Interest in and Use of Smoking Cessation Support Across Pregnancy and Postpartum

The Effectiveness of Text Support for Stopping Smoking in Pregnancy (MiQuit): Multi-Trial Pooled Analysis Investigating Effect Moderators and Mechanisms of Action

INTRODUCTION

Digital cessation support appeals to pregnant smokers. In two pooled RCTs, MiQuit, a pregnancy-specific tailored text messaging intervention, did not show effectiveness for validated prolonged abstinence. However, secondary outcomes and potential moderators and mediators have not been investigated. We aimed to determine, using pooled RCT data: (1) MiQuit effectiveness on a range of smoking outcomes; (2) whether baseline tobacco dependence or quit motivation moderate effectiveness; (3) whether hypothesized mechanisms of action (quitting determination, self-efficacy, baby harm beliefs, lapse prevention strategies) mediate effectiveness.

METHODS

Pooled data analysis from two procedurally identical RCTs comparing MiQuit (N = 704) to usual care (N = 705). Participants were smokers, <25 weeks pregnant, recruited from 40 English antenatal clinics. Outcomes included self-reported 7-day abstinence at 4 weeks post-baseline and late pregnancy, and prolonged abstinence. Late pregnancy outcomes were also biochemically validated. We used hierarchical regression and structural equation modeling.

RESULTS

MiQuit increased self-reported, 7-day abstinence at 4 weeks (OR = 1.73 [95% CI 1.10-2.74]) and was borderline significant at late pregnancy (OR = 1.34 [0.99-1.82]) but not for prolonged or validated outcomes. Effectiveness was not moderated by baseline dependence (heaviness of smoking "low" vs. "moderate-high") or motivation (planning to quit ≤30 days [high] vs. >30 days [low]), but effects on self-reported outcomes were larger for the high motivation sub-group. MiQuit had a small effect on mean lapse prevention strategies (MiQuit 8.6 [SE 0.17], UC 8.1 [SE 0.17]; P = .030) but not other mechanisms.

CONCLUSIONS

MiQuit increased short-term but not prolonged or validated abstinence and may be most effective for those motivated to quit sooner.

IMPLICATIONS

Digital cessation support appeals to pregnant smokers. MiQuit, a tailored, theory-guided text messaging program for quitting smoking in pregnancy, has not shown effectiveness for validated prolonged abstinence in two previous RCTs but its impact on other smoking outcomes and potential mechanisms of action are unknown. When pooling trial data, MiQuit increased self-reported short-term abstinence, including making a quit attempt and abstinence at 4-week follow-up, but not late pregnancy, sustained, or validated abstinence. MiQuit appeared effective at late pregnancy for participants with high quitting motivation, but its mechanisms of action remain uncertain. Additional support components are likely required to enhance effectiveness.

Association between reproductive factors with lung cancer incidence and mortality: A pooled analysis of over 308,000 females in the Asia cohort consortium

Previous studies have investigated the association between reproductive factors and lung cancer risk; however, findings have been inconsistent. In order to assess this association among Asian women, a total of 308,949 female participants from 11 prospective cohorts and four Asian countries (Japan, Korea, China, and Singapore) were included. Cox proportional hazards regression models were used to estimate the hazard ratios (HR) and 95% confidence intervals (CIs). A total of 3,119 primary lung cancer cases and 2247 lung cancer deaths were identified with a mean follow-up of 16.4 years. Parous women had a lower risk of lung cancer incidence and mortality as compared with nulliparous women, with HRs of 0.82 (95% CI = 0.70-0.96) and 0.78 (95% CI = 0.65-0.94). The protective association of parity and lung cancer incidence was greater among ever-smokers (HR = 0.66, 95% CI = 0.49-0.87) than in never-smokers (HR = 0.90, 95% CI = 0.74-1.09) (P-interaction = 0.029). Compared with age at first delivery ≤20 years, older age at first delivery (21-25, ≥26 years) was associated with a lower risk of lung cancer incidence and mortality. Women who ever used hormone replacements had a higher likelihood of developing non-small cell lung cancer (HR = 1.31, 95% CI = 1.02-1.68), compared to those who never used hormone replacements. Future studies are needed to assess the underlying mechanisms, the relationships within these female reproductive factors, and the potential changes in smoking habits over time.

Factors influencing midwives' conversations about smoking and referral to specialist support: a qualitative study informed by the Theoretical Domains Framework

AIMS

The aim of this study was to identify factors influencing midwives' conversations about smoking, and referral to specialist smoking cessation services, using an evidence-based theoretical framework.

METHODS

Semi-structured, qualitative interviews were undertaken with community midwives employed within one health board region of Wales. Deductive framework analysis was employed by coding data to the domains of the Theoretical Domains Framework (TDF) and then identifying themes within domains and across participants.

RESULTS

Seven midwives took part in the study. 13, out of a possible 14 domains, were mapped from the TDF. Key enablers to conversations and referrals include knowledge of the risks of smoking in pregnancy, congruence with the professional identity of a midwife, and the use of carbon monoxide monitors in initiating conversations and referrals. Limited knowledge of the specialist service, confusion about the opt-out pathway, varied skills in communicating and engaging with women, low confidence in ability to influence women's decisions, limited appointment times, and competing priorities were identified as barriers.

CONCLUSION

Midwives recognise the importance of their role within the provision of smoking cessation advice and referral to specialist services. While there are continued time pressures and competing priorities for midwives, enhancing skills and confidence in collaborative, empowering approaches to addressing smoking would further support in optimising the uptake of maternity smoking cessation support. This could also enhance conversations about other public health issues such diet, physical activity, and alcohol use.

The Relationship Between Reported Daily Nicotine Dose from NRT and Daily Cigarette Consumption in Pregnant Women Who Smoke in an Observational Cohort Study

INTRODUCTION

For nonpregnant people unable to quit smoking, the NHS recommends nicotine replacement therapy (NRT) for smoking reduction. This is not recommended during pregnancy due to concerns about higher nicotine intake than smoking alone. We investigated the relationship between daily nicotine dose from NRT and cigarette consumption reported by pregnant women receiving smoking cessation support.

METHODS

We conducted secondary analysis of data from currently smoking pregnant women, recruited from antenatal clinics (Nottingham University Hospitals, UK) or online between June 2019-September 2020. Participants set a quit date, received a prototype NRT adherence intervention, and reported cigarettes per day (CPD) and daily NRT dose (mg) via smartphone app for 28 days.

RESULTS

388 women were screened, 32 (8%) were eligible and joined the study. 24 (75%) submitted 510 app reports in total. 17 (71%) reported smoking and using NRT concurrently on at least one day, with concurrent use reported on 109 (21%) of app reports.The relationship between daily NRT dose and CPD followed an exponential decay curve of approximately 7%. In multilevel repeated measures modelling using 4 linear splines (knots 17, 40, and 85 mg/NRT), significant fixed effects of daily NRT dose on CPD were observed for splines 1, 3, and 4. The strongest association was spline 1 (0-17 mg/NRT), where each 10 mg NRT increase was associated with a 0.6 CPD reduction (24% on average).

CONCLUSIONS

Among women in a cessation study, many smoked and used NRT concurrently; within these women, daily nicotine dose and heaviness of smoking were inversely related.

IMPLICATIONS

Findings have implications for the design of future interventions intended to reduce harm associated with smoking in pregnancy. They suggest using NRT alongside smoking in pregnancy could help some women reduce the number of cigarettes they smoke per day.

Understanding for whom, under what conditions and how smoking cessation services for pregnant women in the United Kingdom work-a rapid realist review

BACKGROUND

Maternal smoking in pregnancy is associated with several adverse maternal and infant health outcomes including increased risk of miscarriage, stillbirth, low birth weight, preterm birth, and asthma. Progress to reduce rates of smoking at time of delivery in England have been slow and over the last decade, less than half of pregnant women who accessed services went onto report having quit. This realist review was undertaken to improve the understanding of how smoking cessation services in pregnancy work and to understand the heterogeneity of outcomes observed.

METHODS

The initial programme theory was developed using the National Centre for Smoking Cession and Training Standard Treatment Programme for Pregnant Women and the National Institute for Health and Care Excellence guidance on treating tobacco dependency. A search strategy and inclusion criteria were developed. Four databases were searched to identify published papers and four websites were hand searched to identify any unpublished literature that could contribute to theory building. Realist logic was applied to the analysis of papers to identify the contexts in which the intended behaviour change mechanism(s) were triggered, or not, and towards what outcomes to develop context mechanism outcome configurations.

RESULTS

The review included 33 papers. The analysis produced 19 context mechanism outcome configurations structured under five closely interconnected domains (i) articulating harm, (ii) promoting support, (iii) managing cravings, (iv) maintaining commitment and (v) building self-efficacy. This review identifies two key processes involved in how services achieve their effects: how material resources are implemented and relationships. Of the two key processes identified, more existing literature was available evidencing how material resources are implemented. However, the review provides some evidence that non-judgemental and supportive relationships with healthcare workers where regular contact is provided can play an important role in interrupting the social cues and social practice of smoking, even where those around women continue to smoke.

CONCLUSIONS

This review clarifies the range of interconnected and bi-directional relationships between services and the personal and social factors in women's lives. It underscores the importance of aligning efforts across the models five domains to strengthen services' ability to achieve smoking cessation.

International and national frameworks, guidelines, recommendations, and strategies for maternal tobacco prevention and cessation: A scoping review protocol

Tobacco use during and around pregnancy can significantly increase the risk of stillbirth, congenital disabilities, premature birth, and low-weight birth. To establish maternal tobacco prevention and cessation frameworks for primary care and dental providers and to facilitate cross-national learning, this scoping review aims: 1) to analyze the body of literature on maternal tobacco prevention and cessation frameworks, guidelines, recommendations, and strategies at the international and national level; 2) to identify common core elements; and 3) to identify gaps in the literature, and propose future initiatives and policy development directions. A systematic database search based on the JBI methodology and corresponding PRISMA-ScR guidelines will be conducted from January 2015 to August 2023. Searches in different databases will be combined with an expert survey among the members of the World Federation of Public Health Associations (WFPHA) - Oral Health, Tobacco Control, and the Women, Adolescent, and Children's Working Groups to evaluate the search outcomes and add maternal tobacco prevention and cessation frameworks, guidelines, recommendations, or strategies. Using a systematic review tool to support the screening, two independent reviewers will screen the titles and abstracts of all articles, in order to include the relevant ones for full-text screening, and an independent third author will resolve conflicts, if there is any discrepancy between the two independent reviewers' search. After a full-text review, data extraction will be conducted for analysis. Descriptive analyses include the publication year, country, legal quality, and target group addressed. A narrative synthesis will describe the scope and content of the frameworks, guidelines, recommendations, and strategies. The scoping review will serve as a stepping-stone to creating a WFPHA policy resolution on tobacco prevention and cessation framework for women of childbearing age led by the WFPHA Oral Health, Tobacco Control and the Women, Adolescent, and Children's Working Group members. This WFPHA policy resolution 'Maternal Tobacco Cessation and Prevention Recommendations for Primary Care Providers and Dental Providers' will be forwarded to the WFPHA General Council and the General Assembly for approval and will be disseminated to the WFPHA public health association members. Ultimately, this recommendation will be used by each national public health association to consider integrating it into their maternal health strategy.

Supporting pregnant women not ready to quit smoking: an economic evaluation

OBJECTIVES

Some pregnant women are not ready or do not want to quit smoking completely, and currently there is no support provided for these women in the UK. Offering help to reduce smoking could reduce the health risks associated with smoking and increase the limited reach of the NHS Stop Smoking Services (SSS) for pregnant women. This study aimed to design and evaluate a hypothetical intervention aimed at pregnant women who are not yet ready or do not want to quit smoking entirely.

METHODS

A hypothetical intervention, the Reduced Smoking During Pregnancy (RSDP) intervention, was conceptualised based on the best available evidence. The intervention was evaluated, using a decision-analytic model developed for SDP interventions. Two different scenarios, a base-case and a cautious-case were developed, and a cost-utility analysis and return on investment analysis were conducted. The uncertainty around the estimates was assessed, using deterministic and probabilistic sensitivity analyses.

RESULTS

The RSDP intervention could prevent the loss of 13 foetuses and generate 43 quitters 1 year after delivery per 1000 women. In the lifetime analysis, the intervention was cost-effective in both scenarios, with an incremental cost of £363 (95% CI £29 to £672) and 0.44 (95% CI 0.32 to 0.53) QALYs gained in the base-case.

CONCLUSIONS

The study found that the hypothetical reduction intervention would produce significant health benefits, reduce smoking and be cost-effective. Offering pregnant smokers help to reduce smoking could reduce health inequalities, widen the reach of SSS and improve health. This economic evaluation of a novel, intensive intervention could inform the piloting of such interventions.

Towards optimum smoking cessation interventions during pregnancy: a household model to explore cost-effectiveness

BACKGROUND AND AIMS

Previous economic evaluations of smoking cessation interventions for pregnant women are limited to single components, which do not in isolation offer sufficient potential impact to address smoking cessation targets. To inform the development of more appropriate complex interventions, we (1) describe the development of the Economics of Smoking in Pregnancy: Household (ESIP.H) model for estimating the life-time cost-effectiveness of smoking cessation interventions aimed at pregnant women and (2) use a hypothetical case study to demonstrate how ESIP.H can be used to identify the characteristics of optimum smoking cessation interventions.

METHODS

The hypothetical intervention was based on current evidence relating to component elements, including financial incentives, partner smoking, intensive behaviour change support, cigarettes consumption and duration of support to 12 months post-partum. ESIP.H was developed to assess the life-time health and cost impacts of multi-component interventions compared with standard National Health Service (NHS) care in England. ESIP.H considers cigarette consumption, partner smoking and some health conditions (e.g. obesity) that were not included in previous models. The Markov model's parameters were estimated based on published literature, expert judgement and evidence-based assumptions. The hypothetical intervention was evaluated from an NHS perspective.

RESULTS

The hypothetical intervention was associated with an incremental gain in quitters (mother and partner) at 12 months postpartum of 249 [95% confidence interval (CI) = 195-304] per 1000 pregnant smokers. Over the long-term, it had an incremental negative cost of £193 (CI = -£779 to 344) and it improved health, with a 0.50 (CI = 0.36-0.69) increase in quality-adjusted life years (QALYs) for mothers, partners and offspring, with a 100% probability of being cost-effective.

CONCLUSIONS

The Economics of Smoking in Pregnancy: Household model for estimating cost-effectiveness of smoking cessation interventions aimed at pregnant women found that a hypothetical smoking cessation intervention would greatly extend reach, reduce smoking and be cost-effective.

Quitting Smoking before and after Pregnancy: Study Methods and Baseline Data from a Prospective Cohort Study

Smoking during pregnancy and postpartum remains an important public health problem. No known prior study has prospectively examined mutual changes in risk factors and women's smoking trajectory across pregnancy and postpartum. The objective of this study was to report methods used to implement a prospective cohort (Msgs4Moms), present participant baseline characteristics, and compare our sample characteristics to pregnant women from national birth record data. The cohort study was designed to investigate smoking patterns, variables related to tobacco use and abstinence, and tobacco treatment quality across pregnancy through 1-year postpartum. Current smokers or recent quitters were recruited from obstetrics clinics. Analyses included Chi-square and independent sample t-tests using Cohen's d. A total of 62 participants (41 smokers and 21 quitters) were enrolled. Participants were Black (45.2%), White (35.5%), and multiracial (19.3%); 46.8% had post-secondary education; and most were Medicaid-insured (64.5%). Compared with quitters, fewer smokers were employed (65.9 vs 90.5%, Cohen's d = 0.88) and more reported financial strain (61.1% vs 28.6%; Cohen's d = 0.75). Women who continue to smoke during pregnancy cope with multiple social determinants of health. Longitudinal data from this cohort provide intensive data to identify treatment gaps, critical time points, and potential psychosocial variables warranting intervention.

Promoting smoking cessation during pregnancy: A feasibility and pilot trial of a digital storytelling intervention delivered via text-messaging

OBJECTIVE

Smoking during pregnancy causes risks to mother and infant health. We investigated the feasibility and likely success of SKIP-IT, a narrative and picture-based smoking cessation intervention delivered via text messages.

METHODS

A feasibility and pilot trial. We aimed to recruit 70 pregnant women who smoked, randomised to usual care alone, or usual care and the SKIP-IT intervention, between 12 weeks of pregnancy and 6 weeks post due-date. Outcomes assessed were recruitment, retention, acceptability of, and engagement with the intervention, smoking behaviour, intentions, perceived risk, and self-efficacy.

RESULTS

Of 312 women initially approached by smoking cessation services only 54 (17%) agreed to be contacted by the research team. Twenty were then either ineligible or uncontactable and 28 (82%) participated. Most women reported texts to be entertaining and helpful. The proportion of women not smoking at follow-up was lower in the intervention group, but numbers were too small to draw conclusions about effectiveness.

CONCLUSION

The intervention was acceptable, but difficulty in making initial and follow-up contacts meant our methods were unfeasible for a larger trial.

PRACTICE IMPLICATIONS

Digital Storytelling interventions could help women quit smoking, but further research is required to identify alternative methods for studies with pregnant women who smoke.

Tobacco use during pregnancy

The use of tobacco during pregnancy is the leading preventable cause of pregnancy complications and adverse birth outcomes. In high-income countries, around one in 10 pregnant women smokes tobacco, while smokeless tobacco is the primary form of tobacco used in many low- and middle-income countries. Although the risk of tobacco-related harms can be reduced substantially if mothers cease smoking in the first trimester of pregnancy, the proportion of women who successfully quit smoking during pregnancy remains modest. Psychosocial interventions are first-line treatment, with some high-quality evidence showing that counselling is effective in promoting smoking cessation among pregnant women. There is insufficient evidence regarding the efficacy and safety of smoking cessation pharmacotherapies when used during pregnancy, although in some countries nicotine replacement therapy is recommended for pregnant women who have been unable to quit without pharmacological assistance. E-cigarettes are increasingly being used as a smoking cessation aid in the general population of smokers, but more research is needed to determine if e-cigarettes are a safe and effective treatment option for pregnant women.

Effectiveness of offering tailored text message, self-help smoking cessation support to pregnant women who want information on stopping smoking: MiQuit3 randomised controlled trial and meta-analysis

AIMS

To test the efficacy of 'MiQuit', a tailored, self-help, text message stop smoking programme for pregnancy, as an adjunct to usual care (UC) for smoking cessation in pregnancy.

DESIGN

Multicentre, open, two-arm, parallel-group, superiority randomised controlled trial (RCT) and a trial sequential analysis (TSA) meta-analysis combining trial findings with two previous ones.

SETTING

Twenty-four English hospital antenatal clinics.

PARTICIPANTS

A total of 1002 pregnant women who were ≥16 years old, were ≤25 weeks gestation and smoked ≥1 daily cigarette and accepted information on cessation with no requirement to set quit dates.

INTERVENTIONS

UC or UC plus 'MiQuit': 12 weeks of tailored, smoking cessation text messages focussed on inducing and aiding cessation.

MEASUREMENTS

Primary outcome: biochemically validated cessation between 4 weeks after randomisation and late pregnancy.

SECONDARY OUTCOMES

shorter and non-validated abstinence periods, pregnancy outcomes and incremental cost-effectiveness ratios.

FINDINGS

RCT: cessation was 5.19% (26/501) and 4.59% (23/501) in MiQuit and UC groups (adjusted odds ratio [adj OR] for quitting with MiQuit versus UC, 95% CI = 1.15 [0.65-2.04]); other abstinence findings were similar, with higher point estimates. Primary outcome ascertainment was 61.7% (309) and 67.3% (337) in MiQuit and UC groups with 71.1% (54/76) and 69.5% (41/59) abstinence validation rates, respectively. Pregnancy outcomes were similar and the incremental cost per quality-adjusted life year was -£1118 (95% CI = -£4806-£1911). More MiQuit group women reported making at least one quit attempt (adj OR [95% CI]) for making an attempt, 1.50 (1.07-2.09). TSA meta-analysis: this found no significant difference in prolonged abstinence between MiQuit and UC (pooled OR = 1.49, adjusted 95% CI = 0.62-3.60).

CONCLUSIONS

Irrespective of whether they want to try quitting, when offered a tailored, self-help, text message stop smoking programme for pregnancy (MiQuit) as an adjunct to usual care, pregnant women are not more likely to stop smoking until childbirth but they report more attempts at stopping smoking.

Accessing specialist support to stop smoking in pregnancy: A qualitative study exploring engagement with UK-based stop smoking services

Objectives

Specialist stop smoking services can be effective for supporting women with smoking cessation during pregnancy, but uptake of these services is low. A novel theoretical approach was used for this research, aiming to identify barriers to and facilitators of engaging with specialist smoking cessation support using the Theoretical Domains Framework (TDF).

Methods

Semi‐structured interviews and a focus group (n = 28) were carried out with pregnant women who smoke/recently quit smoking, midwives and Stop Smoking in Pregnancy advisors from two local authority commissioned services in the UK. Inductive thematic analysis was used to code interview transcripts and deductive thematic analysis used to match emerging themes to TDF domains.

Results

Themes corresponded to seven domains of the TDF: Knowledge: Knowledge of available services for pregnant smokers; Environmental context and resources: Uptake of referral to cessation services by pregnant smokers; Social Influences: Smoking norms and role of others on addressing smoking in pregnancy; Beliefs about Capabilities: Confidence in delivering and accepting pregnancy smoking cessation support; Beliefs about Consequences: Beliefs about risks of smoking in pregnancy and role of cessation services; Intentions: Intentions to quit smoking during pregnancy; Emotions: Fear of judgement from healthcare professionals for smoking in pregnancy.

Conclusions

These novel findings help to specify factors associated with pregnant women’s engagement, which are useful for underpinning service specification and design by public health commissioners and service providers. Addressing these factors could help to increase uptake of cessation services and reduce rates of smoking in pregnancy.

Improving implementation of smoking cessation guidelines in pregnancy care: development of an intervention to address system, maternity service leader and clinician factors

Background

Smoking during pregnancy increases the risk of multiple serious adverse infant, child and maternal outcomes, yet nearly 10% of Australian women still smoke during pregnancy. Despite evidence-based guidelines that recommend routine and repeated smoking cessation support (SCS) for all pregnant women, the provision of recommended SCS remains poor. Guidance on developing complex interventions to improve health care recommends drawing on existing theories, reviewing evidence, undertaking primary data collection, attending to future real-world implementation and designing and refining interventions using iterative cycles with stakeholder input throughout. Here, we describe using the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework to apply these principles in developing an intervention to improve the provision of SCS in Australian maternity services.

Methods

Working closely with key stakeholders in the New South Wales (NSW) health system, we applied the steps of the BCW method then undertook a small feasibility study in one service to further refine the intervention. Stakeholders were engaged in multiple ways—as a core research team member, through a project Advisory Group, targeted meetings with policymakers, a large workshop to review potential components and the feasibility study.

Results

Barriers to and enablers of providing SCS were identified in five of six components described in the BCW method (psychological capability, physical opportunity, social opportunity and reflective and automatic motivation). These were mapped to intervention types and we selected education, training, enablement, environmental restructuring, persuasion, incentivisation and modelling as suitable in our context. Through application of the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects and Equity) in the stakeholder workshop, behaviour change techniques were selected and applied in developing the intervention which includes systems, clinician and leadership elements. The feasibility study confirmed the feasibility and acceptability of the midwifery component and the need to further strengthen the leadership component.

Conclusions

Using the BCW method combined with strong stakeholder engagement from inception resulted in transparent development of the MOHMQuit intervention, which targets identified barriers to and enablers of the provision of SCS and is developed specifically for the context in which it will be implemented. The intervention is being trialled in eight public maternity services in NSW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00235-5.

Barriers and Facilitators to Staying Smoke-Free after Having a Baby, a Qualitative Study: Women's Views on Support Needed to Prevent Returning to Smoking Postpartum

Background: Postpartum return to smoking (PPRS) is a common and important public health problem. Interventions to prevent PPRS have not been shown to be effective. We aimed to qualitatively explore the barriers and facilitators to staying smoke-free after having a baby, and women’s views on the support needed to avoid PPRS to inform future intervention development. Methods: We conducted semi-structured telephone interviews (n = 26) with pregnant women who quit smoking (n = 9), and postpartum women who were abstinent at delivery and returned to smoking (n = 7) or stayed smoke-free (n = 10). Inductive thematic analysis was used. Results: Five overarching themes were identified: (i) smoking intentions; (ii) facilitators to staying smoke-free; (iii) barriers to staying smoke-free; (iv) support to avoid relapse; and (v) e-cigarettes, nicotine replacement therapy, and varenicline. Facilitators to staying smoke-free were the health benefits to their baby, whilst barriers included stress, cravings, and being in environments where they would previously have smoked. Women wanted continuous offers of support to stay smoke-free throughout the extended postpartum period, with a particular interest in support for partners to quit smoking and self-help support. Women expressed safety concerns for e-cigarettes, nicotine replacement therapy, and varenicline. Conclusions: Offers of support to stay smoke-free should continue throughout the postpartum and engage with partners or other household members who smoke. Reassuring women about the relative safety of nicotine replacement therapy and e-cigarettes by a health professional, particularly for those who are breastfeeding, could be beneficial.

Experts' Views on Behaviour Change Techniques for Smoking Cessation in Pregnancy: A Qualitative Study

Smoking during pregnancy is a global health problem which has devastating health implications. Behavioural support is an important part of smoking cessation support for pregnant women. Research has identified barriers and facilitators (B&Fs) and effective behaviour change techniques (BCTs) to aid women's quit attempts. However, the extent to which and how these BCTs are used in practice is unclear. The research aimed to establish experts' views on how behavioural support can be optimised and techniques operationalised in clinical practice, by identifying ways to address known B&Fs for smoking cessation in pregnancy. A focus group discussion took place with six experts, which highlighted how BCTs can be used in practice to support women in their quit attempts. A thematic analysis was conducted to elicit overarching themes. Five themes were found: involving the family, empowering women, using incentives to boost motivation, using practical techniques to help women with their quit attempts and managing expectations about nicotine replacement therapy. Empowering women to make their own decisions and encouraging small positive changes in smoking habits, using visual aids (e.g., growth charts) to inform women of the harms of smoking to the baby and treating families holistically were deemed important.