Themes
Mixed feelings regarding managing smoking during pregnancy
Participants demonstrated a mixture of feelings about optimism. Some were somewhat optimistic, mainly due to perceiving women as more receptive to change due to the pregnancy “Probably optimistic because they do have that added incentive to quit, that sometimes it’s a really good opportunity to get them to quit.” (#10, Female, under 30, Tasmania). Others were pessimistic, mainly due to recurring cases of continuing smoking, and related to all the other psychosocial issues that were out of their abilities to care for “I suppose I feel defeated by the people’s condition, too pessimistic about the people’s condition. So much needs to change in terms of changing tobacco.”(#1, Female, over 60, Northern Territory); “I have had so many experiences where I feel like I’ve provided a lot of education and time I’ve spent invested in trying to help the pregnant woman understand how harmful smoking is and yet she continues to smoke. I think that’s disheartening when you see the effects and you know you have tackled the problem and continue to address it, but that doesn’t necessarily change the patient”(#5, Female, Queensland, age unknown).
Participants viewed addressing smoking as an important part of their role, and viewed their relationship with the patient as imperative to reaching the patient “there is benefit of having us there… as their regular health professional. I think it does make a huge difference to how much they’re likely to listen to that advice and take it on board.” (#5, Female, Queensland, age unknown). Nonetheless, it was evident that they felt that combating smoking in pregnancy is not just a medical condition they can treat, and would require other policy measures that address the psychosocial factors that also impact smoking, and make quitting more difficult “when you’ve got overcrowding, domestic violence, you were abused as a kid, be it physically, emotionally or sexually, when there’s flies crawling all around the floor, when everybody else in the house smokes, I just feel like it’s just such a mountain.” (#1, Female, over 60, Northern Territory).
Time was perceived as problematic for some, usually in relation to other competing priorities. “…something else would have to get cut out. There isn’t really anything you can cut out is the problem…” (#4, Female, 31–44, West Australia). Others, especially those working within Aboriginal Medical Services, found this was not an issue “Fortunately, we’re not as time bound as a city general practice” (#1, Female, over 60, Northern Territory).
Current practices were suboptimal
When asked about their approach to managing smoking, participants described using the “stages of change” approach [
7]
“GP guidelines for quitting have got the whole ‘stages of change’….” (#10, Female, under 30, Tasmania). Women who were perceived as ‘not ready’ were provided with information on smoking harms; whereas women who were perceived as ‘ready’ to quit, were offered options for support
“I give them the information that they needed in order to make a decision, so make sure they knew about the harmful effects of smoking and determine their level of motivation and confidence in quitting, and if they were ready to quit, then we talk about the different ways of doing so.” (#11, Female, 45–60 years, West Australia). Participants also stated they would not mention the Quitline if they felt patients were not ready to quit
“If people don’t indicate to me that they’re interested in a planned cessation or decreasing, I don’t refer them to the Quitline.” (#12, Female, over 60, New South Wales). Participants emphasized a strong focus on providing information on the harms of tobacco smoking:
“explaining to them about the risks of pregnancy, explaining that it is extremely harmful… to understand that the smoking that they’re doing is harming their baby” (#5, Female, Queensland, age unknown). Most participants accepted cutting down consumption as an adequate method for managing smoking during pregnancy
“for the person who says ‘Well I’ll just smoke the minimum and that’s the best I can do’, I accept that.” (#2, Male, 45–60 years, Victoria).
Needing better communication skills
Participants expressed a need to learn ‘how’ to have conversations to support women in their quit journey. They wanted this shown to them explicitly (as opposed to just providing information): “I don’t feel like I know that very well because we don’t really learn that in med school. We learn a lot of the medical issues with smoking, but we’re not learning the psychology of smoking. It could even be just we watch a DVD and watch someone pattern a role model.” (#4, Female, 31–44 years, West Australia).
It was important to the participants to maintain a positive relationship with the pregnant patient “there’s real caution in when to push it and when to slack off a little bit and don’t say anything, but it just means you don’t make the person feel guilty and they’ll never want to see you again and you lose your influence altogether.”(#6, Male, Queensland, age unknown).This led participants to be wary of the way they were conveying the message “I’m inclined to just kind of put my blinkers on, I sort of bite my tongue a little bit when I know that it’s going to make the patient upset, or angry… it’s a tough issue, really tricky.” (#19, Female, 31–44 years, Northern Territory). Furthermore, participants talked about trying to provide information in a non-judgmental and supportive way “it is a delicate conversation to be had with the patient because you are telling them that what they are doing is potentially harming their baby, people can get very defensive, you want to maintain that rapport and you don’t want to be judgmental,” (#14, Female, 31–44 years, New South Wales). Acceptance of ‘cutting down’ was related to wanting to maintain good rapport and being supportive “I congratulate them on cutting down. She knows that she’s not doing the best by her baby or by herself, so forcing the issue and making her feel more bad about herself than she already is, it’s counter-productive”(#6, Male, Queensland, age unknown).
Barriers for NRT prescription
The common experience among participants was that most pregnant women simply did not want to use NRT “There’s quite a number of women who just aren’t interested… even in spite of reassurances that nicotine replacement is preferable to smoking… will say ‘No thanks. That’s just not quite me.” (#9, Female, 41–60 years, Queensland). This was related to safety concerns “They feel that their baby would be better off if they were to smoke intermittently rather than have constant nicotine” (#2, Male, 45–60 years, Victoria); or to women’s negative experiences from prior use “Women are afraid about using patches and then the other half have used them before when they weren’t pregnant and refused to use them again.” (#7, Female, New South Wales, age unknown).
Most of the participants were comfortable prescribing NRT during pregnancy (also evident in their survey answers, Additional file
2), and stated that NRT was safer than smoking. Despite this, some reported concerns
“I always feel a bit concerned about doing actually more harm than good insofar as you know these women that appear to not be smoking very much” (#3, Female, 31–44, Northern Territory). Several participants felt that not all pregnant women were physically addicted to nicotine, and that their smoking was due to other reasons such as stress. Therefore, they did not think NRT to be an appropriate treatment in this context. They described NRT as only appropriate to consider in highly addicted smokers, and/or that combination treatment is not suitable
“it depends why she says she’s smoking. If there’s an element of addiction to it… I do suggest they go on patches” (#4, Female, 31–44, Western Australia).
Participants described several possible facilitators that might help them to improve their confidence and skills regarding NRT prescription:
1)
Needing clear and detailed information
Participants expressed a need for clear guidance on when it was appropriate to initiate NRT and how to determine the dose
“I suppose we need sort of like training modules… like an algorithm about ‘This is what you use. This is how you start it. These are the benefits’.”(#8, Female, South Australia, age unknown); the lack of clear guidance impacted their confidence in discussing NRT “
I would have to look up doses…it might make me a little bit less happy to engage and have a longer consult because I just don’t feel confident with my level of knowledge” (#8, Female, South Australia, age unknown).
2)
Requiring visual resources
Participants wanted resources to guide the conversation on NRT safety, helping them feel more confident to recommend it in pregnancy, and provide an objective portray for the women
"A very simple kind of handout or even if it’s like a poster in the room… it’s more just as a back-up thing. So, like, “Hey, it’s not just me saying it” (#14, Female, 31–44 years, New South Wales). Those working with Aboriginal women emphasized the need for a visual culturally responsive resource
“Handouts that are appropriate for my patients, Aboriginal and Torres Strait Islander women… as you’re explaining it, you’ve got these visuals to point to.” (#14, Female, 31–44, New South Wales).
Those working with Aboriginal people (eligible to receive the patch for free as part of the Australian Government’s Pharmaceuticals Benefit Scheme) viewed the patch as their main option due to the cost of oral NRT, with having the patch at the service for free a major facilitator “in an Indigenous community, if anything costs money… that’s almost out of the question.” (#19, Female, 31–44 years, Northern Territory).
Barriers for Quitline referral
Participants were aware of the Quitline and have referred pregnant women to it, but most remarked about not being familiar with its process “it’s sort of like an unknown…I don’t know what happens when people call up to the Quitline, I don’t know if they would get the same counsellor each time or whether they just call up and then get a random person” (#14, Female, 31–44, New South Wales); feeling disconnected from the treatment their patients were receiving “.. I’ve been referring to the Quit Line, or giving the numbers to patients for the Quit Line for a long time. I’ve never received any information back and neither have I had any patients tell me that they’ve used it or found it effective.” (#7, Female, New South Wales, age unknown).
Several participants, specifically those working with Aboriginal women, remarked on the Quitline not being suitable, preventing them from being more proactive “It wouldn’t be something we’d jump into because of that kind of language and cultural barrier…” (#1, Female, over 60, Northern Territory); “I think it’s pretty unlikely that a young remote Indigenous girl’s going to call the Quitline. I wouldn’t avoid talking about it, but I guess it’s not usually sort of top of my list of things to talk to her about.”(#19, Female, 31–44 years, Northern Territory). When asked directly, participants working with Aboriginal people did not know that you can request an Aboriginal counsellor “if you had an Aboriginal Quitline, they might be more likely to use that…. I’ve never actually rung them up and found out.” (#1, Female, over 60, Northern Territory).