Factors That Influence Smoking During Pregnancy: An Integrative Literature Review Victoria Baylis, DePaul University Background Methods Top 5 Factors Appearing Most Frequently in the Literature Cigarette smoking during pregnancy puts both the mother and infant at risk for multiple health conditions including, but not limited to: Infant: clefts of the lip or palate, low birth weight (average of 200 grams less), premature delivery, and sudden infant death syndrome1-5. Mother: risk for abnormal bleeding during pregnancy, complications with the placenta, decrease in fertility, and increased risk of miscarriage4, 6 The risks of maternal smoking are numerous and have been studied for many decades. Despite this, 1 out of every 10 women continues to smoke during pregnancy4. Some studies have recognized high-risk populations, while other studies have investigated relationships between predisposing factors and the risks of smoking. However, there is no single study or literature review that has analyzed and synthesized these findings to fully clarify factors that influence smoking during pregnancy. An integrative literature review was used. A computer-based search was conducted using CINAHL, PsycInfo, and ProQuest Nursing & Allied Health Source. The search retrieved 31 studies that involved expectant mothers and the factors influencing them to smoke.   Key words: expectant mothers, pregnant, health beliefs, maternal attitudes, perceptions, attitude to health, cigarette smoking, and smoking cessation 1 Lack of knowledge about the effects of smoking on the baby 2 Environmental tobacco smoke exposure 3 Environmental and social stressors 4 Lower level of education 5 Lack of support from healthcare professionals   Data Tables Discussion Figure 2: Data Frequency Tables All 49 factors can either be identified by health care providers (in order to refer patient to cessation services), or modified by health care providers in the office. Modifying variables Identifiable: Lower level of education, lower socioeconomic status, status as a single mother Modifiable: Depression Perceived Seriousness Modifiable: Lack of knowledge about the effects of smoking on the baby, incorrect knowledge about the effects of smoking on the baby Perceived Susceptibility Modifiable: Belief that her baby is not susceptible to the effects of smoking, previous child delivered after maternal smoking had no complications, witnessing a smoker with an uncomplicated pregnancy Perceived Barriers Identifiable: Stressors, environmental tobacco smoke exposure, partner/friends/family who smoke, lack of social support, lack of supportive relationship, fear of gaining weight Modifiable: Lack of support from health care providers, lack of knowledge of smoking cessation tools Self-Efficacy Identifiable: Feelings of having poor mental “strength”, lack of belief in her ability to quit, feelings of powerlessness Research Questions & Purpose What contributing factors influence women to smoke during pregnancy? What factors are modifiable by healthcare providers? This literature review acts as an additional resource that health providers may utilize in order to better understand why their patients continue to smoke and to inform their patients regarding smoking cessation during pregnancy. Conceptual Model Figure 1: Health Belief Model Conceptual Map Modifying Variables Perceived Seriousness Perceived Susceptibility Future Research Lack of healthcare provider support was found to be one of the top 5 factors influencing pregnant women to smoke. Research should focus on a tertiary prevention protocol for healthcare providers such as a required smoking cessation educational course for those who deliver preconception, prenatal, and postpartum care to women. A solution for in-office time constraints could be education on how to refer pregnant smokers to local no-cost or low-cost smoking cessation tools and programs. Perceived Threat Results of concepts that were found in the literature 4 or more times were analyzed in the discussion section, with the exception of perceived susceptibility and self-efficacy, where all factors were discussed. Perceived Benefits minus Perceived Barriers Results There were 49 total factors found to influence smoking during pregnancy. The five concepts used to group the data were the following: modifying variables, perceived seriousness, perceived susceptibility, perceived barriers, and self-efficacy. The modifying variables group had 19 factors, perceived seriousness had 6 factors, perceived susceptibility had 3 factors, perceived barriers had 18 factors, and self-efficacy had 3 factors. Cues to Action The Health Belief Model (HMB) was used to guide this literature review. Cues to action, self-efficacy, and modifying variables have been added more recently to the HBM; therefore, self-efficacy is not included on the conceptual map even though it plays a role in the HBM. Acknowledgement Behavior A special thank you to Linda Graf, DNP, CNM, WHNP-C, APN, RN for support and guidance on this literature review. References   1) Centers for Disease Control and Prevention. (2014). Smoking can cause clefts. Retrieved from https://www.cdc.gov/features/cleft-lip-prevention/index.html 2) Benjamin-Garner, R., & Stotts, A. (2013). Impact of smoking exposure change on infant birth weight among a cohort of women in a prenatal smoking cessation study. Nicotine & Tobacco Research, 15(3), 685-692. doi:10.1093/ntr/nts184 3) Children’s Hospital of Philadelphia. (2017). Low birthweight. Retrieved from http://www.chop.edu/conditions-diseases/low-birthweight 4) Centers for Disease Control and Prevention. (2015). Tobacco use and pregnancy. Retrieved from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/tobaccousepregnancy/ 5) Zhang, K., & Wang, X. (2013). Maternal smoking and increased risk of sudden infant death syndrome: A meta-analysis. Legal Medicine, 15(3), 115-121. http://dx.doi.org.ezproxy.depaul.edu/10.1016/j.legalmed.2012.10.007 6) Ye, X., Skjaerven, R., Basso, O., Baird, D. D., Eggesbo, M., Uicab, L. A., . . . Longnecker, M. P. (2010). In utero exposure to tobacco smoke and subsequent reduced fertility in females. Human Reproduction, 25(11), 2901-2906. doi: 10.1093/humrep/deq235 Contact Information: Victoria L. Baylis Mailing Address: 147 E Bagley St., Woodstock, IL 60098 Phone: (815) 404-8577 Email: vlbaylis@gmail.com