Barriers and facilitators to smoking cessation within pregnant Aboriginal and/or Torres Strait Islander women: An integrative review

A comparative analysis of smoking status among the Roma and the general population during pregnancy: The critical role of midwives in smoking cessation

INTRODUCTION

Tobacco consumption poses severe health risks, particularly for pregnant women, where it exacerbates maternal and fetal morbidity and mortality. This issue is especially critical among minority groups such as the Roma, who face unique socio-economic and cultural challenges that contribute to higher smoking rates. This study investigates the smoking behaviors of pregnant Roma women and the general population, highlighting the role of midwives in smoking cessation.

METHODS

The study involved 142 pregnant women, split equally between Roma women from specific regions in Greece and their counterparts from the general population in 2023. We conducted data collection through multiple site visits, utilizing a comprehensive questionnaire that covered aspects like tobacco use, exposure to passive smoking, and the role of midwives. We performed statistical analysis using SPSS, focusing on differences between the two groups using chisquared tests and linear regression analyses.

RESULTS

We noted significant differences between the groups in age, education level, income, and living conditions (p<0.05). The Roma participants displayed a higher prevalence of smoking during pregnancy (76% vs 54.9%, p=0.018). A higher proportion of the Roma group exhibited moderate to high nicotine dependence compared to the non-Roma group, with 27.8% having moderate and 24.1% having high nicotine dependence (p=0.029). The study also found that Roma women are less likely to have structured healthcare support (17.2% had monitoring from a specific doctor compared to 78.9% of non-Roma, p=0.020) and more likely to engage midwives in discussions about smoking cessation (56.5% vs 48.7%, p=0.024).

CONCLUSIONS

The findings emphasize the need for culturally informed healthcare interventions that enhance the training of midwives in smoking cessation techniques. Such approaches are vital for improving health outcomes for pregnant women within marginalized communities like the Roma, where socio-economic and cultural barriers significantly influence health behaviors.

Why women continue to smoke during pregnancy: a qualitative study among smoking pregnant women

Smoking during pregnancy is a serious public health concern due to its adverse consequences on fetal development and pregnant women's health. For the success of smoking cessation interventions, it is essential to determine why pregnant women continue smoking. The objective of this study is to determine the beliefs, attitudes, and barriers to quitting smoking during pregnancy. We adopted a qualitative research design. The participants consisted of 22 pregnant women who smoke, selected by purposive sampling. We collected data through semi-structured interviews and analyzed it using thematic analysis. We identified six themes namely "Reasons for starting to smoke: family and social environment," "Intention to quit smoking and related factors," "Smoking and emotional well-being," "Smoking and stressful life experiences," "Protective thoughts: reducing smoking to safeguard their babies," and "Belief in a healthy pregnancy and inadequate risk perception." Women expressed the desire to protect their fetus from the harm of smoking. However, they continued to smoke due to a lack of knowledge, inadequate risk perception, psychological difficulties, and lack of motivation. Health professionals should be aware of the difficulties experienced by pregnant women who smoke and should support them in quitting smoking.

"It Needs a Full-Time Dedicated Person to Do This Job in Our Local Communities with Our Aboriginal Health Services"-Aboriginal and Torres Strait Islander Health Workers and Practitioners Perspectives on Supporting Smoking Cessation during Pregnancy

BACKGROUND

Aboriginal and Torres Strait Islander women deserve improved smoking cessation support. Aboriginal health workers (AHW) and practitioners (AHP) can be central to the provision of culturally safe smoking cessation care (SCC). The objective of this study is to explore attitudes and the perceived role of AHWs/AHPs toward providing SCC to Aboriginal and Torres Strait Islander pregnant women.

METHOD

A mixed-method study using quantitative and qualitative data was conducted among AHW/AHPs in 2021 across Australia. Descriptive and analytical statistics were used to characterise AHWs'/AHPs' attitudes towards SCC and to evaluate the factors associated with perceptions of who is best placed to provide SCC.

RESULTS

From the total AHW/AHP workforce, 21.2% (223) completed the survey. Less than half (48.4%) believed that AHW/AHP were best placed to provide SCC for pregnant women. The majority believed that group-based supports (82.5%) and cultural support programs (63.7%) were the best strategies to support Aboriginal and Torres Strait Islander pregnant women to quit smoking.

CONCLUSION

This study highlights the need to enhance SCC offered to Aboriginal and Torres Strait Islander pregnant women. A targeted workforce dedicated to smoking cessation should be resourced, including funding, standardised training, and ongoing SCC support tailored to Aboriginal and Torres Strait Islander pregnant women.

Pregnant and postnatal women's experiences of interacting with health care providers about their tobacco smoking: a qualitative systematic review

OBJECTIVE

The objective of this review was twofold: (i) to comprehensively identify the best available evidence about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) concerning health care providers' interactions with them about their smoking, when such interactions occurred during contact for prenatal or postnatal health care in any health care setting; and (ii) to synthesize the research findings for recommendations to strengthen health care providers' interventions regarding smoking during pregnancy and smoking during the postnatal period.

INTRODUCTION

Maternal tobacco smoking during pregnancy and maternal tobacco smoking postnatally pose serious health risks for the woman, fetus, and offspring, whereas maternal smoking cessation has beneficial health effects. Given the importance of health care providers' interactions with pregnant and postnatal women for smoking cessation care, it is essential to understand women's experiences of such interactions.

INCLUSION CRITERIA

Studies considered for this review had qualitative research findings about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) in relation to health care providers' interactions with them about their smoking.

METHODS

The review was conducted using the JBI approach to qualitative systematic reviews. Published studies were sought through 6 academic databases (eg, CINAHL, MEDLINE). Unpublished studies were searched in 6 gray literature sources (eg, ProQuest Dissertations and Theses, Google Scholar). Reference lists of retrieved records were also searched. The searches occurred in October and November 2020; no country, language, or date limits were applied. Study selection involved title and abstract screening, full-text examination, and critical appraisal of all studies that met the inclusion criteria for the review. Study characteristics and research findings were extracted from the included studies. Study selection and extraction of findings were conducted by two reviewers independently; differences between reviewers were resolved through consensus. The research findings were categorized, and the categories were aggregated into a set of synthesized findings. The synthesized finding were assigned confidence scores. The categories and finalized synthesized findings were agreed upon by all reviewers.

RESULTS

The 57 included studies varied in qualitative research designs and in methodological quality (from mostly low to high). There were approximately 1092 eligible participants, and 250 credible and unequivocal research findings. The research findings yielded 14 categories and 6 synthesized findings with low to very low confidence scores. Some women who smoked tobacco during pregnancy and some women who smoked tobacco postnatally lacked supportive interactions by health care providers regarding their smoking; other women experienced supportive interactions by health care providers. Women were adversely impacted when health care providers' interactions lacked supportiveness, and were beneficially impacted when interactions were supportive. Women varied in openness to health care providers' interactions regarding their smoking, from not being receptive to being accepting, and some women wanted meaningful health care provider interactions.

CONCLUSIONS

Although confidence in the synthesized findings is low to very low, the evidence indicates that supportive health care provider interactions may facilitate positive smoking behavior change in pregnancy and postnatally. It is recommended that health care providers implement accepted clinical practice guidelines with women who smoke prenatally or postnatally, using an approach that is person-centered, emotionally supportive, engaging (eg, understanding), and non-authoritarian.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020178866.

Perspectives about smoking cessation during pregnancy and beyond of Aboriginal women in Australia: A qualitative analysis using the COM-B model

OBJECTIVE

Aboriginal and Torres Strait Islander women (hereafter Aboriginal) and their babies experience poor health outcomes for which smoking is a major risk factor. This paper explores Aboriginal women's perspectives on and experiences of smoking cessation, within and outside pregnancy, and their use of smoking cessation services using the COM-B (Capability, Opportunity, Motivation as determinants of Behaviour) model to understand Aboriginal women's capabilities, opportunities, and motivation for smoking cessation.

METHODS

Data came from 11 focus groups conducted in regional New South Wales, Australia, with 80 women aged between 16 and 68 years. Thematic analysis was performed following the COM-B model.

RESULTS

Seven themes related to capability, opportunity, motivation, and smoking cessation behaviors were identified. The themes highlighted that agency, knowledge, and self-efficacy (as capability), a supportive social environment, and access to culturally appropriate services and resources (as opportunities), together with automatic and reflective motivations for quitting, may enable short- or long-term smoking cessation.

CONCLUSION

Smoking cessation interventions may be more effective if the dynamics of the COM-B factors are considered. Policy and practice changes for further enhancing regional Aboriginal women's psychological capability and supportive social environments, and making smoking cessation services culturally appropriate are warranted.

Indigenous Women's Experiences of Smoking and Quitting Smoking in Pregnancy: A Phenomenological Study

BACKGROUND

Maternal smoking during pregnancy (MSDP) is an important public health concern because of potential adverse health effects to the woman, fetus, and child after birth. Prevalence rates are high among groups with socioeconomic disadvantage, including Indigenous women.

PURPOSE

This study was conducted to understand experiences of MSDP for Indigenous women.

METHODS

The study was conducted using phenomenology. Data were collected through interviews with 15 pregnant and postnatal Indigenous women who had smoked during pregnancy. The data were analyzed for themes using phenomenological methods.

RESULTS

The women's narratives revealed four experiences: quitting smoking during pregnancy to protect the unborn baby from harm; quitting smoking during pregnancy because of personal adverse health effects; cutting down smoking during pregnancy and feeling remorse for not quitting; and keeping on smoking during pregnancy and not planning to try to quit. The women's experiences also indicated several impediments to quitting smoking.

CONCLUSIONS

There is need for health care policy to ensure adequate smoking cessation services and support for Indigenous women who smoke in pregnancy. Health care professionals should provide individualized interventions that take into account the challenges to quitting that pregnant women experience and that are in accordance with clinical practice guidelines for MSDP.

Smoking Cessation Messages for Pregnant Aboriginal and Torres Strait Islander Women: A Rapid Review of Peer-Reviewed Literature and Assessment of Research Translation of Media Content

This review summarized literature about knowledge, attitudes, and beliefs of Aboriginal and Torres Strait Islander women from Australia who smoke during pregnancy, then examined the extent that existing health promotion materials and media messages aligned with evidence on smoking cessation for pregnant Aboriginal and Torres Strait Islander women. Knowledge, attitudes, and beliefs of pregnant Aboriginal women who smoke tobacco were identified in the literature. Health promotion campaigns were retrieved from a grey literature search with keywords and social and professional networks. Key themes from peer-reviewed papers were compared against the content of health promotion campaigns using the Aboriginal Social and Emotional Wellbeing Model, the Behavior Change Wheel and thematic analysis. Eleven empirical studies and 17 campaigns were included. Empirical studies highlighted women sought holistic care that incorporated nicotine replacement therapy, engaged with their family and community and the potential for education about smoking cessation to empower a woman. Health promotion campaigns had a strong focus on 'engagement with family and community', 'knowledge of risks of smoking,' 'giving up vs cutting down' and 'culture in language and arts'. There were similarities and variances in the key themes in the research evidence and promotion materials. Topics highly aligned included risks from smoking and quitting related issues.

Socioecological Mapping of Barriers and Enablers to Smoking Cessation in Indigenous Australian Women During Pregnancy and Postpartum: A Systematic Review

BACKGROUND

With a high prevalence of smoking during pregnancy and limited Indigenous-specific evidence for treatment, we used socioecological mapping to identify multilevel barriers and enablers to smoking cessation related to Indigenous Australian pregnant and postpartum women.

METHODS

Nine electronic databases were searched. Original studies except interventions and trials, published in English, up to February 29, 2020 were included. Studies were appraised using the QualSyst tool. Evidence was narratively synthesized. The review protocol was registered with PROSPERO (CRD42019135543).

RESULTS

A total of 15 studies (10 quantitative, 5 qualitative) were included, covering 1306 women, 3 partners/family members, 234 health professionals (HP), and 2755 patient records. Complex and overlapping barriers were identified at individual, family, community, societal, and system levels. Socioeconomic disadvantages, inequality, and pervasive racism as legacies of colonization, combined with personal, family, and community circumstances intensified individual experiences of stress, which may be heightened during pregnancy. Inadequate smoking cessation care (SCC), inconsistent antitobacco messages, and ineffectual HP interventions underscore a need for service enhancement and further evidence to develop culturally relevant messages. High motivation of pregnant women to quit, resilience, and supports available in the family and community are strengths that warrant attention in future interventions.

CONCLUSIONS

SCC without ameliorating the social disadvantages and the disparities in health determinants between Indigenous and non-Indigenous Australian women may limit the effectiveness of SCC. A comprehensive approach is required that includes policy changes for addressing external stressors the women experience, engagement of family and community, and better training of HP and provision of free pharmacotherapy.

IMPLICATIONS

To systematically address barriers to smoking cessation at multiple levels, initiatives to ameliorate social disadvantages and discrepancies in social determinants of health between Indigenous and non-Indigenous Australians are required to be taken in tandem with SCC. Initiatives may include making relevant policy changes and allocating more resources for education, employment, housing, and community development. Enhancement of knowledge, skills, and confidence of HP regarding the provision of high-quality SCC for Indigenous women and their families is warranted. Future interventions may build on high motivation, resilience, and strengths of individual women, and incorporate support strategies engaging family and community.

The needs of women and their partners regarding professional smoking cessation support during pregnancy: A qualitative study

BACKGROUND

Despite the health risks of smoking, some women continue during pregnancy. Professional smoking cessation support has shown to be effective in increasing the proportion of pregnant women who quit smoking. However, few women actually make use of professional support.

AIM

To investigate the needs of women and their partners for professional smoking cessation support during pregnancy.

METHODS

Semi-structured interviews were held with pregnant women and women who recently gave birth who smoked or quit smoking during pregnancy, and their partners, living in the north of the Netherlands. Recruitment was done via Facebook, LinkedIn, food banks, baby stores and healthcare professionals. The interviews were recorded, transcribed and thematically analysed.

RESULTS

28 interviews were conducted, 23 with pregnant women and women who recently gave birth, and five with partners of the women. The following themes were identified: 1) understanding women's needs, 2) responsibility without criticism, and 3) women and their social network. These themes reflect that women need support from an involved and understanding healthcare professional, who holds women responsible for smoking cessation but refrains from criticism. Women also prefer involvement of their social network in the professional support.

CONCLUSION

For tailored support, the Dutch guideline for professional smoking cessation support may need some adaptations. The adaptations and recommendations, e.g. to involve women and their partners in the development of guidelines, might also be valuable for other countries. Women prefer healthcare professionals to address smoking cessation in a neutral way and to respect their autonomy in the decision to stop smoking.

Pregnant and postnatal women's experiences of interacting with health care providers about their tobacco smoking: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to comprehensively identify and synthesize the best available evidence about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) concerning their health care providers' interactions with them about their smoking.

INTRODUCTION

Smoking tobacco during pregnancy and postnatally continue to be important global public health challenges. Maternal smoking poses risks to the woman's general health and causes pregnancy complications and serious adverse health effects for the fetus and child. Hence, it is essential that health care providers support pregnant and postnatal women to achieve smoking cessation and not relapse. Learning about these women's experiences of health care provider interactions may inform recommendations for health care provider best practice in interpersonal approach.

INCLUSION CRITERIA

The participants of interest are women who smoked tobacco during pregnancy, the postnatal period, or both, with the phenomenon of interest being their experiences of health care provider interactions with them about their smoking. The context is any setting globally. Studies for consideration will have qualitative data, including any mixed methods studies.

METHODS

This qualitative systematic review will be conducted according to JBI methodology. Databases to be searched for published studies include CINAHL, PubMed, APA PsycINFO, Embase, Sociological Abstracts, and SocINDEX. Gray literature will be searched for unpublished studies. The authors will conduct an initial screening and then a full-text review of studies for congruence with the inclusion criteria. A critical appraisal will be performed on eligible studies and data will be extracted from included studies. Meta-aggregation will be used to yield synthesized findings, which will be assigned confidence scores.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020178866.

"They Were Willing to Work with Me and Not Pressure Me": A Qualitative Investigation into the Features of Value of a Smoking Cessation in Pregnancy Program for Aboriginal and Torres Strait Islander Women

With tobacco commonly used for stress relief, smoking cessation during pregnancy can present challenges for women facing stressful circumstances. This can be pronounced for Aboriginal and Torres Strait Islander women who experience disproportionately high smoking rates during pregnancy and also have a greater intersection of stressors from social disadvantage, institutional racism and trauma. To contribute understandings into how women can be best supported at this time, this study identified the features of value of an Aboriginal and Torres Strait Islander pregnancy smoking cessation program that addressed the contexts of women's lives in culturally affirming and strength-based ways. A narrative methodology using a yarning approach was used to interview 7 pregnant women, 6 significant others, 3 case managers, and 4 healthcare professionals. Data were analyzed using thematic analysis, guided by an Indigenist research practice of deep and reflexive researcher listening. Features of value included: relationship-based care, holistic wraparound care, flexibility, individualized care, and culturally orientated care. Combined, they enabled highly relevant and responsive women-centered, trauma-informed, and harm-reducing smoking cessation support that was well received by participants, who achieved promising smoking changes, including cessation. This approach strongly departs from standard practices and provides a blueprint for meaningful support for pregnant women experiencing vulnerabilities.

Addressing stillbirth inequities in Australia: Steps towards a better future

Persistent disparities in stillbirth risk and care are present in Australia. Eliminating these disparities is possible with a commitment to enhancing and scaling up models of culturally safe maternity care shown to be effective for Aboriginal and Torres Strait Islander women and those of migrant and refugee backgrounds. Campaigns to improve public awareness of stillbirth also play an important role in reducing stillbirth risk and consequences. To achieve reach and impact in communities at risk, messaging needs to be framed around the social and cultural context of women's lives. Here we describe important initiatives underway within the Stillbirth Centre of Research Excellence to develop a coordinated national approach to stillbirth prevention and care in communities that bear a disproportionate burden of stillbirth.

Pregnant Aboriginal women self-assess health risks from smoking and efficacy to quit over time using an adapted Risk Behaviour Diagnosis (RBD) Scale

Introduction

During pregnancy, the imperative to stop smoking becomes urgent due to health risks for mother and baby.

Aim

Explore responses to a smoking-related, pregnancy-focused Risk Behaviour Diagnosis (RBD) Scale over time with Aboriginal1 pregnant women.

Methods

Six Aboriginal Medical Services in three states recruited 22 eligible women: ⩽28 weeks' gestation, ⩾16 years old, smoked tobacco, pregnant with an Aboriginal baby. Surveys were completed at baseline (n = 22), 4-weeks (n = 16) and 12-weeks (n = 17). RBD Scale outcome measures included: perceived threat (susceptibility and severity), perceived efficacy (response and self-efficacy), fear control (avoidance), danger control (intentions to quit) and protection responses (protecting babies).

Results

At baseline, the total mean threat scores at 4.2 (95% CI: 3.9–4.4) were higher than total mean efficacy scores at 3.9 (95% CI: 3.6–4.1). Over time there was a non-significant reduction in total mean threat and efficacy; fear control increased; danger control and protection responses remained stable. Reduction of threat and efficacy perceptions, with raised fear control responses, may indicate a blunting effect (a coping style which involves avoidance of risks).

Conclusion

In 22 Aboriginal pregnant women, risk perception changed over time. A larger study is warranted to understand how Aboriginal women perceive smoking risks as the pregnancy progresses so that health messages are delivered accordingly.

General practitioner and obstetrician views on system changes to improve smoking cessation care in pregnancy in Australia: a cross-sectional survey

Introduction

Systemic barriers impacting smoking cessation in pregnant women may include nicotine replacement therapy (NRT) access and training.

Aim

Assess general practitioner (GP) and obstetrician's agreement with system-based changes to improve the management of smoking in pregnancy; compare group responses.

Methods

National cross-sectional survey with two samples: (1) online survey emailed to a random sample of 500 GPs from Royal Australian College of General Practitioners (RACGP); (2) paper survey posted to 5571 GPs and obstetricians from Royal Australia and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Percentages agreeing that specified changes would improve the management of smoking in pregnancy were calculated. Pairwise comparisons used Kruskal–Wallis tests (RACGP/RANZCOG GPs/obstetricians).

Results

N = 378 participated. Response rates 8.4% (N = 42; online survey) and 6% (N = 335; paper survey), respectively. Total percentages agreeing with system-based changes: 79% training, 64% oral NRT subsidy, 62% Medicare item for smoking cessation, 54% improved access to NRT patches. Within RANZCOG, more GPs (73.1%) agreed that oral NRT should be subsidised (P = 0.001) than obstetricians (53.7%).

Conclusion

GPs and obstetricians agreed that system changes would improve their management of smoking in pregnancy. Oral NRT subsidy was the only pairwise group difference. Subsequently, oral NRT has been subsidised; in time, this may influence prescribing and quit rates.

Exposure to Tobacco, Environmental Tobacco Smoke and Nicotine in Pregnancy: A Pragmatic Overview of Reviews of Maternal and Child Outcomes, Effectiveness of Interventions and Barriers and Facilitators to Quitting

The aim of this review of reviews was to collate the latest evidence from systematic reviews about the maternal and child health outcomes of being exposed to tobacco and nicotine during pregnancy; the effectiveness of interventions designed to reduce these exposures, and barriers to and facilitators of smoking cessation during pregnancy. Two databases were searched to obtain systematic reviews published from 2010 to 2019. Pertinent data from 76 articles were summarized using a narrative synthesis (PROSPERO reference: CRD42018085896). Exposure to smoke or tobacco in other forms during pregnancy is associated with an increased risk of obstetric complications and adverse health outcomes for children exposed in-utero. Counselling interventions are modestly effective, while incentive-based interventions appear to substantially increase smoking cessation. Nicotine replacement therapy is effective during pregnancy but the evidence is not conclusive. Predictors and barriers to smoking cessation in pregnancy are also discussed. Smoking during pregnancy poses substantial risk to mother's and child's health. Psychosocial interventions and nicotine replacement therapy (NRT) appear to be effective in helping pregnant women quit smoking. Barriers to smoking cessation must be identified and steps taken to eradicate them in order to reduce smoking among pregnant women. More research is needed on smoking cessation medications and e-cigarettes.