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
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
Larger Study Components
Pregnant
Women
Partners/
Significant
Others
Health Care
Professionals
Systematic Reviews
(Qualitative Studies)
Exploratory Studies
(2 sites)
38 studies in 42 papers
41 women continue to
smoke/recently stopped
Barriers & facilitators not
fixed/mutually exclusive
9 studies in 14 papers
Perspective of partners
under-researched
8 studies in 9 papers
Organisational context &
lack of knowledge/skills
act as barriers
10 post-partum women
32 partners/significant others
living with pregnant women
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
• Scottish site n=21 – all engaged with SSS
• English site n=20 – 20% engaged with SSS
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)
Gestation
Smoking Status
Mean (Range)
19 weeks (12-29)
Smoking
63% (26)
Not Smoking
37% (15)
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
• Sickness during pregnancy
• Lack of understanding /
avoidance of risk
• Perception of risk to baby / own
health (live longer)
• Self-efficacy – self doubt in
quitting ability, lack of
willpower and perceived lack
of control over smoking
• Self-efficacy – determination,
confidence and willpower to quit,
being able to draw on coping
strategies when attempting to quit
Key Findings: Interpersonal Environment
Barriers
• Continued partner smoking/
attitudes/ double standards
• Impact on relationship – useful tool
in maintaining good relationship
Facilitators
• Partners cessation efforts
• Practical & emotional support
provided by partners
• Other women’s stories and
• Exposure to other women’s stories
experiences of smoking in
and experiences - endorsement that pregnancy can reinforce risks
smoking in pregnancy OK
• Positive responses to women
quitting from family i.e. sense of
• Lack of pressure/judgement from
pride
family (esp. mothers) & friends
Key Findings: Organisational Environment 1
Barriers
Facilitators
• Lack of cessation support provided
by midwives – focus on gathering
information on smoking
behaviour/referral
• Midwives raising the issue at
subsequent appointments
• Little detailed risk information
delivered by midwives
• Offering flexibility in method of
support helps with perceived
barriers to attending SSS
appointments – level, frequency,
home appointments
• Negative image of SSS either
through expectations or previous
experience
• Automatic referral
Key Findings: Organisational Environment 1
Barriers
Facilitators
• Lack of cessation support provided • Midwives raising the issue at
by midwives – focus on gathering
subsequent appointments
‘I smoking
think
Imidwife
felt
I tried
like,really
to
theask
midwife,
questions
her
she
job,about
[midwife]
it’smyher job
‘The
didn’t
speak
tothrough
me
‘She
[midwife]
just
wanted
toit’s
getbut
information‘Cause
on
‘Obviously
itall
willthe,
harm
the
baby,
butreferral
not, I was
more
kinda
to
give
told
you
me
that
she’s
like
not
all
a
the
specialist…
information
behaviour/referral
•
Automatic
likeand
you get
know
what
theout,
smoking
notes
them
filled
it askscan
youcause
on theabout
that’s
all to
shewhile
said you’re
really,what
it’s obviously
just
being
wanting
healthy
know
kinda
pregnant
theashe
damage,
and
all the
what
and
things
like
that,
it
was
just …
just
notes if you smoke and how many
day,
and
harming
thehappen
baby,
she
didn’t
say flexibility
noughtso[And]
• Little detailed
risk
information
•kept
Offering
infeels
method
of
information
was
going
to
that
she
can
if
I
about
smoking,…
your
baby,
it
I
mentioned
about
the
smoking
cessation
and
she went onto if I drank
and how
much
delivered by then
midwives
support
helps
withI perceived
much
else
about
it’.
(Site
B
PW11
S)
more,
kinda
it’s
wanted
I don’t
know
know,
attake
thatitto
stage
feels
what
aattending
bit
more
she
asked
melike,
if to
I’d
like
to
part
and
was[NRT
I SSS
drank.
She
didn’t
really
stop
talk
about
barriers
to
acceptable
products]
coming
I could
from
use.
her.
did
‘Cause
think
shemyknows
midwife
what’s
(Site
PW14
smoking.’
(Site
BAIPW12
NS)
• Negative image
of SSSinterested’
either
appointments
– level,
frequency,
she’s
wouldtalking
know
about
— whether
and it’s
she’s
like,a it’s
smoking
specific
specialist
to your
through expectations
or previous
home
appointments
experience situation
or not —
— she’d
it feelsknow
morewhat
specific’.
was dangerous
(Site A PW5
andS)
what was’nae dangerous.’ (Site B S)
Key Findings: Organisational Environment 1
Barriers
Facilitators
• Lack of cessation support provided • Midwives raising the issue at
by midwives– focus on gathering
subsequent appointments
information on smoking
behaviour/referral
Automaticbut
referral
‘That was the first one •[midwife],
then,
‘She did like the first time when I said I was still
that was a stand-in and then I had another
smoking
she did give me the
whole, this
is whatinitmethod of
• Little detailed
risk information
• Offering
flexibility
one the other day and shesupport
never mentioned
it
delivered by midwives
helps
can do and that, but that was
it after
that,with
she perceived
either [smoking]… which I thought
was
attending
never kept mentioning it’barriers
(Site B to
PW7
NS) SSS
strange’ (Siteappointments
A PW7 S) – level, frequency,
• Negative image of SSSquite
either
through expectations or previous
experience
home appointments
Key Findings: Organisational Environment 1
Barriers
Facilitators
• Lack of cessation support provided
by midwives – focus on gathering
information on smoking
behaviour/referral
• Midwives raising the issue at
subsequent appointments
• Little detailed risk information
delivered by midwives
• Offering flexibility in method of
support helps with perceived
barriers to attending SSS
appointments – level, frequency,
home appointments
• Negative image of SSS either
through expectations or previous
experience
• Automatic referral
Key Findings: Organisational Environment 1
Barriers
Facilitators
‘Cause I don’t know because I have heard bad things
• Lack of cessation support provided • Midwives raising the issue at
about
them.
mum
are
more
patronising
‘...the
woman
I sawsaid
wasthey
a bit
rude
really,
she was
by midwives
– focus
onMy
gathering
subsequent
appointments
they
helping
so Inot
said
wellofI don’t
really
informationthan
on
smoking
a bit
youare
know
‘do you
think
your unborn
want toand
do that
gobut
somewhere
and
behaviour/referral
Automatic
referral
child’,
I wasbecause
like wellif• Iyes
you know,
I am
someone
is saying
oh it’s
badhere
that toyou
here for
help about
it, really
I am not
feelsmoke
like
• Little detailed
risk
information
•
Offering
flexibility
innot
method of
andcrap
this,you
thatknow
and the
other
I
will
just
be
like
I
am
about it... like
God ifhelps
I didn’t
need
delivered by midwives
support
with
perceived
giving upa cig
then.
If they
patronising
then
there
before
youare
know.
(Site BtoPW8
S) isSSS
barriers
attending
no point
going because you
just, they make
you frequency,
• Negative image
of even
SSS either
appointments
– level,
feel like rubbish
rather than supporting
you and stuff.
through expectations
or previous
home appointments
experience
(Site B PW17 S)
Key Findings: Organisational Environment 1
Barriers
Facilitators
• Lack of cessation support provided • Midwives raising the issue at
by midwives – focus on gathering
subsequent appointments
information on
smoking
‘I can’t
nip out and I can’t…and he [partner,
behaviour/referral
• Automatic referral
smoker] is the same really. We both work very
squeezing a little• appointment
in is just
• Little detailedhard
riskand
information
Offering flexibility
in method of
delivered by not
midwives
possible’ (Site B PW9 S)support helps with perceived
• Negative image of SSS either
through expectations or previous
experience
barriers to attending SSS
appointments – level, frequency,
home appointments
Key Findings: Organisational Environment 2
Barriers
Facilitators
• Relationship with midwife,
• Positive relationships with SSS
lack of pressure to quit,
advisors / advisor continuity
access SSS,
‘She [MW] said well we can talk about it again at
quitting framed as woman’s choice
sixteen weeks when I see•her
and then
nothing of risk,
COagain,
monitoring
– indicator
for motivation,
else was really said aboutuseful
it. It wasn’t
pushed on me
encouragement,
or anything’ (Site
B PW4 S) feedback &
consideration of passive smoking
Key Findings: Organisational Environment 2
Barriers
• Relationship with midwife,
lack of pressure to quit,
access SSS,
quitting framed as woman’s choice
Facilitators
• 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 • Positive relationships with SSS
pressure to quit/access
SSS, 2] herself had
advisors
/ advisor
continuity
Because [name
smoked
previously
quitting framed
as
woman’s
choice
and
shefantastic,
had stopped
and she knew,
she had
more
‘Oh
her
support’s
been really
good,
ofyou
anknow
understanding
and•the
because
I would–have
… it was just
of
COapprehension
monitoring
indicator of risk,
‘She is just always there,
you
know I can
found
it very
if she
hadn’t
thinking
‘Oh,contradicting
how am I going
tofor
do
this?have
…
useful
motivation,
text and I can be open encouragement,
and honest aboutfeedback &
smoked
andI somebody
wasnow?’
tellingand
me ithow
‘How am
going to stop
wasbad
justit
what my needs are’ (Site
A PW18) of passive smoking
consideration
was
... I would
found
itencouragement
very hard if she
speaking
to her,have
just getting
hadn’t
(Site B (Site
PW3ANS)
and stuff,
it’ssmoked’
been fantastic.
PW12 NS)
Key Findings: Organisational Environment 2
Barriers
Motivation & Feedback
Facilitators
They told me all the risks, and it just did’nae sink in
Repeat
to see the/ actual
to relationships
have physicalwith SSS
• Relationship ‘And
with midwife
lack
ofdifference,
•testing
Positive
But
see
when
it
goes
up
it’s
horrible,
but
even
if1,it
the
midwife,
it
wis’nae
until
I
went
wi’
Name
pressure towi’
quit/access
SSS,
quitting
advisors
/
advisor
continuity
‘two
weeksyou’re
I’dmaybe
quit
smoking
I went
tothe
see
evidence,
Iafter
think
people‘cause
would
beingot
like
‘Actually
quite
shocked
it’s
only
goes
up
a
couple,
my
mum
still
smokes,
so
like
and
she
showed
me
what
carbon
monoxide
was
in
‘I‘wow’.
wis’nae
thinking
about
me
taking
in
the
fumes,
framed as woman’s
choice
her again
and Ijust
did now,
the same
test and
result
Whereas
because
you the
can’t
see
foetal
thing
tae upset
and,
soonly
itgotells
you
what
a’NS)
the
ifand
she
is having
aand
fagken,
Iwas
don’t
near
her
anymore,
the
baby’s
lungs,
I
maybe
nine
weeks
that
kinda
me
a
bit’.
(Site
A
PW11
came
upand
as athat
zero….
honestly
I’ve,
I’veIthat
never
been
the
damage
that
smoking
does
toquite,
you,
think
it’s
•
CO
monitoring
–
indicator
of risk,
levels
are,
so
that
was
was
a
but shethen,
used so
to smoke
instill,
thehe
house
and nowa’she
pregnant
he
was
still
needed
his
that
(Site
A
PW12
NS)
less kind
ofthrilled’
in your
face’
(Site
Afor
PW21
NS)
useful
motivation,
shock…
(Site
A
PW11
NS)
doesn’t
she
smokes
outside.
(Site
A
P17
NS)
crucial things to develop and
stuff, I think that’s
encouragement,
feedback &
what made me just realise…,consideration
I had my lastoffagpassive
on smoking
the Thursday and that was when I stopped, after I’d
been to see Name 1 (Site A PW3 NS)
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
Project Team
Chief Investigator - Professor Linda Bauld
University of Stirling
University of York
University of Cambridge
Dr Allison Ford
Professor Hilary Graham
Dr Felix Naughton
Lesley
Sinclair McCaughan
Dr Kate Flemming
Dorothy
Kathyrn Angus
Sarah Hopewell
Dorothy McCaughan
Jennifer McKell
NO CONFLICTS OF INTEREST
THANK-YOU
(l.a.sinclair@stir.ac.uk)