CE: Original Research: The Experiences of Pregnant Smokers and Their Providers

Cigarette Smoking Cessation Counselling in Pregnant Smokers with Mental Illness/Substance Use Disorders

Our objective was to determine if past-year mental illness and substance use disorders (SUD) among pregnant smokers predicted the probability of receipt of counselling for cigarette smoking cessation. A secondary analysis of data from the National Survey on Drug Use and Health 2016-2019 was conducted. We found that approximately 83% of pregnant smokers (N = 373) received screening for cigarette smoking, and 65% received cessation counselling. Having mental illness predicted the probability of receipt of counselling for smoking cessation in pregnant smokers (adjusted odds ratio [AOR]: 3.75; 95% confidence interval [CI]: 1.25-11.27). However, having SUD (alcohol [AOR: 2.30; 95%CI: 0.57-9.26] or illicit drug use [AOR: 1.32; 95%CI: 0.26-6.82]) or comorbid mental illness and SUD (AOR: 0.23; 95%CI: 0.03-2.03) was not associated with receipt of counselling for smoking cessation. Practice guidelines and policy initiatives are needed to reduce cigarette use and its related adverse health outcomes in pregnant smokers with SUD.

Smoking cessation care during pregnancy: A qualitative exploration of midwives' challenging role

PROBLEM

The majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas.

BACKGROUND

Understanding challenges in midwives' provision of smoking cessation care can elucidate opportunities to facilitate women's smoking cessation.

AIM

We aimed to understand midwives' perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care.

METHODS

An exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups.

FINDINGS

Four themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives' ability to provide smoking cessation care.

DISCUSSION

A combination of interpersonal, organisational and individual barriers impeded on midwives' capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife's role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care.

CONCLUSION

Providing midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines.

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.

The Development and Testing of a Perinatal Tobacco Attitudes and Behaviors Survey

Background and Purpose: Accurate assessment of tobacco use in pregnant smokers is key to effective nursing intervention. There is a lack of valid and reliable tools easily integrated into prenatal care. Therefore, the purpose of this study was to develop and test a perinatal survey, guided by the Health Promotion Model (HPM). Methods: The survey was tested with 107 pregnant women via iPad. Urine cotinine assays and a process evaluation were conducted. Results: Reliability yielded a Cronbach's alpha of .873 for the ever-smoker sample and .835 for the total sample. Factors dovetailed with HPM constructs. Conclusions: Perinatal Tobacco Attitudes and Behaviors Survey (PTABS) exhibits high reliability and validity and is easily utilized. Updates need to include questions on all nicotine products and to be streamlined. With accurate identification of nicotine users nurses can provide targeted interventions early in pregnancy.

Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies

Background

Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework.

Methods

A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW’s and HPs’ quotes, as well as the authors’ analysis, were extracted and double-coded (30%) using the COM-B framework.

Results

Thirty-two studies included research from 5 continents: twelve on HPs’ perspectives, 16 on PW’s perspectives, four papers included both. HPs’ capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women’s psychological state (capability) and stressors into consideration. Pregnant women’s physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women’s motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement.

Conclusions

HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs’ and PW’s attitudes and supportive campaigns for pregnant smokers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03773-x.

Facilitators and barriers to substance-free pregnancies in high-income countries: A meta-synthesis of qualitative research

BACKGROUND

Previous studies have associated substance use (alcohol, illicit drugs and smoking) to negative pregnancy outcomes, including higher risk of stillbirth.

AIM

This study aims to identify facilitators and barriers reported by women to remain substance free during pregnancy.

METHODS

A systematic search was conducted in six databases from inception to March 2019 and updated in November 2020. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women's experiences of substance use during pregnancy were eligible. Meta-ethnography was used to facilitate this meta-synthesis.

FINDINGS

Twenty-two studies were included for analysis. Internal barriers included the perceived emotional and social benefits of using substances such as stress coping, and the associated feelings of shame and guilt. Finding insensitive professionals, the lack of information and discussion about risks, and lack of social support were identified as external barriers. Furthermore, the social stigma and fear of prosecution associated with substance use led some women to conceal their use. Facilitators included awareness of the health risks of substance use, having intrinsic incentives and finding support in family, friends and professionals.

DISCUSSION

Perceived benefits, knowledge, experiences in health care settings, and social factors all play important roles in women's behaviours. These factors can co-occur and must be considered together to be able to understand the complexity of prenatal substance use.

CONCLUSION

Increased clinical and community awareness of the modifiable risk factors associated with substance use during pregnancy presented in this study, is necessary to inform future prevention efforts.

Challenges Experienced by Women Who Smoke During Pregnancy or Postnatally

Maternal smoking during pregnancy and maternal smoking postnatally are important public health concerns worldwide. Smoking adversely affects the woman's general health and is causally related to pregnancy complications and serious health outcomes for the child, such as stillbirth, preterm delivery, low birth weight, and sudden infant death. The purpose of this research was to examine maternal smoking through a quantitative descriptive survey of 164 women, 120 who were pregnant and 44 who were postnatal. Women experienced barriers to quitting smoking, including dealing with stress, being exposed to smokers, not being ready to quit, not knowing how to quit, not looking for or not being able to find information about smoking or quitting smoking, and lacking adequate social and healthcare provider support. On the other hand, women revealed characteristics that suggest they might have had improved potential for quitting smoking, including having negative feelings about smoking, having cut down on smoking, smoking at a low level, having made quit attempts, thinking it would not be hard to quit smoking, being in the preparation stage of behavioral change, and thinking their healthcare providers (HCPs) would help them if they decided to quit. Taken together, those findings suggest that HCPs could offer important assistance to help women achieve smoking cessation. However, more research needs to be conducted to clarify the role and effectiveness of various HCPs in smoking cessation interventions and to identify measures to strengthen their provision of such interventions.

Factors influencing the uptake and use of nicotine replacement therapy and e-cigarettes in pregnant women who smoke: a qualitative evidence synthesis

BACKGROUND

Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non-pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e-cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e-cigarettes in pregnancy are unknown.

OBJECTIVES

To explore factors affecting uptake and use of NRT and e-cigarettes in pregnancy.

SEARCH METHODS

We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies.

SELECTION CRITERIA

We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e-cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy.

DATA COLLECTION AND ANALYSIS

We identified determinants of uptake and use of NRT/e-cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review.

MAIN RESULTS

We included 21 studies: 15 focused on NRT, 3 on e-cigarettes, and 3 on both. Studies took place in five high-income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e-cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e-cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e-cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e-cigarettes; when health professionals tell women that NRT or e-cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e-cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e-cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e-cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e-cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues.

AUTHORS' CONCLUSIONS

Consistent messages from health professionals, based on high-quality evidence and clearly explaining the safety of NRT and e-cigarettes compared to smoking in pregnancy, could help women use NRT and e-cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e-cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke-free.

Smoking cessation in pregnancy: An update for maternity care practitioners

INTRODUCTION

This paper provides an up-to-date summary of the effects of smoking in pregnancy as well as challenges and best practices for supporting smoking cessation in maternity care settings.

METHODS

We conducted a qualitative review of published peer reviewed and grey literature.

RESULTS

There is strong evidence of the effects of maternal tobacco use and secondhand smoke exposure on adverse pregnancy outcomes. Tobacco use is the leading preventable cause of miscarriage, stillbirth and neonatal deaths, and evidence has shown that health effects extend into childhood. Women who smoke should be supported with quitting as early as possible in pregnancy and there are benefits of quitting before the 15th week of pregnancy. There are a variety of factors that are associated with tobacco use in pregnancy (socioeconomic status, nicotine addiction, unsupportive partner, stress, mental health illness etc.). Clinical-trial evidence has found counseling, when delivered in sufficient intensity, significantly increases cessation rates among pregnant women. There is evidence that the use of nicotine replacement therapy (NRT) may increase cessation rates, and, relative to continued smoking, the use of NRT is considered safer than continued smoking. The majority of women who smoke during pregnancy will require support throughout their pregnancy, delivered either by a trained maternity care provider or via referral to a specialized hospital or community quit-smoking service. The 5As (Ask, Advise, Assess, Assist, Arrange) approach is recommended for organizing screening and treatment in maternity care settings. Additionally, supporting smoking cessation in the postpartum period should also be a priority as relapse rates are high.

CONCLUSIONS

There have been several recent updates to clinical practice regarding the treatment of tobacco use in pregnancy. It is important for the latest guidance to be put into practice, in all maternity care settings, in order to decrease rates of smoking in pregnancy and improve pregnancy outcomes.