Lack of a comprehensive programming approach
There was a perceived absence of cessation programs tailored to meet the diverse needs of women. Specifically, programming lacked a woman-centred approach that incorporated the social determinants of health. Key informants also noted that existing cessation programs were “too cessation-focused” and emphasized the importance of adopting harm-reduction approaches, specifically reducing consumption, when working with this population. Harm-reduction was a means to build self-efficacy in the pursuit of quitting and reduce the fear and/or feelings of failure should a woman not meet a quit date or relapse. Key informants thus advocated for a “no-wrong door” approach to cessation. This entailed having dedicated cessation programs for pregnant and postpartum women within public health and integrated support in maternal and child health services. In line with this suggestion, both women and key informants stressed that smoking by partners, family members and friends deterred quit or reduction attempts and thus conveyed the need for programs and services that target partner and family smoking.
It’s hard because I want to keep trying to not do it all but it’s just always in my mind. Yeah, and I see him doing it all the time…I’m glad now that we’re living at in his dad’s that it’s an outside thing. You have to go outside to smoke because the place we’re living in before, everyone is smoking inside. It was horrible. (Pregnant woman, Central region)
Inconsistent practice
Key informants sensed a lack of comfort and confidence in addressing smoking cessation among service providers and a lack of clarity about the safety of perinatal cessation and the use of NRT/quit smoking medication. Some acknowledged that providers sometimes feel uneasy addressing tobacco and other addictions in this population and that fear of harming the fetus through smoking cessation activities might be the root cause of this trepidation.
…I find, fear and stigma around working with pregnant women because of (Name of Children’s Interest Organization), because there is this unborn child and, and there’s that sort of stuff that you can’t…like it’s hard to control for everything. (Key informant, Central region)
Further, women in this study reported discrepancies in the cessation support received from their providers. Some providers reportedly advised women to cut down and eventually quit and continued to inquire about smoking throughout the pregnancy. Others reportedly inquired at the beginning, but did not follow-up throughout pregnancy. Women also described direct and indirect experiences with providers’ hesitancy prescribing NRT.
They told me here not to do that and they wouldn’t give me the patch because I was pregnant. (Postpartum woman, Central region)
Key informants recommended annual training in minimal contact intervention (MCI) and training in the best practices in smoking cessation for pregnant and postpartum women, as well as incorporating modules on perinatal cessation into diploma, undergraduate, postgraduate or continuing education credits. Developing systemic relationships between organizations, practitioners and experts that work with this population was also suggested to facilitate referral within and between community organizations, promote individualized treatment plans and promote learning across sectors and communities. Knowledge exchange channels, such as perinatal smoking cessation coalitions, communities of practice and/or working groups were recommended to achieve this.
Engagement and accessibility issues
The women noted competing priorities as a barrier to engaging in cessation support. Attending pre/postnatal appointments, alternate substance use, difficult domestic situations and socioeconomic factors, such as housing and food insecurity, often take precedence in these women’s lives, potentially leaving little time to attend a cessation program or service. Women also highlighted the following as barriers to accessing programs: failure to meet program inclusion criteria, inadequate cessation support for partners and family members, lack of childcare and transportation, timing of programs, cost and fear of failure.
Participants highlighted various ways to improve reach and engagement. Engaging local women in program development and implementation was important to inform relevant and accessible community support, establish program ownership and thus facilitate uptake. Providing incentives such as grocery or pharmacy gift certificates or free meals was considered especially useful for pregnant and postpartum participants who are more socioeconomically disadvantaged. For example, a young mother discussed how the weekly grocery store gift cards she received for attending the local perinatal cessation group empowered her to replace smoking with healthy eating.
They give free transportation and they give you a $20.00 gift card towards (Name of grocery store) to get your fruits or whatever you need to supplement healthy eating and to stop binge eating from smoking [Laughs]…I think it’s a really good incentive for people to go…I feel good about myself and this is making me feel even better because after this I don’t need a cigarette. I can go to the grocery store and get healthy food or whatever. (Postpartum woman, Central East Region)
Key informants recommended offering transportation, childcare and meals/snacks; adopting woman-centred and harm-reduction approaches; and promoting programs through a variety of local venues (i.e., grocery store bulletin boards, laundromats, community centres). Provider home visits were also perceived as an avenue to better understand the clients’ needs and their environment, to tailor support and build provider-family trust.
In addition to program characteristics, stigma and misconceptions about smoking cessation during pregnancy emerged strongly in interviews and were noted barriers to accessing adequate support. Women often mentioned hiding their smoking and their bodies because of the judgment they experienced when they smoked in public or in front of family. While some women felt very comfortable with their physicians, others felt intimidated or feared judgment. A young mother described feeling ‘ashamed’ and ‘devastated’ when ‘people stared’ and when her physician spoke to her about smoking during pregnancy. Key informants believed that stigma and fear of judgment prevented some women from revealing smoking status to their providers and/or from accessing help. This was evident in the narratives of some women.
I find like I’m embarrassed and like if I go into the hospital or anything, I kind of like lie and say I don’t smoke, when I do, because I get less shamed when…they start like lecturing me. I get kind of frustrated and I just want it to be over and done with…So now if I go to like the hospital or if I go my appointments and stuff, I kind of lie and say I don’t smoke when I do…Which I shouldn’t do, but I don’t want to feel that judgment. (Pregnant woman, Central Region)
Many women perceived quitting during pregnancy as too stressful for the fetus, potentially causing harm or even miscarriage. Some cited service providers and others cited family and friends as the source of this information. There was also confusion about the general safety of using the nicotine patch and its effects not only on the woman’s health, but the health of the baby. When asked about the nicotine patch, a young pregnant woman noted that she “didn’t think pregnant woman could take them.” Two young women felt that NRT was “not good for you” because it “screws up your period,” and “screws up your sleeping patterns.” These young women likened NRT to “24/7 cigarette.” Key informants vocalized concern that misconceptions might prevent women from seeking help and/or providers from offering appropriate support.
To address issues surrounding stigma and misconceptions, key informants articulated the importance of training service providers to understand the role of smoking within a woman’s life, use positive messaging and to practice in an empathetic manner. In addition to physicians and public health nurses, key informants emphasized the need for smoking cessation training among health/social care professionals who work with women, particularly those who work with women that experience disadvantage. Social, youth, addiction and community health workers were considered especially important as they often have longstanding trusting relationships with women. Finally, key informants conveyed the importance of provincial media campaigns to raise awareness about programs and services, reduce stigma, and dispel the misconceptions surrounding quitting and NRT use during pregnancy.