Lived experiences of young pregnant women who smoke

Smoking tobacco during pregnancy contributes to numerous adverse pregnancy outcomes (Salihu and Wilson, 2007; Marufu et al, 2015). Early life influences later health outcomes and exposure to problems in fetal growth may lead to higher risks of disease in adult life (Gluckman et al, 2008; Eriksson, 2010; Sipola-Leppänen et al, 2015).

Women who smoke during pregnancy tend to be younger and from lower socioeconomic groups (Hiscock et al, 2012; NHS Digital, 2012). Despite a steady decline in the number of pregnant women in England who smoke, from 15.8% in 2006/7 to just under 11% in 2017/18 (NHS Digital, 2018), younger women are least likely to stop smoking, with only 38% reporting any cessation (NHS Digital, 2012). Two systematic reviews have found that smoking cessation interventions for pregnant women were effective and significantly reduced smoking in late pregnancy (Lumley et al, 2009; Chamberlain et al, 2013); however, it is unclear whether this applies to younger women, as only two studies in the above reviews specifically considered women aged 20 years old or younger. The first (Albrecht et al, 1999) may be less applicable in today's context, although their more recent study (Albrecht et al, 2006) demonstrated that for those aged between 14 and 19 years, cognitive behavioural therapy (CBT) combined with peer support from a non-smoking friend had significantly more effect than the usual care provided to the control group.

A literature review by Flemming et al (2013) suggested that contextual issues significantly affected smoking in pregnancy. This review included two UK studies of younger women (Bryce et al, 2009; Hill et al, 2013). Bryce et al's (2009) mixed method study identified that women aged 25 years and under were nervous of engaging with services, perceiving they would be ‘told off’ for smoking. Hill et al's (2013) qualitative study found that women aged 16-19 years old preferred to try and give up on their own and distrusted smoking cessation provision.

More research is needed on the most effective ways of helping pregnant teenagers to stop smoking (National Institute for Health and Care Excellence, 2010; Action on Smoking in Pregnancy, 2013), as the information and smoking cessation support provided by maternity services appears not to translate into younger women successfully quitting (Hill et al, 2013). Due to the paucity of evidence and understanding, gaining an insight into this age group was considered necessary before proposing specific interventions. This study therefore aimed to explore the experiences of young women aged 18–20 years who had smoked tobacco at some point during their pregnancy.

Method

Creswell (2013) identified phenomenology as an appropriate methodology for describing individuals' lived experience of a concept or phenomenon. This study used descriptive phenomenology to explore young women's lived experiences of smoking tobacco while pregnant.

Ethical approval

Approval to conduct the study was sought and granted by the relevant university ethics committee. The study was conducted in line with the approval granted.

Sample and recruitment

A purposive sample of young women who had smoked during pregnancy was recruited, as the intention was not to seek representativeness, but to select a sample for defined purposes (O'Leary, 2004). The inclusion criteria for women were:

• Aged 18-20 years
• Pregnant or have given birth within the last year
• Smoked tobacco at some point during pregnancy.

Creswell (2013) recommends a sample of between one and ten people for phenomenological studies. Five women participated in this study (six had been the desired number but one young woman was unavailable during the interview period).

Recruitment occurred via an organisation that ran a group to support young parents through pregnancy and beyond. The researcher met with a group of women to explain the research and build trust (Robinson, 2014). All potential participants received a verbal explanation and a participation information sheet clarifying what involvement would entail, and were given time to consider their decision. Those who agreed to participate were asked to sign a agreement form and an interview was arranged. Of the five participants, three had smoked in pregnancy and two had given up when they realised they were pregnant. All participants were white British, engaged with the service through which recruitment took place, and none had planned their pregnancy.

Data collection

Data were collected using face-to-face, semi-structured interviews with open-ended questions. Interviews lasted between 18–39 minutes and were audio recorded with participants' permission. One researcher conducted and transcribed all the interviews verbatim in order to give continuity, consistency and to allow full engagement in the topic.

Data analysis

The data analysis process was based on the Giorgi (2009) approach to descriptive phenomenology, shown in Box 1.

Box 1.Descriptive phenomenology

Source: Giorgi (2009)

From the data, seven key themes emerged, describing the essence of young women's experiences. The themes and related sub-themes are shown in Table 1.

Findings

Culture and routine

Participants reported that smoking was a key element of their social routine and culture. All had smoked for several years, mostly starting at approximately 14 years of age in social gatherings. Smoking was now a part of their daily routine: most of the people they spent time with smoked, they had not previously considered giving up, and some felt that it would be hard to stop smoking after so long:

‘I've smoked for so long, that I can't imagine not doing it.’

(P1)

Psychological wellbeing

The participants who continued to smoke identified it as a stress and anxiety relief mechanism; their ‘go to’ when things were difficult emotionally. They described feeling relaxed or calm when they smoked, and able to cope with difficulties. Some thought that giving up completely would be stressful and harmful for them.

‘It's going to be more stressful for me to try and cut it all out now.’

(P3)

Self-efficacy for quitting

Those who continued to smoke felt that stopping completely would be too difficult to achieve.

‘I knew I wasn't going to be a heavy smoker, but I knew from day dot that I wasn't going to give up […] otherwise I would have given up already. I knew for a fact that I wasn't going to stop smoking.’

(P3)

Women who did not give up smoking did what they considered the next best thing and cut down. They found this hard but spread a low number of cigarettes out until they felt that they really needed them.

Public opinion

All those who smoked throughout pregnancy experienced a strong social pressure not to. Consequently, they did not want to be seen smoking in public, describing an anxious tension from the weight of other people's opinion towards them. Having to deal with this made them want to smoke more:

‘If I was out in public, I would feel more of the need to smoke but also not want to, ‘cause I wouldn't like people looking at me and thinking, “Oh god, she's smoking and she's pregnant, like, what is she doing?” So I kind of wait until we found, like, a kind of private area or just try and go as long as I could without having one.’

(P2)

Recognition of harm

All the participants recognised that smoking was bad for their babies and changed their habits. They recalled receiving information at school, at a first aid course or through TV adverts, which prompted two participants to stop smoking, describing it as a ‘no no’ from the start. These two young women had been provided with strong mental images of what was happening to their baby, although they did not specify who had given them this information:

‘Smoking while you were pregnant it's like, for the baby, crushing the umbilical cord for the baby to breathe and they said it was something like, it can last for 10 minutes.’

(P4)

‘I just thought like, how can I smoke a cigarette knowing that it's the same as crushing its breathing pipe basically, because when it come out and it was born I wouldn't sit there and put my thumb on its throat for 10 minutes, so why would I smoke a fag ‘cause it's going to do the same thing.’

(P4)

The two young women who gave up found it surprisingly easy: something ‘clicked’ and the desire to smoke had gone. This was before they had contact with any health professionals.

‘I think it was quite easy, I kind of just had the appeal to stop, the second I found out I was pregnant it didn't appeal to me to have a cigarette, ‘cause I know it is so not healthy for pregnancy and, like, if I stop it will just be easier, so I stayed away from friends from family, from anyone who smoked.’

(P5)

Those who continued to smoke described knowing that giving up was a good thing but also feeling that it would cause stress for them and the baby, which was bad. Later on in pregnancy, they deemed it better to cut down than give up entirely, as this might cause the baby distress.

‘It's dangerous to stop smoking completely if you are so far into your pregnancy. Sometimes I feel like the baby wants it cause I didn't stop at 5 weeks.’

(P3)

Those who cut down felt that smoking one or two cigarettes per day was not harmful.

‘I think just one and a half a day, maybe one is just alright; it's not going to do that much damage, if I'm honest.’

(P3)

All participants described e-cigarettes as harmful in pregnancy, and considered them worse than a cigarette; they had heard this from friends and health professionals and those who sold e-cigarettes.

‘Half these products are just replaced by chemicals, to think you are putting into your lungs [sic]. To be honest with you, I'd rather sit there and smoke a fag than sit and vape on a cigarette that's got chemicals going into my lungs, I don't like them at all.’

(P3)

‘I think they are probably worse than a cigarette ‘cause of what is in them.’

(P5)

There was also a distrust of nicotine replacement therapies (NRT), and no belief that they could work from two of the women who smoked.

‘It just doesn't work, like, all that gum stuff, like you don't chew gum to help you stop smoking, you can feel it in your lungs that you need it, how is chewing a piece of gum going to stop you from smoking?’

(P3)

The two young women who had given up smoking had not used any NRT or approached anyone for help.

Professionals women spoke to about smoking

The young women were all happy to discuss smoking with their midwives:

‘I did speak to them [midwives] a bit about it, like how many I was smoking in a day, and they did keep mentioning to me about going to a stop smoking person that comes here I think, not really sure, but I did get the number down and, like, and then I just never ended up going.’

(P2)

All the women received carbon monoxide (CO) screening through their midwives and considered this a positive and useful experience. However, the negative side of this was that one young woman who had not stopped smoking felt that, as her CO reading had reduced, her baby was now adequately protected.

‘I'm blowing a 6 and that's classed as a non-smoker so it's not like I'm smoking 10 a day and putting my baby at serious harm.’

(P3)

Approaches that helped behaviour change

The scan appointment, when women saw their babies, was a significant time, reassuring them that everything was alright and motivating them to ‘really cut down’ if they were smoking.

‘Yes, didn't believe I was pregnant till I had my 12-week scan, it made me cut down a lot more than I had already.’

(P1)

Three of the participants were offered the opportunity to access a smoking cessation service, and two had given up before this was offered. However, only one sought this support, as participants generally wanted to be in control of their situation themselves, and felt that other people could not really help them. Those who gave up smoking achieved this unaided and were proud of it. One woman, who did not give up smoking, explained why she did not want assistance to do so.

‘‘Cause it's quite an achievement, giving up smoking, so I kind of thought, “I don't want to do it just ‘cause somebody's telling me to, I want to make that decision and, kind of, on my own.”’

(P2)

The only woman who accessed the smoking cessation service found it unhelpful and upsetting:

‘It makes you feel more bad than it does help you. It just makes you feel like, really horrible; it doesn't help and then you just want a fag, ‘cause you just feel horrible.’

(P1)

Discussion

Young women's experiences

These young women's experiences indicated that discovering they were pregnant and the 12-week scan appointment were significant times for motivating them to change their smoking behaviour. Previous studies (DiClemente et al, 2000; Olander et al, 2016) have recognised a change of outlook during pregnancy and the opportunity that this may offer in relation to smoking cessation. This study additionally suggests that the 12-week scan appointment may provide an important specific opportunity to revisit smoking with young women.

Young women in this study valued CO screening, but a perceived low CO reading did not motivate them to stop smoking, instead it endorsed an opinion that cutting down was enough. There is a lack of clarity over the CO level commensurate with non-smoking, with 3 ppm, 4 ppm and 6-10 ppm all being cited (NICE, 2010; The Smoking in Pregnancy Challenge Group, 2016). This suggests that health professionals should follow NICE (2010) guidance and assess smoking through both CO monitoring and discussion, exploring with women how low CO readings should be interpreted, explaining the reasons for, and implications of, lower readings.

Barriers to smoking cessation

This study identified psychological wellbeing as a key factor preventing young women from quitting smoking. Flemming et al's (2015) systematic review also found that women of all ages identified smoking as a stress reliever and a way of coping with anxiety. Although young pregnant women in this study experienced guilt resulting from perceived social disapproval for smoking—as identified by other studies (Flemming et al, 2013; 2015; Bauld et al, 2017)—this increased their stress; hindering, rather than enhancing, any attempt to stop smoking. This study also supports Bull et al's (2007) evidence that the stigma of smoking could make women covert about their habits, and harder to reach for the purpose of smoking cessation support.

The women in this study who continued to smoke while pregnant described a low self-efficacy in their ability to quit, which was also identified by Bauld et al (2017) in women of all ages. This suggests that younger women's belief in their own capacity may dictate whether they successfully stop smoking. Understanding and trying to build up young women's self-efficacy could therefore be a key element in helping them to stop smoking. Two previous studies (Wakschlag et al, 2003; Pickett et al, 2009) have suggested that interventions should go beyond behaviour to explore the psychosocial context for the smoker and provide tiered support depending on the need.

Facilitators of smoking cessation

This study, like that of Bauld et al (2017), indicated that women valued and trusted their midwifery contact when discussing smoking. As Bauld et al (2017) identified, understanding the risk of smoking during pregnancy helped some young women in this study to stop smoking. Those who did not were either unaware of the specific risks from continued smoking or diminished them by rationalising their importance with other messages, as has been acknowledged in women of all ages (Flemming et al, 2015). Helping younger women to understand and perceive the risks of smoking while pregnant may therefore be helpful. However, for the young women in this study, feeling judged or told what to do was unhelpful and could increase their stress and reduced the likelihood of giving up. The approach taken to discussing smoking cessation with young women is therefore as crucial as the content.

Despite valuing their midwives' support, the young women in this study did not consider seeking additional smoking cessation support worthwhile, wanting to retain control of their decision-making, possibly relating to their self-efficacy and beliefs about stopping smoking. This corroborates Hill et al's (2013) finding that young women did not see smoking cessation services as relevant or beneficial, preferring to quit alone. This suggests, as DiClemente (2016) highlights, that in order to help young women to change their behaviour, professionals also need to change what they do. Services should also be proactive, non-judgemental and woman-centred.

NRT and e-cigarettes were unacceptable to the young women in this study, with cutting down considered less harmful. These findings reflect those of Bovill et al (2018), but demonstrate perceptions contrary to advice that NRT and e-cigarettes have fewer risks for pregnant women than smoking (NHS Choices, 2016). Other studies, however, have found that women deem e-cigarettes to be preferable to smoking during pregnancy (Kahr et al, 2015; England et al, 2016). This inconsistency suggests that further research on the acceptability of e-cigarettes as an alternative to smoking in pregnancy is needed, particularly among younger women. Cutting down is not a recognised harm reduction method in pregnancy and is not mentioned in NHS advice (NHS Choices, 2016). Its absence may leave women and professionals unclear about the risks associated with smoking small amounts of tobacco, and has implications for helping young pregnant women to make informed decisions.

Strengths

This study used a recognised phenomenological methodology to give it credibility. It was important to ensure honesty from the participants, to gain an accurate account, and so a venue that was familiar and that provided a private space to talk was chosen. The researcher made every effort to build a rapport with the participants and used active listening skills.

The study has been reported in a clear, systematic and consistent manner in order to provide dependability. The confirmability is established as the study provides a data-orientated audit trail, showing how the data were gathered and how the evidence was produced.

Limitations

It should be recognised that this study is context-specific and the intention is that the findings should be applied if the context is comparable. Description of the participants and setting has been provided to allow readers to assess its applicability.

In this study, a sample of voluntary participants was used and for ethical reasons it was vital that they were willing to contribute. Therefore, it is recognised that there will be self-selection bias. The researcher was aware that bias could arise in the results from her own assumptions and interpretations, and so a reflective journal was used to support this process before and during the study. By using a debrief session between the researcher and supervisors, a level of scrutiny and challenge to bias and preconceptions was provided. Early transcribing of initial interviews was also used as a positive way of helping to assess bias.

Implications for practice

Midwives play a key role in supporting younger women who smoke during pregnancy as health professionals who are accepted, trusted and seen regularly (Bauld et al, 2017). Non-judgemental discussions with young women, exploring self-efficacy, CO monitoring, NRT and e-cigarettes, as well as links to women-centred smoking cessation services are critical for optimum support.

Conclusion

Many psychosocial factors hampered young women's ability to stop smoking during pregnancy, with self-efficacy being a key element of successful smoking cessation. Additional smoking cessation services were not valued by young women, and, contrary to guidelines, cutting down, rather than using NRT or e-cigarettes, was considered a viable way of minimising harm to the unborn baby. Midwives were seen as the trusted health professional by young women, but a non-judgemental and empowering approach, in which the woman maintains control, needs to be used when addressing smoking. Appreciating the risk for the unborn child helped to facilitate smoking cessation and was the main motivation for those who gave up, with the scan appointment a key time of behaviour change. CO screening was considered helpful, although low level results could encourage cutting down instead of stopping smoking.

Key points

• Midwives are seen as the trusted health professional by young women and a non-judgemental approach is valued to promote self efficacy
• Helping younger women perceive the risks of smoking tobacco while pregnant is helpful in supporting a quit attempt but this must be done in a non-judgemental, empowering manner
• Carbon monoxide readings need to be discussed carefully so that misleading information is not taken from the screening process
• Smoking cessation pathways should consider the importance of the 12-week scan appointment for young women and how this can be used to support motivation to change smoking behaviour
• Nicotine replacement therapy (NRT) and e-cigarettes were unacceptable to the young women in this study, with cutting down considered less harmful. This demonstrate perceptions contrary to current advice that NRT or e-cigarettes have fewer risks for pregnant women than smoking (NHS Choices, 2016)

CPD reflective questions

• How would you seek to develop a non-judgemental approach when discussing smoking?
• What do you think could be done to enable young women to gain greater sense of self efficacy?
• How would you explore CO levels with women who had significantly reduced their smoking habit, but had not given up?