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

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The needs of women and their partners regarding professional smoking cessation support

during pregnancy

Weiland, S; Warmelink, J C; Peters, L L; Berger, M Y; Erwich, J J H M; Jansen, D E M C

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Women and Birth

DOI:

10.1016/j.wombi.2021.03.010

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Publication date:

2021

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Weiland, S., Warmelink, J. C., Peters, L. L., Berger, M. Y., Erwich, J. J. H. M., & Jansen, D. E. M. C.

(2021). The needs of women and their partners regarding professional smoking cessation support during

pregnancy: A qualitative study. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.010

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The

needs

of

women

and

their

partners

regarding

professional

smoking

cessation

support

during

pregnancy:

A

qualitative

study

S. Weiland

a,b,

*

,

J.C.

Warmelink

a,b

,

L.L.

Peters

a,b

,

M.Y.

Berger

a

,

J.J.H.M.

Erwich

c

,

D.E.M.C.

Jansen

a,b

a_University_of_Groningen,_University_Medical_Center_Groningen,_Department_of_General_Practice_&_Elderly_Care_Medicine,_Groningen,_The_Netherlands b

AmsterdamUMC,VrijeUniversiteitAmsterdam,DepartmentofMidwiferyScienceAVAG,AmsterdamPublicHealthResearchInstitute,Amsterdam,The Netherlands

c

UniversityofGroningen,UniversityMedicalCenterGroningen,DepartmentofObstetrics&Gynecology,Groningen,TheNetherlands

ARTICLE INFO

Articlehistory:

Received12October2020

Receivedinrevisedform1March2021 Accepted10March2021 Availableonlinexxx Keywords: Tobaccosmoking Pregnancy Smokingcessation Tailoredsupport Guidelines Qualitativeresearch ABSTRACT

Background:Despitethehealthrisksofsmoking,somewomencontinueduringpregnancy.Professional smokingcessationsupporthasshowntobeeffectiveinincreasingtheproportionofpregnantwomen whoquitsmoking.However,fewwomenactuallymakeuseofprofessionalsupport.

Aim:Toinvestigatetheneedsofwomenandtheirpartnersforprofessionalsmokingcessationsupport duringpregnancy.

Methods:Semi-structuredinterviewswereheldwithpregnantwomenandwomenwhorecentlygave birthwhosmokedorquitsmokingduringpregnancy,andtheirpartners,livinginthenorthofthe Netherlands.RecruitmentwasdoneviaFacebook,LinkedIn,foodbanks,babystoresandhealthcare professionals.Theinterviewswererecorded,transcribedandthematicallyanalysed.

Results:28interviewswereconducted,23withpregnantwomenandwomenwhorecentlygavebirth, andfivewithpartnersofthewomen.Thefollowingthemeswereidentified:1)understandingwomen’s needs,2)responsibilitywithoutcriticism,and3)womenandtheirsocialnetwork.Thesethemesreflect thatwomenneedsupportfromaninvolvedandunderstandinghealthcareprofessional, whoholds womenresponsibleforsmokingcessationbutrefrainsfromcriticism.Womenalsopreferinvolvementof theirsocialnetworkintheprofessionalsupport.

Conclusion:Fortailoredsupport,theDutchguidelineforprofessionalsmokingcessationsupportmay needsomeadaptations.Theadaptationsandrecommendations,e.g.toinvolvewomenandtheirpartners inthedevelopmentofguidelines,mightalsobevaluableforothercountries.Womenpreferhealthcare professionalstoaddresssmokingcessationinaneutralwayandtorespecttheirautonomyinthedecision tostopsmoking.

Statementofsigni_ﬁcance

Problemorissue

Despite theavailabilityofprofessionalsmoking cessation support,onlyfewpregnantwomenmakeuseofprofessional supportandcontinuesmoking.Smokingduringpregnancy hasnegativehealthconsequencesforthemotherandfetus.

Whatisalreadyknown

A reason why pregnant women do not use professional smoking cessation supportis because the supportis not tailoredtotheirneeds.

Whatthispaperadds

Theresults ofthis studyprovideinsightintotheneedsof pregnant women and their partners for professional smokingcessationsupport.Ourﬁndingsindicatethatthey have clear ideas about how this support should be organised.

*Correspondingauthorat:UniversitairMedischCentrumGroningen,Hanzeplein 1,9713GZ,Groningen,TheNetherlands.

E-mailaddress:s.weiland@umcg.nl(S. Weiland).

http://dx.doi.org/10.1016/j.wombi.2021.03.010

xxx–xxx

Pleasecitethisarticleas:S.Weiland,J.C.Warmelink,L.L.Petersetal.,Theneedsofwomenandtheirpartnersregardingprofessionalsmoking cessationsupportduringpregnancy:Aqualitativestudy,WomenBirth,https://doi.org/10.1016/j.wombi.2021.03.010

ContentslistsavailableatScienceDirect

Women

and

Birth

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1.Introduction

Smokingduringpregnancyis associatedwithadverse health outcomesforboththebaby,suchasanincreasedriskoflowbirth weight,fetalgrowthrestrictionandstillbirth,andforthemother, suchascardiovasculardiseaseandcancer[1,2].However,despite these health risks, some women continue to smoke during pregnancy. Withanestimatedprevalence ofaround8%, Europe hasthehighestprevalenceofsmokingduringpregnancycompared tootherregionsintheworld[3]. Womenfromlower socioeco-nomicgroups,womenwhoexperiencehigherlevelsofstress,and womenwithasmokingpartneraremorelikelytosmokeduring pregnancy[4,5].

Toencouragepregnantwomentoquitsmokingandtoremain abstinentpostpartum,healthcareprofessionalsprovidesmoking cessationsupport.Severalguidelinesrecommendthathealthcare professionalsprovidecounsellingforbehaviouralchanges[6–8], oftenbasedonstagesofanindividual’sreadinessforsuchchange [9].Ifneeded,behaviouralcounsellingcanbecombinedwithmore intensiveinterventions,likepharmacotherapyortelephone-based support [6–8]. Smoking cessation support has shown to be effectiveinincreasingtheproportionofwomenwhoquitsmoking duringpregnancy[10,11].

However,despiteitseffectiveness,onlyasmallpercentageof pregnant women make use of professional smoking cessation support: in the United Kingdom (UK) and in the Netherlands respectively12%and7%ofpregnantwomen[12,13].Reasonsfor this mightbethatsomehealthcareprofessionalsdonotdiscuss smoking behaviour or offer support because they lack the necessaryknowledgeandtrainingandareconfrontedwithtime restrictionsand women’slackof motivationtodiscusssmoking cessation [14,15]. On the other hand, some pregnant women perceive thatthey havemissedopportunities,as theywerenot informed about support options or have not received the information and support they preferred, and the support by professionalsdidnotﬁttheirneeds[16,17].

Tothebestofourknowledge,onlyafewstudiestodatehave investigated pregnant women’s needsfor professionalsmoking cessationsupport.Thesestudies,performedintheUK,Australia, andNewZealand,werefocusedmainlyonindigenousandsocially disadvantaged women [17–20]. Personalised support, easily accessibleinformation,andrespectfuldiscussionswithout judge-ment were identiﬁed as women’s needs when considering smoking cessation support [17–19]. In addition, the study that focusedonamoregeneralpopulationfoundthatpregnantwomen prefer to receive support from someone who has also had experiencewithsmoking[20].

Because of cross-country differences in smoking cultures, it cannot be said with certainty that these reported needs for professionalsmokingcessationsupportarethesameasthoseof pregnant women in the Netherlands. Compared to the Netherlands,theUKandAustraliahavehighlevelsofimplemented tobacco control policies (e.g. budget for public information campaignsandsmokingcessationservices)[21,22].Furthermore, in these countries the smoking cessation support services for pregnantwomendiffer.TheUKhandlesanopt-outreferralsystem forpregnantwomen,andoffersCarbonMonoxide(CO)testingas standard procedure[6].InAustraliaandNewZealand,pregnant womenarereferredtotelephone-basedcounselling(Quitline)for smoking cessation support [8,23], whereas in the Netherlands pregnantwomenareadvisedtoconsultaspecialisedhealthcare professionalformoreintensivesupport[7].

Studies performed to evaluate these smoking cessation programs generallyreport that theyareeffective byincreasing theproportionofpregnantwomenwhostopsmoking.IntheUK, the introductionoftheopt-out referral systemwithCO testing

has-, compared to the previous opt-in system, doubled the proportion of pregnant women who set a quit date and who actuallystoppedsmoking[24].Althoughnostudiesareavailable ontheuseoftheQuitlinebypregnantwomeninAustraliaandNew Zealand, telephone-based counselling in general seems to be effectivebyincreasingcessationrates[11].Astudyperformedin theNetherlandsreportedthatbehaviouralcounsellingprovidedby midwivesdoubledtheproportionofpregnantwomenwhostop smoking[25].However,only10%oftheDutchmidwivesactually providefullbehaviouralcounselling;morethan79%oftheDutch midwivesreferpregnantwomenformorespecialisedsupport[26]. Theaimofthisqualitativestudywastoinvestigatetheneedsof pregnantwomenandtheirpartnersinthenorthernNetherlands forprofessionalsmoking cessationsupport.Thefocusis onthe north of the Netherlands because of its high percentage of pregnant women who smoke [27]. Moreover, as the smoking behaviour of pregnant women is associated withthe smoking behaviourofpartners,theneedsofthelatterwillalsobetakeninto account[5].

2.Methods 2.1.Design

This qualitative study makes use of a phenomenological framework,aimedatunderstandingpeople’sexperienceswithin thecontextoftheirdailylife[28].Semi-structuredinterviewswere heldtogaininsightintotheneedforsmokingcessationsupport duringpregnancyonthepartofwomenandtheirpartnerslivingin the northern Netherlands [28]. In February 2020, at a Dutch conferencefortobaccocontrol,apeerdebriefingwasperformed. Thepurposeofapeerdebriefingistoestablishthereliabilityand trustworthinessofthedata[28]. Ontheconferencefortobacco control, we presented themethod and results of this study to researchersandhealthcareprofessionalsresponsiblefor support-ingsmokingcessation.Afterthepresentation,theinterpretationof theresultswasdiscussedwiththepeerresearchersandhealthcare professionals.Theresearchersandhealthcareprofessionalsatthe Dutchconferencefortobaccocontrolconfirmedtheresultsofthis paper.

2.2.Recruitmentofwomenandtheirpartners

Interviewswereconductedwithwomenandpartnerslivingin thenorthernprovincesoftheNetherlands,i.e.Groningen, Fries-landandDrenthe.Becausetheprevalenceofwomenwhosmokeis knowntoincreasepostpartum intheNetherlands[13],women who had recentlygiven birth werealsoinvolved in this study. Womenwereinvitedtoparticipateiftheywerepregnantandwere currentlysmoking,pregnantandhadquitsmokingatthestartofor duringtheirpregnancy,oriftheyhadgivenbirthwithinthelast yearandwerecurrentlysmoking.

Twoexpertsbyexperienceinpovertyandsocialexclusion,and tworesearchersfromanorganisationthatrepresentsthevoicesof consumersinresearch(inDutch:Zorgbelang),wereinvolvedinthe recruitmentofwomen.Aﬂyerwithinformationaboutthestudy and contactdetailsof theﬁrstauthor(SW)was distributed via Facebook groups targeting mothers in the north of the Netherlands,socialmediapagesoftheresearchers(i.e.LinkedIn and Facebook), the network of Zorgbelang, food banks, super-markets, baby stores, midwives, and obstetricians, and subse-quentlyvia women and theirpartners. We aimed toinclude a representativesampleofwomenandtheirpartnerswithdifferent socialbackgrounds,livinginthenorthoftheNetherlands.Women couldsignup fortheinterviewbycontactingSW viae-mailor telephone. Partnerswererecruitedviatheinterviewedwomen.

S.Weiland,J.C.Warmelink,L.L.Petersetal. WomenandBirthxxx(xxxx)xxx–xxx

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Recruitmentcontinueduntildatasaturation fortheinterviewed womenwasreached.

Thewomenandtheirpartnerswereinformedabouttheaimof theinterviewsbothinpersonandbyaninformationletter,after which they were asked to sign an informed consent form. Participationwasvoluntaryandwomenandtheirpartnerscould withdrawfromtheinterviewatanymoment.Fortakingpartinthe study,womenandtheirpartnersreceivedavoucherworths25. 2.3.Datacollection

Semi-structured interviewswere held from May 2019 until October2019.Theexpertsbyexperienceandtheresearchersfrom Zorgbelangwereinvolvedinthedevelopmentofasemi-structured interview guide, whereby special attention was paid to the phrasing of the questions. The main questionof interest was: “How would you like tobe supportedwith smoking cessation duringpregnancy?”Aftereachinterview,ﬁeldnoteswerewritten downandtheinterviewguidewasevaluated.Noquestionswere addedtotheinterviewguide.

TheinterviewswereconductedinDutchbySW,eitheraloneor together with an expert by experience or a researcher from Zorgbelang.Allinterviewerswerefemaleandreceivedinterview trainingbeforehand.Atthestartoftheinterview,theinterviewers introducedthemselvestotheparticipant,tellingbrieﬂyabouttheir workandtheirinvolvementinthestudy.Theinterviewershadno relationship with the women and their partners before the interview. Theinterviewswereheldata locationof thewomen and theirpartners’choice,mostoftenat theirhomesor atthe UniversityMedicalCenterGroningen.Childrenofthewomenand theirpartnerswerepresentduringeleveninterviews.The inter-viewslastedonaverage39min(range18 66min).Theinterviews wereaudiorecordedwithpermissionfromthewomenandtheir partners.Amembercheckwasperformedbygivingwomenand theirpartnerstheoptiontoreadandcommentonthecompleted transcripts[28].Aftercompletionofthestudy,womenandtheir partnerswereinformedabouttheresults,butnoneofthemgave feedbackonthetranscriptsorresults.

2.4.Dataanalysis

Therecordingsoftheinterviewsweretranscribedverbatimand anonymised. Data management and coding was donewiththe software ATLAS.ti 8.4. Data collection and analysis took place concurrently.Thedatawasanalysedusingasix phasethematic approach [29]. First, SW (health scientist) read all transcripts multiple times to become familiar with the data. The second author (JCW – psychologist) also read seven transcripts. After becoming familiar with the data, SW and JCW discussed the transcriptswiththeaimtogenerateinitialcodes.Afterwards,SW appliedtheformulatedcodestothedata.Inthethirdphase,SW and JCWdiscussedthecodeswiththeaimtoidentifypotential patternsinthedata.Thecodeswerearrangedincategorieswhich

definedthemesandsub-themes.Inthefifthphase,theidentified themeswerefurtherrefinedtointerpretthedata,asillustratedin

Table1.SWandJCWcomparedthreetranscriptswiththecodetree toensurethatthethemescompletelycoveredtheessenceofthe data.During thepeerdebrieﬁng,theresearchersandhealthcare professionals agreedwiththemethods usedand the results as formulated.Lastly,thereportofthe_ﬁndingswaswritten.Quotes weretranslatedintoEnglishbyanativespeaker.

3.Results

3.1.Womenandtheirpartners

Demographiccharacteristicsofthewomenandtheirpartners areillustratedin Table2.In total, 23women and ﬁvepartners participatedintheinterviews.Ninewomenwhoinitiallyapplied fortheinterviewdidnotparticipate;twowerenotlivinginthe northoftheNetherlandsandsevendidnotrespondtotherequest to make an appointment. The women and partners were on average 29 years old (range 20 41 years). At the time of the interview, thirteen womenwere pregnant,of whomfour were currentlysmokingandninehadquitsmokingduringpregnancy. Mostwomenquitsmokingdirectlyafterapositivepregnancytest, andoneofthewomenattheendofherpregnancy.Tenwomenhad recently given birth, of whom ﬁve smoked during the entire

Table1

Examplesofthecodingprocess:theneedsofwomenandtheirpartnersregardingprofessionalsmokingcessationsupportduringpregnancy.

Codedsegment Sub-theme Theme

“Deﬁnitelyiftheyknowthatyousmokedbeforethepregnancy,justaskeverytimeyoucome,uh, everytimeyoucome,areyousmoking?Youknow,giveitsomeattention.”(#3,pregnant,currentsmoker)

Involvement Understandingwomen’sneeds “So,justthatitisimportantthatyoufeelrespected,thatyoudon’tjustgetthefeelingthatyouaredoing

somethingbadandthatyouhavetostop.”(#1,recentlygavebirth,quitsmokingduringpregnancy)

Beingvalued Responsibilitywithoutcriticism “Ithinkthatifyouinvolvethepartnermore,youknow,becausetheysay:Yeah,youneedtostopsmoking

becauseYOUarecarryingthechild.Yeah,that’salllogicalandso,butifyouhaveapartnernexttoyou whojustkeepsonsmokinganddoesn’tevencutdown,thenitisn’teasierforyourself.”

(#8,recentlygavebirth,smokedduringpregnancy)

Roleofthepartner Womenandtheirsocialnetwork

Table2

Demographiccharacteristicswomenandtheirpartners.

Characteristic Frequency

Gender

Female 23

Currentlypregnant 13

Recentlygavebirth 10

Male 5

Age,average(range) 29(20 41)

Smokingstatus Women

Currentlypregnant 13

Smokingatthetimeoftheinterview 4 Quitsmokingatthetimeoftheinterview 9

Recentlygavebirth 10

Smokingatthetimeoftheinterview 10 Quitsmokingduringpregnancy 5 Men

Smokingatthetimeoftheinterview 4 Quitsmokingatthetimeoftheinterview 1 Socioeconomicstatusa LowSES 5 MiddleSES 19 HighSES 4 Province Groningen 16 Friesland 5 Drenthe 7 a_Classiﬁed

accordingtoDutchstandardeducationdivision[40].

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pregnancyandﬁvestartedsmokingagainpostpartum.Fourofthe ﬁveinterviewedpartnerswerecurrentlysmoking.

3.2.Themes

Fromtheanalysisofthedatawederivedthefollowingthree mainthemesregardingtheneedsofwomenandtheirpartnersfor professionalsmokingcessationsupport:1)Understanding wom-en'sneeds,2)Responsibilitywithoutcriticism,and3)Womenand theirsocialnetwork.ThecodingtreeisshowninTable3.

1 Understandingwomen_’sneeds

Women and their partners expressed that apart from the complexityofanicotineaddiction,circumstancesintheirdailylife inﬂuencedtheirdecisiontocontinuesmokingduringpregnancy. Somewomenexperiencedseriouslife-eventsbefore andduring pregnancy,suchasunstablerelationships,ﬁnancialstress,andloss offamilymembers.Forthesewomensmokingwasawayofcoping withthese life-events;they expressedthat theycouldconsider smokingcessationonlywhenthesestressorsweredealtwith.

In my case it’sto havesomething todo andaslittle stressas possible.Itactuallyhasabittodowithexternalcircumstances–. Yeah,withmeit’sjustatypicalviciouscircle.SoIknowwhyI smokeandso.(#16,pregnant,currentsmoker)

Womenwhoweremotivatedtostopsmokingpreferredthatthe healthcare professional continue to ask about their smoking behaviourandneedforsupportduringtheentirepregnancy.With allwomensmokingwasdiscussedduringtheﬁrstvisit,butoften remainedunaddressedinsubsequentconsultations.Bothwomen who managedtoquitsmokingand thosewho didnot succeed, wouldhavepreferredtodiscusstheirsmokingbehaviourandneed for smoking cessation more often. The women who stopped smoking would have liked toshare theirstruggles and receive complimentsfromthehealthcareprofessional.

Shedidnotdiscussitanyfurther,like"areyoustrugglingwithit?". No, shejustasked "haveyoustopped(smoking)?".AndwhenI conﬁrmed,thatwasthat.ThenIwasthinkingyes[..]'givemea compliment orsomething'. Butshe was like "okay,ﬁne!". (#9, pregnant,quitsmoking)

Women who continued to struggle with smoking cessation would have preferred the healthcare professional to keep considering waysto stopsmoking. On theother hand,women whodidnotwanttostopsmokingexpressedthattheydidnot wantthehealthcare professionaltoaddress theissuein subse-quentvisits.Accordingtothewomen,healthcareprofessionalscan best discuss smoking cessation by asking open questions (e.g. ‘whatwouldbeareasonforyoutothinkaboutsmokingcessation?’ and‘howcanIsupportyouwithsmokingcessation?’).

Ithink, just asking whatsomeone needs, [...] more like if a midwifeasks'howcanIsupportyou?'Likethat.(#12,pregnant, quitsmoking)

Womenandtheirpartnershaddifferentpreferencesastothe kind of healthcare professional tosupport them withsmoking cessation:theirmidwife,generalpractitioner,apracticenurse,an addiction expert, or an expertby experience withsmoking. In general,womenandtheirpartnersemphasisedtheimportanceof someonewithpersonalknowledgeofnicotineaddiction,someone whounderstandstheirstruggle.Somewomenperceivedthattheir healthcare professional didnot really understand how difﬁcult smokingcessationwasforthem.

Butthenyougetthatadvice,thereallystandardadvice.Likeohyes, youjusthavetogoon,andifyoufeeltheurgeyoushouldeata grapeordrinkaglassofwater.Ithinkthatisjustnouse.That’sjust thekindofadvicenon-smokersgive.(#26,pregnant,quitsmoking)

2Responsibilitywithoutcriticism

Themajorityof women andsomepartners highlightedhow important it was that the healthcare professional recognise a woman’sownresponsibilityin smokingcessation.Smokingand smoking cessationwere seen as individual decisions. Although womenwantedthehealthcareprofessionaltoshowinvolvement, somewomenandtheirpartnersexpressedthat theywantedto makethedecisiontoquitsmokingthemselves,andthereforedid notneedadditionalsupportfromahealthcareprofessional.

ButIwanttodoitmyself.I’mthebossovermyownbody;that’s howIseeit.[...]ThenIthink‘yes,I’mtheonewhostarted,Iknow there are lots of disadvantages to smoking, um, I’m a grown

Table3

Codingtree:theneedsofwomenandtheirpartnersregardingprofessionalsmokingcessationsupportduringpregnancy.

Theme Sub-theme Sub-category

1.Understandingwomen’sneeds Stressors

Involvement GivecomplimentsandDiscussitmoreoften

Communication Askopenquestions

Healthcareprofessional Understandcomplexity 2.Responsibilitywithoutcriticism Individualresponsibility

Information Healthconsequencesandsupportoptions Nojudgment

Beingvalued

3.Womenandtheirsocialnetwork Inﬂuenceoffriends,colleaguesandfamily

Roleofthepartner Involvepartnerinsmokingcessationsupport

Peersupport Group-basedprenatalcare

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woman.SothenIshouldbeabletodoitmyself.(#4,pregnant,quit smoking)

Formostwomen,thehealthofthefetusandtheirwishtobea role modelfor theirchildrenwas theirmain motivationtoquit smoking.Tobeabletomakeanautonomous,informeddecision, women indicated that they would have liked to receive more tailored and visual information from healthcare professionals aboutthehealthdamageofsmokingforthemandfortheirfetus, forexampleinformationabouttheoxygenlevelintheirplacentaor theconditionoftheirownlungs.

Idon’tknow,Ithinkthatitisbecausethesetelevisionprogramslike 'Fourhandsononebelly'whereyouseethatababyisactuallyborn prematurelyandissmallandhastobeputintheincubator.[...] Thatcouldehbeatip,toreallymakeitvisual.(#7,pregnant,quit smoking)

In addition,womenwantedtoreceiveinformation aboutthe various methods for smoking cessation support (e.g. nicotine replacement therapy). A few women expressed a need for medication that can help with smoking cessation and can be takenduringpregnancy.

Since women and theirpartnersperceivedsmoking astheir ownresponsibility,theydidnotwanthealthcareprofessionalsto interfere with this. Therefore, healthcare professionals who criticisewomenforsmokingduringpregnancy,andwhoaddress theissueinajudgmentalway,evokeresistanceonthepartofthe women and their partners. The women and their partners expressed that they wantedtobevalued and respectedbythe healthcareprofessionals,whetherornottheystoppedsmoking.

Thattheydidn’tusepressureornag,thattheymadetheirpoint clear in a very respectful manner. But that they tried to do everythinginagreementwithme,alsogivinginformation.That wayyoudon’tfeelforced,youdon’tfeelasiftheschoolteacheris wavinghisﬁngeratyou.Thatwasverynice.(#21,recentlygave birth,smokedduringpregnancy)

3 Womenandtheirsocialnetwork

Thewomenhadmanysmokersintheirsocialnetworks.Apart from their partners, most women had friends, family, and colleagues who also smoked. Being exposed to the smoking behaviourofotherscanbechallengingforthesewomen.Although mostwomendidnotexpecttheirpartnertostopsmokingduring theirpregnancies, they didexpressthat this would beof great supportforthem.

AndIthinkehifmyboyfriendwouldnotsmoke,itwouldbealot easier.Well,hecanquit,buthesays:"oneshouldbereadyforit, oneshouldnotbeobligedtostop,becausethenitwon’twork".And thenforawhile,heonlysmokedathiswork.ButthenInoticedthat hebecameabitmore grumpyandbecauseofthat wegotinto arguments.AndthenIsaid:youknow,pleasestartsmokingagain. BecauseI ... itshouldn’tbeattheexpenseofyourrelationship. (#2,pregnant,currentsmoker).

Wedidtalkaboutit,thathewouldalsoquitsmoking.Especially whenthebabyisborn.Butyes,Ialsoknowhowdifﬁcultitistostop smoking[...].Thebabyisofcourseinmybelly,notinhis.SoI alsounderstandthatforhim-,well,thathedoesnothavethebig stickthatIhave.(#17,pregnant,quitsmoking)

Somewomenindicatedthatthehealthcareprofessionalshould involvethepartnerinsmokingcessationduringpregnancy.

Imean,uh,Ideﬁnitelythinkthatiftherearetwosmokersina relationship, that you should almost, uh, actually take on the projecttogether.Ofcourse,uh,somethingsyoucanonlydoalone, butyouneedsupportfromothersandifyouareconstantlybeing

tempted,yeah,thatdoesn’thavemuchimpact.(#10,partner,quit smoking)

Inadditiontotheroleofthepartner,thewomenfelttheneedto receivesupportfromothersintheirsocialnetwork.Mostwomen saidthatduringtheirpregnancytheirfriendsandfamilydidnot smokeintheirpresence.Somewomenpreferredthesupportof friendsandfamilyabovesupportfromaprofessional.

Yes,Ireallydothinkfromthefamily.Ithinkfamilyandfriends couldpullmethroughbetterthansomebodyfromoutside.(#25, recentlygavebirth,quitsmoking)

Furthermore, some women experienced great support from other pregnant women when dealing with smoking cessation. Theyexpressedthatthesewomenknewandunderstoodwhatthey weregoingthrough.Anumberofwomenreceivedgroupprenatal care, where they experienced professional support in a group wheresomeotherwomenhadalsostoppedsmoking.

4.Discussion

Although healthcare professionals offer smoking cessation supportforpregnantwomen,onlyfewwomenactuallymakeuse ofthissupport[12,13].Weaimedtogaininsightintotheneedsof pregnantwomen,andofwomenwhorecentlygavebirthandtheir partners in the north of the Netherlands with different social backgroundsinrelationtoprofessionalsmokingcessationsupport. We identiﬁed three main themes: 1) Understanding women’s needs,2)Responsibilitywithoutcriticism,and3)Womenandtheir socialnetwork.Theresultsindicatethatwomenneedsupportfrom anunderstandingandinvolvedhealthcareprofessionalwhotailors thesupporttotheirneeds;women_’s experiencedstressors and motivation levels have implications for their support needs. Women want the healthcare professional to discuss smoking cessationinaneutralwayandtosupporttheminmakingtheir owndecisionaboutit.Womenalsovaluetheinvolvementoftheir socialnetworkintheprofessionalsupport.

Ourfirstresultsuggeststhatsomepregnantwomendowantto quitsmoking,butcannotbecauseofseriouslife-eventswhichthey haveexperiencedbeforeorduringpregnancy.Womenindicated thatitisdifficultforthemtobeopentosmokingcessationsupport ifthesestressorspersist.Thisresultisinlinewithotherstudies thatidentifiedstressasanimportantbarriertosmokingcessation [15,30].Thesestudiesconcludethatlearningtocopewithstressors shouldbepartofsmokingcessationprograms[15,30].However, althoughstressreductioninterventionsseemtobeeffectivefor reducingstresslevelsduringpregnancy[31],thepregnancyperiod may be too short and too intensive to deal adequately with stressors.Inlightoftheimportanceofsmokingcessationduring pregnancy, stressors should be made open to discussion and womentaughttocopewiththese,preferablyinanearlyphaseor evenbeforepregnancy.

Asecondresultisthattheneedsofwomenwhoaremotivated to stop smoking seem to differ from those of non-motivated women.Whilemotivatedwomenindicatedthattheyneed(more) supportfromaninvolvedhealthcareprofessional,non-motivated womenseemedtopreferlessinvolvement.Thisresultillustrates thatwomen needsupportthat istailoredtotheirown levelof readiness to quit smoking [9]. In previous qualitative studies, women perceived healthcare professionals to be coercive or naggingwhenthesupportwasnottailoredtotheirownreadiness to change [17,20]. Although the Dutch guideline recommends repeateddiscussionofsmokingcessationevenifwomenarenot motivatedtostopsmoking[7],littleevidenceisavailableaboutthe effectiveness of such repetition [32]. This raises the question whether healthcare professionals should persist in discussing

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smoking cessationif womenare notready for it.Based onthe needsofthewomenandtheirpartnersinourstudy,healthcare professionalsmightﬁrstneedtoaskwomeninwhatwayandhow frequentlytheywanttobesupported,soastotailorthesupportto theirreadinesstochange.Thisiscontradictorytotheprincipleof an opt-out referral system in the UK, where women are automaticallyreferredforsmokingcessationsupport[6].

Athirdﬁndingofourstudyisthatpregnantwomenandtheir partnersperceivesmokingbehaviourastheirownresponsibility. Thisperceivedautonomyinsmokingbehaviourwasnotreported in previous studies, performed in the UK, Australia and New Zealand, to address pregnant women_’s support needs [17_–20]. However,aDutchstudyamongpeoplewithchronicobstructive pulmonarydisease(COPD)alsoreportedthattheyhadaneedfor autonomyinsmokingbehaviour.Theauthorsstatedthatthiscould berelatedtotheDutchemphasisonindividualism[33]. Further-more,theperceptionofautonomymightbefedbypublichealth campaigns that hold the individual responsible for adopting a healthy lifestyle [34]. Our ﬁnding implies that respect for autonomyinthesmokingbehaviourofwomenandtheirpartners isanimportantelementfortailoredsmokingcessationsupport.

Relatedtothewomenandtheirpartners’desireforautonomy in smokingbehaviouristheirwish toreceivemoreinformation abouthowsmokingaffectstheirownhealthandthehealthofthe fetus;womenindicatedthattheypreferredtoseeproof,hoping thatthisinformationwouldmotivatethemtoquitsmoking.This could indicate that to enhance women's motivation to stop smokingmoreattentioncouldbefocusedonprovidingfeedback andpersonalisedinformation[11].IntheUKthis informationis givenintheformofCarbonMonoxide(CO)feedback,foundtobea helpfultoolinmotivatingwomentoquitsmoking[24].COtesting isnotastandardpartoftheDutchguidelineforsmokingcessation supportduringpregnancy,butmightbeanoptiontoexplore[7]. Thewomeninourstudypreferredthehealthcareprofessional toinvolvetheirsocialnetworkinthesmokingcessationsupport. Having ascertainedthe great inﬂuenceof partners onwomen’s smoking behaviour [5], previous studies also reported the importance of involving them in smoking cessation support [5,35].Althoughwomeninourstudypreferredtheinvolvement oftheirsocialnetworks,thismightbedifﬁculttoachievebecause partners and others members of their network are not always willing to be involved and to stop smoking [36]. Despite this discrepancy, a recent Dutch study recommends adjusting the guideline for smoking cessation support toinclude individuals fromwomen’s social network insmoking cessation supportby givingthemadvicetostopsmoking,providinginformationabout third-hand smoke, and referring them for intensive smoking cessationsupport[36].

4.1.Strengthsandlimitations

A strength of this study is its use of multiple methods to increasethevalidityandreliabilityoftheresults.Afterconducting theinterviews,weusedamembercheckandpeerdebrie_ﬁngto ensure agreement over the results. Furthermore, we involved expertsbyexperienceandresearchersofZorgbelanginthedesign andexecutionoftheinterviews.Theyensuredthattheinterview questionswerephrasedinawaythatmadewomenfeelateaseto sharetheirexperiences,assmokingduringpregnancycouldbea delicateissuetodiscuss.Furthermore,theinvolvementofthese experts made it possible to recruit women with a lower socioeconomicstatus,whoaredifﬁculttorecruit[37].

Somelimitationsofthisstudymustalsobeacknowledged.One isthataresponsebiasmaybepresentintherecruitmentofthe women and their partners. The women who applied for the interviewmightbemorewillingthanotherwomentosharetheir

needs.Furthermore,becauseweinterviewedonlyasmallnumber ofpartnerswedidnotreachdatasaturationforthem.

4.2.Recommendations

Basedonourresultswecanofferafewrecommendationsto improve the implementation of the guidelines for smoking cessation support and thereby the use of smoking cessation supportbypregnantwomen.Theadaptationsand recommenda-tionsmightalsobevaluableforothercountries.

First, already in an early phase or before pregnancy some womenmightneedtoreceivesupportfocusedonstressreliefand coping with stress. Second, healthcare professionals can best discusssmokingcessationinaneutralway,andtailortheirsupport towomen’sneedsbyaskingthemhowtheywanttobesupported. Third,optionscouldbeexploredtoincorporate inthesmoking cessation supportguidelines tailoredinformation and feedback aboutthenegativeeffectsofsmokingonwomen’sownhealthand thehealthofthefetus.Fourth,futureresearchcouldexploreways toincreasetheinvolvementofpartnersandothers(e.g.friendsand familymembers)fromwomen’ssocial networksinprofessional smoking cessation support. Lastly, involvement of women and theirpartnersinthedevelopmentofsmokingcessationsupport guidelinescouldmakethelattermoretailoredtowomen’sneeds andthusmorelikelytobeimplemented[38,39].

5.Conclusion

Althoughprofessionalsmokingcessationsupportincreasesthe prevalenceof womenwhoquitsmoking duringpregnancy,few womenactuallymakeuseofsmokingcessationsupport.Weaimed togaininsight intotheneedsof womenand theirpartnersfor professional smoking cessation support during pregnancy. The findingsofourstudyindicatethatwomenandtheirpartnershave clearideasabouthowthesupportcouldbeorganised.Tobetter tailorthis supporttowomen’sneeds, thecurrentguidelinesfor professionalsmokingcessationsupportcouldbenefitfromsome adaptations. Moreover, women’s needs for smoking cessation supportmaydifferdependingontheinfluenceofstressintheir livesandtheirmotivationlevels.Thefindingsofourstudyaddthat pregnantwomenandtheirpartnersperceivesmokingbehaviour astheirownresponsibility.Therefore,healthcareprofessionalscan best address smoking cessation in a neutral way, and respect women’s autonomy in their decision about smoking cessation. Moreresearchisneededregardingtheinclusionofwomen’ssocial networks in smoking cessation support. Early involvement of womenandtheirpartnersinthedevelopmentofguidelinescould improve the implementation of the guidelines and the use of smoking cessation support. Healthcare professionals in other countrieswheresmokingduringpregnancyisprevalentmayalso bene_fitfromtheinsightsprovidedbythisstudy[3].

Authoragreement

Thearticleistheauthorsoriginalworkandhasnotreceived priorpublicationand isnotunderconsiderationfor publication elsewhere.Allauthorshaveseenandapprovedthesubmissionof themanuscript.Theauthor(s)abidebythecopyrighttermsand conditionsofElsevierandtheAustralianCollegeofMidwives. Funding

This work was supported by the Dutch institute ZonMW (number531003018)andispartofthebroaderproject‘Together we’llquitsmoking!OptimizingtheimplementationoftheTrimbos guideline ‘smoking cessation counseling’ in daily practice of

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healthcareprofessionalssupportinglowSESpregnantwomenin theNorthortheNetherlands’.ZonMWhadnoinvolvementinthe studydesign,thecollection,analysisorinterpretationofthedata. Ethicalstatement

Awaiver(number:METc2019/099)wasobtainedat12-02-2019 fromtheethicalreviewboardoftheUniversityMedicalHospital Groningen which states that the Medical Research Involving HumanSubjectsAct(WMO)doesnotapplytothisstudy. Con_ﬂictofinterest

Nonedeclared.

CRediTauthorshipcontributionstatement

S.Weiland:Conceptualization,Datacuration,Formalanalysis, Investigation, Methodology, Project administration, Writing -original draft. J.C. Warmelink: Data curation, Formal analysis, Project administration, Writing - review & editing. L.L. Peters: Conceptualization,Datacuration,Fundingacquisition, Methodol-ogy, Project administration, Resources, Supervision, Writing -review & editing. M.Y. Berger: Conceptualization, Funding acquisition,Projectadministration,Supervision,Writing-review &editing.J.J.H.M.Erwich:Conceptualization,Fundingacquisition, Projectadministration,Resources,Supervision,Writing-review& editing.D.E.M.C.Jansen:Conceptualization,Fundingacquisition, Methodology, Project administration, Resources, Supervision, Writing-review&editing.

Acknowledgments

Theauthorswouldliketothanktheexpertsbyexperiencein povertyandsocialexclusionLindaDrenthandRianeKuzeefrom thefoundationStrongOutofPoverty(inDutch:SterkuitArmoede) andtheresearchersofZorgbelang(Dr.MariekeNanningaandRoos Edens,MSc)fortheirimportantcontributiontotheinterviews.We wouldalsoliketothanktheparticipantsoftheinterviewsandthe healthcareprofessionalswhosharedtheﬂyerforrecruitment.

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