1. Barriers & facilitators to smoking cessation experienced by pregnant women : a qualitative exploration Allison Ford, Lesley Sinclair, Kathryn Angus on behalf of study team UKNSCC 12th June 2015

2. Background & Aims Part 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

3. 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

4. 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

5. Sample Characteristics Age Mean (Range) 26 (16-42) Under 25 yrs 44% (18) 25yrs or over 56% (23) Deprivation (IMD) Most Deprived 50% (20) Scottish Site 71% (15) English Site 25% (5) GestationMean (Range) 19 weeks (12-29) Smoking StatusSmoking 63% (26) Not Smoking 37% (15) Scottish site n=21 – all engaged with SSS English site n=20 – 20% engaged with SSS

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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)

12. 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

13. 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)

14. 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)

15. 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)

16. 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

17. 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)

18. 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) ‘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) ‘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) 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) 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) 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)

19. Conclusion & Next Steps Conclusion 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

20. Project Team Chief Investigator - Professor Linda Bauld NO CONFLICTS OF INTEREST THANK-YOU (l.a.sinclair@stir.ac.uk) Dorothy McCaughan University of StirlingUniversity of YorkUniversity of Cambridge Dr Allison FordProfessor Hilary GrahamDr Felix Naughton Lesley SinclairDr Kate FlemmingSarah Hopewell Kathyrn AngusDorothy McCaughan Jennifer McKell