Why Do Women Continue to Smoke in Pregnancy?
In line with the general downward trend in smoking, the rates of smoking in pregnancy have
also decreased. Smoking is defined as the “inhaling of burning tobacco fumes: an act of
smoking a cigarette, cigar, or pipe” (1). For this paper a smoker is defined as a woman who
smokes/ed one or more cigarettes at any time during her pregnancy (2). Passive smoking is
excluded from this definition.
National figures for 2001 report 27% of all females aged 15-44 years identified as smokers,
whilst 23% reported smoking during pregnancy and/or breastfeeding. The latest national data
is from 2004 by which time all females smoking had declined to 24% and smoking in
pregnancy and/or breastfeeding had declined to 20% respectively (3). Smoking and quit
rates in pregnancy are linked to race and socio-economic class. The World Health
Organization (4) reports smoking amongst women in the lowest socio-economic band is
three times higher than women in the highest band in some countries (4).
The paper begins by presenting an outline of the National Tobacco Strategy that forms
background for this paper. Next the literature search strategies that were used are
summarised. This review paper is primarily focused, not on the methodologies of the various
research studies, but on the problems of conceptualising the causes and ‘treatments’ of
smoking in pregnancy. It is these conceptualisations that guide the intervention strategies
that are used in both research and health care practice during childbearing. The
interventions that have been tested in research and been found to be most and least
effective are identified.
It is estimated that 19,000 Australians die each year from tobacco-induced illnesses (5). The
National Tobacco Strategy, 2004-2009 (6) is intended to provide federal, state and territory
governments an evidenced-based, co-ordinated, national plan to reduce tobacco smoking in
Australia. Smoking, above all other health risk factors is presented as the national health
priority, with the goal of the strategy to reduce social costs and inequities exacerbated by
tobacco consumption (6).
It is recommended anti-smoking interventions be based on the best practice guidelines. In
relation to quit smoking this means following the “5As” approach in health care practice (7).
See table 1 for details of what the levels and strengths of evidence means for each of the 5
1. Ask. In order to support persons to quit, we need to identify them as a smoker
(evidence II, strength A)
2. Assess. Determine the persons willingness to alter their smoking behaviour (evidence
III, strength B)
3. Advise. Inform persons of the dangers of smoking and the benefits of quitting
(evidence I, strength A)
4. Assist. Provide assistance targeted at individual’s needs and level of readiness to
change (no level of evidence provided)
5. Arrange Follow-up. Ensure to arrange to see person again to follow-up quit attempt
(evidence I, strength A)
The National Tobacco Strategy is designed to be general in nature; when talking about
someone who might quit the document normally assumes someone who wants to quit for
their own benefit. This is not necessarily the case in pregnancy where health professionals
are advised to focus on the baby’s health. Smoking in pregnancy is discussed in the National
Strategy in relation to the rates of smoking and the financial burden of premature births to the
health system in a total of two sentences. There is an outcome indicator aimed at having
“fewer infants exposed to tobacco in-utero and after birth” (6, p. 11). The National Tobacco
Strategy does not specifically discuss any strategies or allocate any funding towards
improving the health of women who smoke in pregnancy. Since the Strategy gives no clear
guidance about how to assess and support women who commence pregnancy as a smoker
it is necessary to review the relevant research that has been conducted.
Smoking in Pregnancy: Literature Search Strategy
Following guidelines set by Rumsey (8) a search on smoking cessation in pregnancy was
conducted through the Clinical Information Access Program (CIAP) with CINHAL, MEDLINE,
PubMed, the Cochrane library and the Midwifery and Infant Care databases being searched.
The MIDIRS database was accessed independently and the SuperSearch database was
accessed through the University of Newcastle’s electronic library. Individual searches of
midwifery and allied health journals were also performed for articles relevant to smoking
cessation and pregnancy. Finally, the bibliographies of articles obtained were examined for
further relevant articles, publications and books. Key search terms were smok$, cessation,
midwi$ and pregnancy. Subheadings accessed were pregnancy complications, addiction,
social disadvantage, poverty, health behaviour and gender. Over 600,000 hits for smoking in
pregnancy were obtained. International papers were included in the search and within this
paper. The focus however, was Australian women and their smoking tends. Only primary
research papers were included. The search was limited to:
Subjects – humans;
Language – English; and
Time frame – 1990 to 2006.
1990 was selected as the commencement date for searching as several systematic reviews
had been performed during the 90’s (9-11). All retrieved articles were assessed individually
for relevance. Papers included; all systematic reviews, all individual studies of smoking
cessation interventions, all descriptive studies of women’s and or health care workers view’s
of smoking cessation interventions. Papers that focussed exclusively on passive smoking
Effectiveness of Quit Smoking Interventions: Findings of Systematic Review
A systematic review performed in 1994 (10) revealed treatment group quit rates ranging from
4.9% to 31.9%. These figures are similar to figures derived from single studies reported in
the past decade with intervention group quit rates ranging from 4.8% to 33.3% (12-18) This
means that although smoking cessation research and anti-smoking advice to pregnant
women has intensified over the past 2 decades (19) quit rates attributable to interventions by
health professionals have remained constant.
The latest systematic review concerning anti-smoking interventions used pooled data from
48 trials (19). These trials used a variety of interventions, which are summarised on table 2.
The systematic review reported a statistically significant reduction in smoking with an
absolute difference in quit rates of 6.0% (RR=0.94, 95% CI 0.93 to 0.95) (19). This is an
increase in quit rates, which equals 6 more smokers per 100 pregnant women who agreed to
participate in a quit smoking intervention actually quitting when compared with a control
group who experienced standard care.
Trials using interventions that involved social support coupled with rewards were statistically
the most effective (20, 21). One study (21) required participants to select a social supporter
(preferably a female non-smoker) to encourage them throughout pregnancy and postpartum
in their quit attempt. Both the participant and supporter received financial rewards of a $50
voucher at various intervals when it was confirmed by urine testing that the participant was
bio-chemically free of nicotine. A second study (20) requested all participants seek an adult
supporter to accompany them in their quit efforts. Participants were provided with
confectionary gum and bio-chemically validated abstainers received lottery tickets for a prize
Trials (22-34) using “stages of change” theory were least effective in assisting women to
quit. Poor outcomes associated with “stage of change” interventions may be explained by
the fact that women who smoke during pregnancy use different processing and behavioural
coping mechanisms from non-pregnant smokers (35). In relation to quit smoking attempts,
women are not as fully engaged during pregnancy with regards to self-efficacy, level of
activity processes and the action stage of change (36).
Trials using Nicotine Replacement Therapy (NRT) in pregnancy (37-39) demonstrated no
significant advantage over other types of interventions (19). A recent study using NRT in
pregnancy was undertaken in Australia, in 2006 (17). Findings reported a 15% quit rate in
the intervention group versus 0% in the control group. However, only 25% of the
intervention group complied with treatment protocol and 25% reported adverse reactions to
the NRT (17).
Smoking Behaviours in the Childbearing Period
The majority women who commence pregnancy as a smoker attempt to alter their smoking
habits. Most women decrease their smoking, although some women report increasing their
smoking as a result of increased stress associated with the current pregnancy, additional
mothering role and the guilt of not being able to quit smoking (40). Overall there is little
change in smoking rates long-term. Only 20% to 30% of women, who commence pregnancy
as smokers, abstain for a period of their pregnancy. Half of the women who do manage to
abstain for the pregnancy relapse within six months of having birthed and 70% have relapsed
within the first twelve months (41). These figures are comparable to those of other developed
countries such as America (14, 42-44) Canada (45), Sweden (46) and England (47). This
means that current anti-smoking interventions in pregnancy are not very effective in
achieving either short or long term quitting.
Socio-Economic Disadvantage and Smoking
Socio-economic factors and smoking are closely correlated (48-60). Women who sustain
quitting during pregnancy are more likely to report having a positive social environment
including being married or in a stable co-habitating relationship. They are likely to have been
older when they first commenced smoking. Women who successfully quit have higher formal
educational qualifications. They have a lower number of existing children and their partners
and significant others are more likely to be non-smokers. They are more likely to have had a
low level pre-pregnant nicotine intake. (46, 61-66).
In contrast, women who continue to smoke are more likely to be poor and less likely to
participate in positive health-promoting behaviours in pregnancy (67). They are also less
likely to initiate or maintain breastfeeding (68). Some women have reported prematurely
ceasing breast-feeding so they can resume smoking without judgement by others (69, 70).
Women who smoke in pregnancy are less likely to feel personally responsible for the health
outcomes of their fetus (67). Weight gain during pregnancy and the social pressure to regain
pre-pregnancy stature after birthing also impacts on smoking and relapse rates (69, 71-73).
Smoking is viewed by socio-economically disadvantaged smokers as one of the best ways to
take a break from daily hardships, deal with stress, the responsibilities of caring for others
and controlling their emotions (70, 71, 74). The additional stressors associated with quitting
whilst pregnant are seen as too demanding so that pregnancy is often seen as a time where
it is more difficult to quit (75). Women frequently smoke because remaining abstinent is
challenging, particularly during pregnancy (64). The constant physiological and psychological
effort required to remain smoke free following birth requires women to expend additional
emotional energy they may not posses. Additional stressors for women who are socio-
economically disadvantaged include greater incidence of disruptive home or neighbourhood
environments, lack of transport, which compounds feeling isolated, and lack of social
support. Women who are economically disadvantaged and socially unsupported face
parenting challenges in isolation and report smoking to relive anxiety and depression (74).
The Physiology of Smoking and Pleasure/Addiction
People who smoke cite the personal benefits of continued smoking. They say that mood,
anxiety, and stress can be improved or relieved by smoking. People who smoke claim
concentration and arousal is enhanced following a cigarette (76, 77). Research supports that
visual perception, motor function and cognitive functioning is improved following a cigarette
The pleasure that smoking provides is mediated by nicotine which is delivered to the Central
Nervous System within 10-20 seconds of inhalation (78). Nicotine activates Nicotinic
acetylcholine receptors (nAChRs) in the brain. Initially nAChR activation produces a cascade
of actions resulting in a dose dependant increase in dopamine levels (77). Dopamine is a
neurotransmitter that is associated with the pleasure system. Dopamine release provides
feelings of pleasure and satisfaction thus reinforcing behaviour that created the dopamine
release. Any experience or ingested chemical that produces a sense of well-being or
satisfaction will activate the release of Dopamine (79). Repetition of the initiating behaviour,
in this case, smoking, strengthens the feelings of gratification or the “feel good” sensation
associated with the behaviour. Dopamine is a key regulator of behavioural adaptation and
anticipatory processes (80) and appears to be involved in all addictive behaviour (81).
Women of lower socio-economic status may have less internal and/or external sources of
“feel good” experiences that are capable of activating dopamine releases (79). Nicotine can
provide women experiencing hypo-satisfaction with a surge of Dopamine thereby delivering a
short-term feeling of satisfaction(79).
What Women Feel about Smoking in Pregnancy
Although women say that smoking provides relief from their daily stressors, they feel
embarrassment and self-loathing about smoking (70). Pregnant women feel vulnerable to
social pressure (82). They feel constantly judged by others and guilty from the time their
pregnancy is confirmed (40, 69). Women have been found to feel shame at their own lack of
motivation to abstain from smoking and disturbed by the anti-smoking propaganda constantly
thrust upon them whilst pregnant (69). Social pressures to conform to the image of a “good
mother” by not smoking externally motivates women to modify their smoking behaviour (83).
Some women feel such anxiety and pressure associated with pregnancy, they continue to
smoke at their existing rate or increase their tobacco intake as the pregnancy progresses
Women who continue to smoke whilst pregnant conduct a self-risk assessment; either
consciously or unconsciously (84). Women report smoking is less harmful than the possible
outcomes of not smoking e.g. some women state that smoking buffers their children from the
woman’s anger (85). Smoking allows the woman a brief, pleasurable break from the stressful
situations in which they live. The health risks associated with smoking are abstract and
distant in relation to the immediate gratification experienced with smoking (86).
Women’s views on smoking cessation interventions
The views of women who continue to smoke in pregnancy haven’t specifically been
canvassed in relation to smoking cessation intervention research. Eighty two percent (82%)
of women believe that behaviourally based support strategies would benefit them most in
their attempt to quit smoking. However, behaviourally based methods have been found to
be one of the least effective methods (19). Behaviouristic interventions view the act of
smoking as a stimulus that is reinforced following a positive or pleasant response
(discussed above) (87). Women say they would welcome behaviourist interventions aimed
at changing their smoking behaviour (88). In spite of what they say however, only 5% of
women use behaviourally based support programs when they are offered. The poor uptake
may be due to support being offered regardless of the woman’s readiness to quit or
because the long-term internally motivated rewards are not as rewarding as the short-term
satisfaction derived from the physical and psychological act of smoking (89).
Seventy seven percent (72%) of women believe self help materials would be beneficial (89).
The appeal of Self-help materials may indicate the number of women who would prefer
health professionals handed out information and left the decision up to the woman, without
further scrutiny and related embarrassment. Women believe that without self-determination
and will power it is not be possible to quit regardless of the support offered (74). They said
that shifting the focus of health to themselves from that of their fetus strengthened their
determination to maintain abstinence (69). Face-to-face support sessions with additional
assistance such as exercise programs and buddy systems involving close friends
encouraging their quit efforts was thought by women to be beneficial (89). These views are
somewhat supported by Donatelle et al., (21) and Walsh et al. (20) who implemented
support coupled with reward, incentive based interventions. What portion of the success
rates was attributable to social support, separate to financial and/or reward incentives is not
known. A review of social support interventions in 2000, revealed that “buddy supporters”
may be of benefit to potential quitters within the context of a delineated smoking clinic.
Social support, however, was not found to be of benefit in community settings (90).
Women’s views on smoking cessation advice
Women generally believe decisions and responsibilities regarding health behaviours are the
responsibility of the individuals concerned (40, 91). Very few women feel that health care
professionals influence their smoking behaviour. There are, of course, conflicting voices as
not all women think the same. Some women believe their doctors to be the most
appropriate authority figure to provide smoking cessation information and that midwives
should be the link person to other forms of support (40). Other studies reveal that women
feel midwives played an important role in their motivation to stop or reduce tobacco intake
during pregnancy. A woman centred-approach with the health care provider having
knowledge of the woman’s social situation and viewpoints was said to be helpful (69).
Some women are critical of health professionals who benignly advise them to stop rather
than strongly recommending that they quit (40). These women believe this negates the
severity of the situation and lessens the motive to quit. Other women, particularly the most
socially disadvantaged ones, may cease attending antenatal clinics if they feel judged or
embarrassed about their lifestyle (92). Some women complain that worrying about smoking
increases their stress and anxiety, making quitting more difficult and/or increased their
smoking (69). Most women do not like to feel harassed into quitting. This view is supported
by a group of non-pregnant women who smoke. They believe the relationship between
themselves and the doctor was damaged when smoking advice was discussed at each visit
Some women expect the topic of smoking to be introduced during their antenatal care,
sustained throughout the whole of their pregnancy and be delivered by a person whom they
respect and with whom they have formed a relationship (40). Although women consider
midwives to be nagging if the subject is discussed each visit, most women still feel it would
be helpful (69). Women believe that identifying as a non-smoker rather than a temporary
abstainer helps their quit efforts but it may also mask women who relapse and smoke in
pregnancy (35, 36).
Discussion and Conclusion
Research on the effectiveness of quit smoking campaigns in pregnancy indicates a relatively
low level of success with the most recent systematic review showing a 6% increase in quit
rates for women in the intervention arms of RCTs. Relapse rates remain high and delivery of
smoking cessation advice is mixed in relation to content and intensity. Though the National
Tobacco Strategy 2004-2009 argues that “Tobacco use, more than any other single factor,
contributes to the gap in healthy life expectancy” (6, p.1) no strategies specific to pregnant
smokers are presented.
The experiences of women in relation to being subjected to quit smoking interventions in
pregnancy have been mixed. Some women feel it is reasonable for health professionals to
address their smoking behaviour with them whilst others feel unhappy about it. The
development of mutually respectful and trusting relationships may be disturbed by
inconsistencies in messages and actions delivered by midwives in relation to health care
issues such as smoking. In at least one study women who were socially-economically
disadvantaged reported ceasing attendance at the antenatal clinic after feeling criticised by
In our view the midwifery partnership requires midwives to take a woman-centred approach.
By contrast the quit smoking campaigns and the way that research has been conducted is
baby-centred with the woman who smokes seen as the perpetrator of ‘bad’ behaviour.
Pregnant women who smoke access health services for pregnancy related issues, not
smoking issues. Health care professionals nonetheless, use the visit as a ‘teachable
moment’ regarding smoking cessation (93). The discrepancy in reasons for the antenatal
interaction no doubt explains why health professionals aren’t very effective in changing
women’s smoking behaviour. In line with the woman-midwife partnership, the woman should
plan the mode and focus of quit interventions. Health care workers, specifically midwives,
must support the woman to maintain her own general health and well-being without focusing
exclusively on the benefits for the baby (94). Midwives should address smoking from a
perspective that includes the broader socio-political context.
Midwives and other health care workers must be invited to express their needs and concerns
with regards to providing pregnant women smoking cessation advice thus qualitative
research is required. Women should feel their views on smoking and health strategies are
valued so they provide researchers and health care workers with knowledge regarding the
the best ways to talk about smoking in pregnancy in ways that support the woman-midwife
partnership and are not seen as cursory, critical or patronising. Until health professionals
can gain these types of insights and work in partnership with women in a mutually respectful
manner the question is why would women stop smoking?
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National Health and Medical Research Council. How to assess the evidence:
Table 1.1 Levels of evidence
Levels of evidence
Evidence obtained from systematic review of relevant randomised controlled trials
Level II Evidence obtained from one or more well-designed, randomised controlled trials
Level III Evidence obtained from well-designed, non-randomised controlled trials; or from well-
designed cohort or case control studies
After searching no evidence was found relevant to general practice on the issue being
Strength of recommendation
A There is good evidence to support the recommendation
B There is fair evidence to support the recommendation
Source: NHMRC handbook How to Assess the Evidence: Assessment and application of scientific evidence (95).
Table 2 Smoking Cessation Intervention Strategies in Research
Educational and motivational strategies aimed at changing 1.
attitudes, knowledge and behaviours of health
professionals with respect to smoking cessation.
A combination of two or more of the intervention strategies
Information about smoking and pregnancy and the harmful
The provision of
information effects of tobacco use on the baby, woman and/or family
Advice about smoking cessation strategies without 4. Direct advice to stop
smoking supplemental materials or services offered
Advice about smoking cessation support services and
strategies with reinforcement at each subsequent visit
Advice about smoking cessation support services and
strategies with supplemental materials and or services
Supplementation of advice consisted of one or more of the following:
Individualised counselling based on ‘stages of change’
Provision of peer support
Documentation of progress in smoking cessation attempts and validation of
self-reported smoking behaviour at subsequent visits by means of bio-
Direct feedback of the negative effects of smoking on the fetus by means of e.
measuring fetal heart rates, fetal movements and fetal breathing
Direct feedback of positive information regarding fetal development f.
associated with changes in smoking status
Telephone follow-up with reinforcement of quitting advice and quit strategies
Nicotine replacement therapy
Rewards and incentives - money, vouchers, confectionary, prizes