Addressing and Overcoming Barriers to E-Cigarette Use for Smoking Cessation in Pregnancy: A Qualitative Study
2. Materials and Methods
2.1. Recruitment and Screening
3.1. Theme 1: Facilitating Beliefs
3.1.1. Subtheme 1.1: Understanding the Relative Safety Compared to Tobacco Smoking
“I just feel that because there’s, obviously there’s nicotine but because there’s not all the other harmful chemicals in it, I feel it’s a lot better for yourself and the baby than smoking, so I guess nothing is better, but it’s better than still craving the cigarettes and wanting it, like, smoking them than it is to have something that’s got a lot less bad stuff in it.”Exclusive user (ID, 2)
3.1.2. Subtheme 1.2: Economic Sense
“You can get sort of like a cheaper device that’s sort of like 20, 30 quid. But when you think about that, if you think about the cost of a packet of cigarettes and how long you’re going to be using it for, the cost of the vape and the juice and coils and everything, the cost compared to smoking is minimal.”Exclusive user (ID, 7)
“Perhaps look for your cheaper supermarket versions of the pens and not go for—if you—there’s, like, stores and stuff in, like, our shopping centre and you’re looking on about, sort of, £30 to £40 for very similar, but because it’s sort of the—whatever company they’re from, because it’s their brand and then you’re paying sort of about £6 for the liquids as well. And I think, you know, it is pretty much the same but because you’ve got someone there demonstrating it for you and it’s their brand, they charge you a lot more.”Exclusive user (ID, 2)
“But it is cheaper than cigarettes and it’s obviously investing for your health long term isn’t it?”Exclusive user (ID, 13)
3.1.3. Subtheme 1.3: Pregnancy as a Motivator
“And I think if you’re strong enough to follow through and pursue with it and set your mind to it and think ‘hang on this is a healthier option for me and my baby’, then you can actually conquer the cravings.”Exclusive user (ID, 15)
“I just knew that I had to, I just knew that…and I knew that even when I wasn’t pregnant, when I’ve got a young baby, smoking around them isn’t the right thing to do and even though, you know, vaping around them isn’t the best thing to do either, at least they’re not breathing in the chemicals, you know, they’re not passive smoking”Dual user (ID, 6)
3.2. Theme 2: Gaining Confidence as a Vaper
3.2.1. Subtheme 2.1: Experimentation
“To be honest my husband, if anything goes wrong with it [e-cigarette) he tends to fiddle with it and fix it any way, he’s pretty good. He uses his far more than I use mine. So yeah, he knows what he’s doing with it, I just hand it over.”Exclusive vaper (ID, 13)
“It’s a completely experience to smoking, you do sort of have to learn how to use them I think because it’s not the same as smoking.”Dual user (ID, 6)
“It has changed over time but to begin with I’d use it a lot, so I’d sit at home and I’d be like using it constantly, but I sort of don’t use it as much anymore.”Exclusive User (ID, 11)
3.2.2. Subtheme 2.2: Seeking or Experiencing Social Support
“Everyone was really supportive. They said it was great that I was managing to quit because quite a lot of my family use e-cigarettes so they’ve had experience with it.”Exclusive user (ID, 7)
“I was quite worried about using one but then also I felt it was better than cigarettes and my midwife actually praised me for it because she said you know, all my readings come up as the carbon monoxide and everything was all zeros, so she said to me ‘obviously that shows that it’s better to use one of them than it is to smoke cigarettes.”Exclusive user (ID, 2)
3.2.3. Subtheme 2.3: Actively Seeking Confirmation about E-cigarette Safety
“If it’s a choice between cigarettes and a vape, I’d take a vape every day of the week, it’s got to be better compared to what’s in a cigarette and there’s not a massive amount of research done on vaping so far. I mean I know a doctor, not in a university and he makes it when I said to him ‘what do you think about this?’ he said ‘I’d rather you do that any day of the week than stick a cigarette in your mouth’ and this was before I was pregnant he was like ‘that’s got to be 10 times better.”Exclusive user (ID, 12)
3.2.4. Subtheme 2.4: Employing Strategies to Deal with Social Stigma
“I’ve stayed away from vaping in front of the like complete strangers and then when people did say ‘oh well, this is bad for you, is it not bad for the baby?’ I would explain to them ‘well actually no, I’ve spoken to the midwife, this is 10 times better.”Exclusive user (ID, 12)
“I will sometimes sneak off……depending on where I am, if I can sort of sneak off or have some in the car before or whatever, then I will. But yeah no, it is difficult if I’m going to be out especially, because my parents don’t know so if I’m out with my parents all day then that’s particularly difficult, so I might just leave [child’s name] with them and just say ‘oh, I’m just going to go and have a look over here.”Exclusive user (ID, 13)
3.3. Themes within the Theoretical Domain Framework (TDF)
Conflicts of Interest
- Delpisheh, A.; Kelly, Y.; Rizwan, S.; Attia, E.; Drammond, S.; Brabin, B.J. Population attributable risk for adverse pregnancy outcomes related to smoking in adolescents and adults. Public Health 2007, 121, 861–868. [Google Scholar] [CrossRef]
- Cnattingius, S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine Tob. Res. 2004, 6 (Suppl. S2), S125–S140. [Google Scholar] [CrossRef][Green Version]
- Lange, S.; Probst, C.; Rehm, J.; Popova, S. National, regional, and global prevalence of smoking during pregnancy in the general population: A systematic review and meta-analysis. Lancet Glob. Health 2018, 6, e769–e776. [Google Scholar] [CrossRef][Green Version]
- NHS Digital. Statistics on Women’s Smoking Status at Time of Delivery: England Quarter 3, 2019–2020. 2020. Available online: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-women-s-smoking-status-at-time-of-delivery-england/statistics-on-womens-smoking-status-at-time-of-delivery-england-quarter-3-2019-20 (accessed on 28 May 2020).
- McAndrew, F.; Thompson, J.; Fellows, L.; Large, A.; Speed, M.; Renfrew, M.J. Infant Feeding Survey 2010: Health and Social Care Information Centre. 2012. Available online: http://digital.nhs.uk/catalogue/PUB08694 (accessed on 2 June 2019).
- Cooper, S.; Orton, S.; Leonardi-Bee, J.; Brotherton, E.; Vanderbloemen, L.; Bowker, K. Smoking and quit attempts during pregnancy and postpartum: A longitudinal UK cohort. BMJ Open 2017, 7. [Google Scholar] [CrossRef][Green Version]
- West, R.; Beard, E.; Brown, J. Trends in electronic cigarette use in England. 2019. Available online: http://www.smokinginengland.info/sts-documents/ (accessed on 21 October 2019).
- Kapaya, M.; D’Angelo, D.V.; Tong, V.T.; England, L.; Ruffo, N.; Cox, S.; Warner, L.; Bombard, J.; Guthrie, T.; Lampkins, A.; et al. Use of Electronic Vapor Products Before, During, and After Pregnancy Among Women with a Recent Live Birth—Oklahoma and Texas, 2015. MMWR Morb. Mortal. Wkly. Rep. 2019, 68, 189–194. [Google Scholar] [CrossRef][Green Version]
- Liu, B.; Xu, G.; Rong, S.; Santillan, D.A.; Santillan, M.K.; Snetselaar, L.G.; Bao, W. National Estimates of e-Cigarette Use Among Pregnant and Nonpregnant Women of Reproductive Age in the United States, 2014–2017. JAMA Pediatr. 2019, 173, 600–602. [Google Scholar] [CrossRef] [PubMed]
- Kurti, A.N.; Redner, R.; Lopez, A.A.; Keith, D.R.; Villanti, A.C.; Stanton, C.A.; Gaalema, D.E.; Bunn, J.Y.; Cepeda-Benito, A.; Roberts, M.E.; et al. Tobacco and nicotine delivery product use in a national sample of pregnant women. Prevent. Med. 2017, 104, 50–56. [Google Scholar] [CrossRef] [PubMed]
- Mark, K.S.; Farquhar, B.; Chisolm, M.S.; Coleman-Cowger, V.H.; Terplan, M. Knowledge, Attitudes, and Practice of Electronic Cigarette Use Among Pregnant Women. J. Addict. Med. 2015, 9, 266–272. [Google Scholar] [CrossRef] [PubMed]
- Ashwin, C.; Watts, K. Exploring the views of women on using nicotine replacement therapy in pregnancy. Midwifery 2010, 26, 401–406. [Google Scholar] [CrossRef] [PubMed]
- Bowker, K.; Orton, S.; Cooper, S.; Naughton, F.; Whitemore, R.; Lewis, S.; Bauld, L.; Sinclair, L.; Coleman, T.; Dickinson, A.; et al. Views on and experiences of electronic cigarettes: A qualitative study of women who are pregnant or have recently given birth. BMC Pregn. Child. 2018, 18, 233. [Google Scholar] [CrossRef][Green Version]
- Bauld, L.; Graham, H.; Sinclair, L.; Flemming, K.; Naughton, F.; Ford, A. Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: Literature review and qualitative study. Health Technol. Assess. 2017, 21. [Google Scholar] [CrossRef] [PubMed]
- Bowker, K.; Campbell, K.A.; Coleman, T.; Lewis, S.; Naughton, F.; Cooper, S. Understanding Pregnant Smokers’ Adherence to Nicotine Replacement Therapy During a Quit Attempt: A Qualitative Study. Nicotine Tob. Res. 2016, 18, 906–912. [Google Scholar] [CrossRef] [PubMed][Green Version]
- England, L.J.; Tong, V.T.; Koblitz, A.; Kish-Doto, J.; Lynch, M.M.; Southwell, B.G. Perceptions of emerging tobacco products and nicotine replacement therapy among pregnant women and women planning a pregnancy. Prevent. Med. Rep. 2016, 4, 481–485. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Grant, A.; Morgan, M.; Gallagher, D.; Mannay, D. Smoking during pregnancy, stigma and secrets: Visual methods exploration in the UK. Women Birth 2018, 33, 70–76. [Google Scholar] [CrossRef]
- Bauld, L.; Graham, H.; Sinclair, L.; Flemming, K.; Naughton, F.; Ford, A.; McKell, J.; McCaughan, D.; Hopewell, S.; Angus, K.; et al. Chapter 11. Perceptions of new interventions from three prespectives: Pregnant and postpartum women, their significant others and health-care professionals. In Barriers to and Facilitators of Smoking Cessation in Pregnancy and Following Childbirth: Literature Review and Qualitative Study; Health Technology Assessment: Southampton, UK, 2017. [Google Scholar]
- Fallin, A.; Miller, A.; Assef, S.; Ashford, K. Perceptions of Electronic Cigarettes Among Medicaid-Eligible Pregnant and Postpartum Women. J. Obst. Gynecol. Neonat. Nurs. 2016, 45, 320–325. [Google Scholar] [CrossRef]
- Hajek, P.; Phillips-Waller, A.; Przulj, D.; Pesola, F.; Smith, K.M.; Bisal, N.; Li, J.; Parrott, S.; Dawkins, L.; Ross, L.; et al. E-cigarettes compared with nicotine replacement therapy within the UK Stop Smoking Services: The TEC RCT. Health Technol. Assess. 2019, 23, 43. [Google Scholar] [CrossRef]
- Shahab, L.; Goniewicz, M.L.; Blount, B.C.; Brown, J.; McNeill, A.; Alwis, K.U.; Feng, J.; Wang, L.; West, R. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-sectional Study. Ann. Intern. Med. 2017, 166, 390–400. [Google Scholar] [CrossRef][Green Version]
- Cardenas, V.M.; Cen, R.; Clemens, M.M.; Moody, H.L.; Ekanem, U.S.; Policherla, A.; Fischbach, L.A.; Eswaran, H.; Magann, E.F.; Delongchamp, R.R.; et al. Use of Electronic Nicotine Delivery Systems (ENDS) by pregnant women I: Risk of small-for-gestational-age birth. Tob Induc Dis. 2019, 17, 44. [Google Scholar] [CrossRef]
- Gillen, S.; Saltzman, D. Antenatal exposure to e-cigarette vapor as a possible etiology to total colonic necrotizing enterocolitits: A case report. J. Pediatr Surg Case Rep. 2014, 2, 536–537. [Google Scholar] [CrossRef][Green Version]
- McDonnell, B.; Dicker, P.; Regan, C. Electronic cigarettes and obstetric outcomes: A prospective observational study. BJOG Int. J. Obstetr. Gynaecol. 2020, 127, 750–756. [Google Scholar] [CrossRef]
- Benowitz, N.L.; Burbank, A.D. Cardiovascular toxicity of nicotine: Implications for electronic cigarette use. Trends Cardiovasc. Med. 2016, 26, 515–523. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Dejmek, J.; Solansky, I.; Benes, I.; Lenicek, J.; Sram, R.J. The impact of polycyclic aromatic hydrocarbons and fine particles on pregnancy outcome. Environ. Health Perspect. 2000, 108, 1159–1164. [Google Scholar] [CrossRef] [PubMed]
- Wickström, R. Effects of Nicotine During Pregnancy: Human and Experimental Evidence. Cur. Neuropharmacol. 2007, 5, 213–222. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Ogburn, P.L., Jr.; Hurt, R.D.; Croghan, I.T.; Schroeder, D.R.; Ramin, K.D.; Offord, K.P.; Moyer, T.P. Nicotine patch use in pregnant smokers: Nicotine and cotinine levels and fetal effects. Am. J. Obstet Gynecol. 1999, 181, 736–743. [Google Scholar] [CrossRef]
- Wright, L.N.; Thorp, J.M., Jr.; Kuller, J.A.; Shrewsbury, R.P.; Ananth, C.; Hartmann, K. Transdermal nicotine replacement in pregnancy: Maternal pharmacokinetics and fetal effects. Am. J. Obstet. Gynecol. 1997, 176, 1090–1094. [Google Scholar] [CrossRef]
- Bar-Zeev, Y.; Lim, L.L.; Bonevski, B.; Gruppetta, M.; Gould, G.S. Nicotine replacement therapy for smoking cessation during pregnancy. Med. J. Aust. 2018, 208, 46–51. [Google Scholar] [CrossRef]
- American Lung Association. What’s in an E-cigarette. 2020. Available online: https://www.lung.org/quit-smoking/e-cigarettes-vaping/whats-in-an-e-cigarette (accessed on 24 June 2020).
- Smoking in Pregnancy Challenge Group. Use of Electronic Cigarettes Before, During and After Pregnancy. A Guide for Maternity and Other Healthcare Professionals. 2019. Available online: http://smokefreeaction.org.uk/wp-content/uploads/2019/07/2019-Challenge-Group-ecig-briefing-A4-FINAL.pdf (accessed on 3 March 2020).
- Tong, A.; Sainsbury, P.; Craig, J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care 2007, 19, 349–357. [Google Scholar] [CrossRef][Green Version]
- BabyCentre. Pregnancy, baby and toddler health information at BabyCentre UK. 2019. Available online: https://www.babycentre.co.uk/ (accessed on 29 June 2020).
- Bradshaw, C.; Atkinson, S.; Doody, O. Employing a Qualitative Description Approach in Health Care Research. Glob. Qual. Nurs. Res. 2017, 4, 2333393617742282. [Google Scholar] [CrossRef][Green Version]
- Cane, J.; Richardson, M.; Johnston, M.; Ladha, R.; Michie, S. From lists of behaviour change techniques (BCTs) to structured hierarchies: Comparison of two methods of developing a hierarchy of BCTs. Br. J. Health Psychol. 2015, 20, 130–150. [Google Scholar] [CrossRef] [PubMed]
- Michie, S.; Atkins, L.; West, R. The Behaviour Change Wheel: A Guide to Designing Interventions, 1st ed.; Silverback Publishing: Surrey, UK, 2014. [Google Scholar]
- Campbell, K.; Fergie, L.; Coleman-Haynes, T.; Cooper, S.; Lorencatto, F.; Ussher, M. Improving Behavioral Support for Smoking Cessation in Pregnancy: What Are the Barriers to Stopping and Which Behavior Change Techniques Can Influence Them? Application of Theoretical Domains Framework. Int. J. Environ. Res. Public Health 2018, 15, 359. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Scotland, J. Exploring the philosophical underpinnings of research: Relating ontology and epistemology to the methodology and methods of the scientific, interpretive, and critical research paradigms. Engl. Lang. Teach. 2012, 5, 9–16. [Google Scholar] [CrossRef][Green Version]
- Braun, V.; Clarke, V. Using thematic analysis in psychology. Qual. Res. Psychol. 2006, 3, 77–101. [Google Scholar] [CrossRef][Green Version]
- Orton, S.; Bowker, K.; Cooper, S.; Naughton, F.; Ussher, M.; Pickett, K.E.; Leonardi-Bee, J.; Sutton, S.; Dhalwani, N.N.; Coleman, T. Longitudinal cohort survey of women’s smoking behaviour and attitudes in pregnancy: Study methods and baseline data. BMJ Open 2014, 4, e004915. [Google Scholar] [CrossRef] [PubMed]
- Emery, L.J.; Coleman, T.; Sutton, S.; Cooper, S.; Leonardi-Bee, J.; Jones, M. Uptake of Tailored Text Message Smoking Cessation Support in Pregnancy When Advertised on the Internet (MiQuit): Observational Study. J. Med. Inter. Res. 2018, 20, 146. [Google Scholar] [CrossRef][Green Version]
- Hoek, J.; Thrul, J.; Ling, P. Qualitative analysis of young adult ENDS users’ expectations and experiences. BMJ Open 2017, 7, e014990. [Google Scholar] [CrossRef]
- Borland, T.; Babayan, A.; Irfan, S.; Schwartz, R. Exploring the adequacy of smoking cessation support for pregnant and postpartum women. BMC Public Health 2013, 13, 472. [Google Scholar] [CrossRef]
- Mantzari, E.; Vogt, F.; Marteau, T.M. The effectiveness of financial incentives for smoking cessation during pregnancy: Is it from being paid or from the extra aid? BMC Preg. Child. 2012, 12, 24. [Google Scholar] [CrossRef][Green Version]
|Theme and Subtheme||Number of Participants Contributing to Theme. Total n = 15|
|Understanding the relative safety of vaping compared with tobacco smoking||11/15|
|Believing vaping made economic sense||12/15|
|Pregnancy as a motivator||7/15|
|Gaining confidence as a vaper|
|Seeking or experiencing social support||13/15|
|Actively seeking confirmation about e-cigarette safety||12/15|
|Employing strategies to address social stigma||11/15|
|Theme||Theoretical Domain Framework (TDF)||Recommendations for Interventions|
|Understanding the relative safety compared to tobacco smoking||Beliefs about consequences: believing that vaping was safer than smoking minimised women’s concerns about the harmfulness of vaping. Increased determination and confidence to vape.||Women require information about the safety and costs (economic and health) of vaping in comparison to smoking. Intervention delivery could include leaflets, websites, text messaging support and HP discussions.|
|Economic sense||Environmental context and resources: women need to be able to afford the upfront costs associated with vaping; remembering they will be better off financially in the long run was important.|
Beliefs about consequences: immeasurable gains as vaping is beneficial for health and wellbeing in the long term.
|Actively seeking confirmation about the safety of e-cigarettes.||Knowledge: the process of seeking and accumulating knowledge was important for women to validate their reasons for vaping.|
Social influences: HPs’ endorsement of the safety of vaping in comparison to smoking was important for continued use.
|Employing strategies to deal with social stigma||Social influences: women felt social pressure not to vape during pregnancy.|
Knowledge: being able to defend their decision to vape was empowering.
Behavioural regulation: to fit in with social norms, women often hid their vaping or took actions to only vape in situations they felt comfortable with.
|Women require support to develop self-confidence/belief in their decision to vape as method to help them stop smoking. Interventions could include HP encouragement and showing the benefits of stopping smoking such as regular carbon monoxide readings.|
|Pregnancy as a motivator||Beliefs about capabilities: determination and self-belief that they have the ability to change their smoking behaviour was crucial.|
Beliefs about consequences: women felt guilty about smoking; they worried about the effects on their baby and this was a motivator to vape rather than smoke.
|Experimentation||Skills: through practice women acquired the skills to vape. This required time and persistence.|
Environmental context and resources: access to vape shops was a source of advice.
Social influences: family and friends who were vapers were able to assist with choosing, experimenting and maintaining e-cigarettes.
|Women need to develop practical skills to successfully vape. Intervention delivery could include peer support and HPs disseminating practical advice.|
|Seeking or experiencing social support||Social influences: supportive friends, family and HPs increased motivation. Peer support from other vapers was regarded highly.||Women who cannot quit via other methods require support to vape in order to quit smoking. Interventions could involve peer support groups and involving family members in discussions with HPs about vaping. |
Support is also required for vapers who have stopped smoking but also want to stop vaping too.
© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Bowker, K.; Ussher, M.; Cooper, S.; Orton, S.; Coleman, T.; Campbell, K.A. Addressing and Overcoming Barriers to E-Cigarette Use for Smoking Cessation in Pregnancy: A Qualitative Study. Int. J. Environ. Res. Public Health 2020, 17, 4823. https://doi.org/10.3390/ijerph17134823
Bowker K, Ussher M, Cooper S, Orton S, Coleman T, Campbell KA. Addressing and Overcoming Barriers to E-Cigarette Use for Smoking Cessation in Pregnancy: A Qualitative Study. International Journal of Environmental Research and Public Health. 2020; 17(13):4823. https://doi.org/10.3390/ijerph17134823Chicago/Turabian Style
Bowker, Katharine, Michael Ussher, Sue Cooper, Sophie Orton, Tim Coleman, and Katarzyna Anna Campbell. 2020. "Addressing and Overcoming Barriers to E-Cigarette Use for Smoking Cessation in Pregnancy: A Qualitative Study" International Journal of Environmental Research and Public Health 17, no. 13: 4823. https://doi.org/10.3390/ijerph17134823