the pregnant woman, or her husband, in this endeavour. Implications for research Future research based on our study of women's strategies is warranted. Such research could focus on spousal interactions when a pregnant woman is attempting to quit smoking; moreover, it could consider the development of guidelines and methods for health care providers to support such pregnant women and their spouses. Serendipitously, such research and education may also lead to a lower recidivist rate.
Conclusion Our results support the view that understanding spousal influences on pregnant women's smoking behaviour is necessary to enrich our understanding of their smoking and attempts at quitting, and to provide a foundation for developing interventions. Interventions that aim to encourage expectant fathers' tobacco reduction or cessation have the clear potential to decrease relationship tensions and reduce pressure on pregnant women to be solely responsible for regulating expectant fathers' smoking. Continuing to listen to pregnant women's stories is paramount to understanding their experiences of tobacco cessation, and for developing gender appropriate interventions to support their efforts.
This study therefore represents the perspective of women and a challenge to the development of appropriate health services, which should be needs-oriented, and health promotion campaigns. If we affirm a family-centred philosophy, then antenatal education should include consideration of expectant fathers along with the traditional attention provided to expectant mothers who wish to quit smoking.
Conflict of interest The authors confirm and prove the study without any conflict of interest. There is no funding for this research.
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