Barriers & facilitators to smoking cessation experienced by pregnant women : a qualitative exploration

Allison Ford, Lesley Sinclair, Kathryn Anguson behalf of study team

UKNSCC 12th June 2015

Background & AimsPart of larger study funded by NIHR that aims to:

• Enhance understanding of barriers and facilitators to cessation in pregnancy and after birth from 3 perspectives:

‒ Pregnant women‒ Partners/significant others‒ Health care professionals

• To inform recommendations for practice• Provide foundation for development of proposals for interventions that can be tested in future

Larger Study Components Systematic Reviews

(Qualitative Studies) Exploratory Studies(2 sites)

Pregnant Women

38 studies in 42 papers

Barriers & facilitators not fixed/mutually exclusive

41 women continue to smoke/recently stopped

10 post-partum women  

Partners/Significant Others

9 studies in 14 papers

Perspective of partners under-researched

32 partners/significant others living with pregnant women 

Health Care Professionals

8 studies in 9 papers

Organisational context & lack of knowledge/skills act as barriers

48 health care professionals involved in care of pregnant women

Exploratory Study with Pregnant Women Objectives:

• Identify common barriers and facilitators to smoking cessation in pregnancy• Identify factors that could potentially be incorporated into future interventions 

to aid both uptake of support and cessation 

Recruitment:• Women recruited from 2 NHS sites – 1 in Scotland and 1 in England• Differences in service configuration / recruitment methods between sites • Inclusion criteria: self-reported smoker at maternity booking

Interviews:• Fieldwork conducted Nov-13 to Sep-14 • Face-to-face depth interview in woman’s home - 30 mins to over an hour• Informed consent obtained prior to interview• Ethical approval obtained from NRES

Sample Characteristics

Age Mean (Range)26 (16-42) 

Under 25 yrs44% (18)

25yrs or over56% (23)

Deprivation (IMD) Most Deprived50% (20)

Scottish Site71% (15) 

English Site25% (5)

Gestation Mean (Range)19 weeks (12-29)

Smoking Status Smoking63% (26)

Not Smoking37% (15)

• Scottish site n=21 – all engaged with SSS• English site n=20 – 20% engaged with SSS

Analysis• Framework approach• Social Ecological Model

Social-ecological models

• facilitate ways of understanding individuals in the context of their environment

• typically locate the individual in a set of concentric circles (or layers)

Key features model recognises

• multiple factors that influence behaviour and behaviour change - Individuals and their environments change and both influence each other

• interventions are more likely to be effective if they address multiple layers of the system

Key Findings: Individual Environment Barriers

Facilitators

• Boredom /stress

• Lack of understanding / avoidance of risk

• Self-efficacy – self doubt in quitting ability, lack of willpower and perceived lack of control over smoking

• Sickness during pregnancy

• Perception of risk to baby / own health (live longer)

• Self-efficacy – determination, confidence and willpower to quit, being able to draw on coping strategies when attempting to quit

Key Findings: Interpersonal Environment Barriers

Facilitators

• Continued partner smoking/ attitudes/ double standards

• Impact on relationship – useful tool in maintaining good relationship

• Exposure to other women’s stories and experiences - endorsement that smoking in pregnancy OK

• Lack of pressure/judgement from family (esp. mothers) & friends

• Partners cessation efforts

• Practical & emotional support provided by partners

• Other women’s stories and experiences of smoking in pregnancy can reinforce risks

• Positive responses to women quitting from family i.e. sense of pride

Key Findings: Organisational Environment 1 Barriers

Facilitators

• Lack of cessation support provided by midwives – focus on gathering information on smoking behaviour/referral

• Little detailed risk information delivered by midwives 

• Negative image of SSS either through expectations or previous experience

• Midwives raising the issue at subsequent appointments

• Automatic referral

• Offering flexibility in method of support helps with perceived barriers to attending SSS appointments – level, frequency, home appointments

Key Findings: Organisational Environment 1 Barriers

Facilitators

• Lack of cessation support provided by midwives – focus on gathering information on smoking behaviour/referral

• Little detailed risk information delivered by midwives

• Negative image of SSS either through expectations or previous experience

• Midwives raising the issue at subsequent appointments

• Automatic referral

• Offering flexibility in method of support helps with perceived barriers to attending SSS appointments – level, frequency, home appointments

‘The midwife really didn’t speak to me about like

you know what the smoking can cause and

things like that, it was just … she just mentioned

about the smoking cessation and she asked me if I’d like to take part

and was I interested’ (Site A PW14 NS)

‘Obviously it will harm the baby, but not, that’s all she said

really, it’s obviously harming the baby, she didn’t say nought much else about it’. (Site B

PW11 S)

‘I think I tried to ask questions but she [midwife]

kinda told me that she’s not a specialist… I was just wanting

to know kinda what the damage, what was going to happen if I kept smoking,…

[And] I kinda wanted to know at that stage what [NRT

products] I could use. I did think my midwife would know — whether she’s a smoking

specialist or not — she’d know what was dangerous

and what was’nae dangerous.’ (Site B S)

‘She [midwife] just wanted to get through my notes

and get them filled out, it asks you on the notes if

you smoke and how many a day, and then she went onto if I drank and how

much I drank. She didn’t really stop to talk about

smoking.’ (Site B PW12 NS)

‘Cause I felt like, the midwife, it’s her job, it’s her job more to

give you all the, like all the information about being

healthy while you’re pregnant and all the information that she can about your baby, so it feels more, it’s like, I don’t know, it

feels a bit more acceptable coming from her. ‘Cause she knows what’s she’s talking

about and it’s like, it’s specific to your situation — it feels

more specific’. (Site A PW5 S)

Key Findings: Organisational Environment 1 Barriers

Facilitators

• Lack of cessation support provided by midwives– focus on gathering information on smoking behaviour/referral

• Little detailed risk information delivered by midwives 

• Negative image of SSS either through expectations or previous experience

• Midwives raising the issue at subsequent appointments

• Automatic referral

• Offering flexibility in method of support helps with perceived barriers to attending SSS appointments – level, frequency, home appointments

‘That was the first one [midwife], but then, that was a stand-in and then I had another one the other

day and she never mentioned it either [smoking]… which I thought was quite

strange’ (Site A PW7 S)

‘She did like the first time when I said I was still

smoking she did give me the whole, this is what it can do

and that, but that was it after that, she never kept mentioning it’ (Site B PW7

NS)

Key Findings: Organisational Environment 1 Barriers

Facilitators

• Lack of cessation support provided by midwives – focus on gathering information on smoking behaviour/referral

• Little detailed risk information delivered by midwives 

• Negative image of SSS either through expectations or previous experience

• Midwives raising the issue at subsequent appointments

• Automatic referral

• Offering flexibility in method of support helps with perceived barriers to attending SSS appointments – level, frequency, home appointments

Key Findings: Organisational Environment 1 Barriers

Facilitators

• Lack of cessation support provided by midwives – focus on gathering information on smoking behaviour/referral

• Little detailed risk information delivered by midwives 

• Negative image of SSS either through expectations or previous experience

• Midwives raising the issue at subsequent appointments

• Automatic referral

• Offering flexibility in method of support helps with perceived barriers to attending SSS appointments – level, frequency, home appointments

‘Cause I don’t know because I have heard bad things about them. My mum said they are

more patronising than they are helping so I said well I don’t

really want to do that because if I go somewhere and

someone is saying oh it’s really bad that you smoke and this,

that and the other I will just be like I am not giving up then. If

they are patronising then there is no point even going because

you just, they make you feel like rubbish rather than

supporting you and stuff. (Site B PW17 S)

‘...the woman I saw was a bit rude really, she was a bit

you know ‘do you not think of your unborn child’, and I was like well yes but you know, I am here for help about it, I am not here to feel like crap you know

about it... like God if I didn’t need a cig before you know.

(Site B PW8 S)

Key Findings: Organisational Environment 1 Barriers

Facilitators

• Lack of cessation support provided by midwives – focus on gathering information on smoking behaviour/referral

• Little detailed risk information delivered by midwives 

• Negative image of SSS either through expectations or previous experience

• Midwives raising the issue at subsequent appointments

• Automatic referral

• Offering flexibility in method of support helps with perceived barriers to attending SSS appointments – level, frequency, home appointments

‘I can’t nip out and I can’t…and he [partner, smoker] is the same really. We both work very hard and squeezing a little appointment in is just not possible’ (Site B PW9 S)

Key Findings: Organisational Environment 2 Barriers

Facilitators

• Relationship with midwife, lack of pressure to quit, access SSS, quitting framed as woman’s choice

• Positive relationships with SSS advisors / advisor continuity 

• CO monitoring – indicator of risk, useful for motivation, encouragement, feedback & consideration of passive smoking

‘She [MW] said well we can talk about it again at sixteen weeks when I see her again, and then

nothing else was really said about it. It wasn’t pushed on me or

anything’ (Site B PW4 S)

Key Findings: Organisational Environment 2 Barriers

Facilitators

• Relationship with midwife,           lack of pressure to quit,                                   access SSS,                                                  quitting framed as woman’s choice

• Positive relationships with SSS advisors / advisor continuity 

• CO monitoring – indicator of risk, useful for motivation, encouragement, feedback & consideration of passive smoking

Key Findings: Organisational Environment 2 Barriers

Facilitators

• Relationship with midwife / lack of pressure to quit/access SSS, quitting framed as woman’s choice

• Positive relationships with SSS advisors / advisor continuity

• CO monitoring – indicator of risk, useful for motivation, encouragement, feedback & consideration of passive smoking

‘Oh fantastic, her support’s been really good, you know … it was just the apprehension of thinking ‘Oh, how am I going to do this? … ‘How am I going to stop now?’ and it was just speaking to her, just getting encouragement and stuff, it’s been fantastic. (Site A PW12 NS)

‘She is just always there, you know I can text and I can be open and honest about what my needs are’ (Site A PW18)

Because [name 2] herself had smoked previously and she had stopped and she knew,

she had more of an understanding and because I

would have found it very contradicting if she hadn’t

have smoked and somebody was telling me how bad it

was ... I would have found it very hard if she hadn’t

smoked’ (Site B PW3 NS)

Key Findings: Organisational Environment 2 Barriers

Facilitators

• Relationship with midwife / lack of pressure to quit/access SSS, quitting framed as woman’s choice

• Positive relationships with SSS advisors / advisor continuity 

• CO monitoring – indicator of risk, useful for motivation, encouragement, feedback & consideration of passive smoking

‘I wis’nae thinking about me taking in the fumes, and that kinda upset me a bit’. (Site A

PW11 NS)

‘Actually you’re quite shocked ‘cause it’s got the

foetal thing tae and, ken, so it tells you what a’ the levels

and that are, so that was quite, that was a shock…

(Site A PW11 NS)

Motivation & Feedback

‘And to see the actual difference, to have physical

evidence, I think maybe people would be like ‘wow’. Whereas just now, because you can’t see the damage

that smoking does to you, I think it’s less kind of in your

face’ (Site A PW21 NS)

They told me all the risks, and it just did’nae sink in wi’ the

midwife, it wis’nae until I went wi’ Name 1, and she showed me what carbon

monoxide was in the baby’s lungs, and I was only maybe

nine weeks pregnant then, so he was still, he still needed a’ his crucial things to develop and stuff, I think that’s what made me just realise…, I had my last fag on the Thursday

and that was when I stopped, after I’d been to see Name 1

(Site A PW3 NS)

Repeat testing‘two weeks after I’d quit

smoking I went in to see her again and I did the same test and the result came up as a

zero…. honestly I’ve, I’ve never been that thrilled’ (Site

A PW12 NS)

But see when it goes up it’s horrible, but even if it only goes up a couple, my mum still smokes, so like if she is having a fag I don’t go near

her anymore, but she used to smoke in the house and now

she doesn’t she smokes outside. (Site A P17 NS)

 

Conclusion & Next StepsConclusion• Interventions must take account of interplay between the individual, interpersonal and environmental aspects of women’s lives

Next Steps• Compare and contrast with  partners and healthcare professional findings

• Inform recommendations for practice• Consider development of proposals for interventions that can be tested in future

Project TeamChief Investigator - Professor Linda Bauld

NO CONFLICTS OF INTEREST

THANK-YOU(l.a.sinclair@stir.ac.uk)

Dorothy McCaughan

University of Stirling University of York University of Cambridge

Dr Allison Ford Professor Hilary Graham Dr Felix Naughton

Lesley Sinclair Dr Kate Flemming Sarah Hopewell

Kathyrn Angus Dorothy McCaughan

Jennifer McKell