Getting over the shock: taking action on Indigenous maternal smoking

Indigenous smoking rates must reduce at six-fold the current decline rate to achieve the 2018 Close the Gap target (Thomas 2012). Among Indigenous women in the 25- to 34-year age range, and smokers living in remote locations, rates have remained unchanged for the last decade (Australian Bureau of Statistics 2014). Recently, the Cancer Council Queensland expressed ‘shock over Indigenous pregnancy smoking rates’, with 53% of Indigenous pregnant women smoking v. 15% of their non-Indigenous counterparts (Cancer Council Queensland 2014). Similarly in NSW, 50% of Indigenous women smoke compared with 9% of their non-Indigenous counterparts, with a three to five-fold increase in relative risk since 1996 (NSW Department of Health 2014).

Tobacco smoking during pregnancy is the most important preventable risk factor for maternal and infant health and is linked with growth restriction, miscarriage and preterm birth (Li et al. 2012). Some 7000 Indigenous babies per annum are exposed in utero to smoking (Li et al. 2012). Indigenous babies are twice as likely to be of low birthweight, yet if during the first 4 months of pregnancy the mother stops smoking, the low birthweight risk decreases to non-smoking levels (Li et al. 2012).

In light of these patterns and trends, and the benefits for smoking cessation to Indigenous health generally, this article summarises recent evidence, from the body of our work and others, and vigorously debates the following pertinent questions:

1. Are anti-tobacco messages having an effect on Indigenous pregnant women?

2. What evidence-based cessation strategies are recommended in pregnancy and how can Indigenous pregnant smokers be encouraged to use them?

3. What are the systemic barriers for Indigenous pregnant women accessing evidence-based cessation methods, and how can these be addressed?

With these three questions, we take an integrated view of primary healthcare approaches. Health promotion messages are included in our deliberations; these are not just the domain of media campaigns, but are important for everyday communication. The Primary Health Care Research and Information Service website includes in their definition of primary health care (PHC): ‘In Australia, PHC incorporates personal care with health promotion, the prevention of illness and community development.’ Understanding the responses of pregnant Indigenous women in this area is important for primary care. We draw inferences from the Behaviour Change Wheel (BCW), a parsimonious model developed from an overarching synthesis of behaviour intervention frameworks, and use it to structure our discussions about how strategies for this population can be strengthened (Fig. 1) (Michie et al. 2011). The BCW has been used previously to review the barriers and enablers for smoking cessation in this target group (Gould 2014). This paper addresses recent research to determine how the BCW can be practically applied. The outer circle of the BCW comprises a policy layer, the inner circle represents the individual’s behaviour and the middle circle an interventional layer that connects the inner and the outer layers.

Fig. 1.  Behaviour Change Wheel (reproduced with permission from Michie et al. 2011).

Tobacco campaigns operate on the outer circle or policy layer of the BCW (communication and marketing) and influence multiple points on the middle interventional layer by persuasion, education, enablement, coercion and modelling. In turn, these interventions centrally influence the individual’s capability (C), opportunity (O) and motivation (M) for change – the authors of the model propose that all three C–O–M are required to change behaviour (B) – otherwise known as the COM-B approach (Michie et al. 2011).

Table 1 chronologically summarises tobacco campaigns directed towards Indigenous Australians. Indigenous-targeted national campaigns achieve limited media exposure compared with campaigns aimed at the general Australian population. Many local Tackling Indigenous Smoking campaigns are operating out of primary health centres such as Aboriginal Health Services, both community-controlled and government-run; 55% are targeting pregnant women. Funding to this program has been substantially cut before the outcomes have been assessed.

Table 1.  Timeline of anti-tobacco message development for Indigenous Australians
AMA, Australian Medical Association

Indigenous Australians prefer culturally targeted messages (Gould et al. 2013a). A national survey of 47 organisations, including primary health services, reported that community responses to messages targeting Indigenous Australians positively exceeded the organisations’ expectations (Gould et al. 2014). Indigenous Australian smokers demonstrated good recall of anti-tobacco messages (Gould et al. 2013a; Nicholson et al. 2015a) and these messages were associated with intentions to quit smoking (Nicholson et al. 2015b). This may be mediated by increased perceptions of the threat from smoking and reflective motivation (Nicholson et al. 2015a). However, messages in isolation may not provide the opportunity, nor improve the capability of Indigenous smokers to quit, thus they should be supported by primary healthcare approaches.

Australian Indigenous pregnant women may encounter psychosocial challenges related to their use of tobacco. These include the historical aspects of smoking and colonisation, the social norms of smoking in some Indigenous communities, the stressors associated with everyday life and the added concern of using an addictive substance (Gould et al. 2013b). In pregnancy, women perceive their smoking risks and their role differently, thus pregnancy can be considered a ‘teachable moment’ for smoking cessation (McBride et al. 2003). In this case, motivation, as per the BCW, is an automatic or instinctive activity, but can lead to reflective evaluations and plans. When Indigenous women recognise the presence of adverse outcomes in their own or others’ children through their smoking, they may express shame and guilt. The stigma of smoking with a ‘big belly’ has been reported (Gould et al. 2013b, 2013c). Messages about smoking in pregnancy are salient in these instances.

Conversely, anti-tobacco messages can lack salience in pregnancy (Gould et al. 2013b, 2013c). A mismatch in prevailing messages and women’s lived experiences of smoking can affect women’s psychological capability and motivation to take action. For example, there can be a lack of visibility of harm for babies, if other family members have smoked without obvious adverse outcomes. Anti-tobacco messages can be experienced as too confronting when a woman is pregnant, thus the woman may avoid TV advertisements by leaving the room, or deny their relevance (Gould et al. 2013b, 2013c).

Some pregnant Indigenous smokers want to cut down or quit smoking (Gould et al. 2013b, 2013c). Reduced consumption is usual and although quit attempts are made, they have seldom been reported as successful. This may be due to women having a lack of opportunities for advice and assistance with cessation. Others regard cessation as ‘too hard’ in pregnancy (Passey et al. 2012a), and can even experience stronger urges to smoke during pregnancy, thus affecting a woman’s physical capability of cessation (Gould et al. 2013c). A lack of family and partner support can impair a pregnant woman’s intention and confidence to quit, and reduce capability, opportunity and motivation. Social norms of smoking, smoking for cohesion and peer bonding, the stressors of everyday life plus lack of self-efficacy (perceived capability) for quitting, can translate into continued tobacco use (Passey et al. 2011, 2012a; Gould et al. 2013b, 2013c). Furthermore, other issues may affect Indigenous women at this time: the pregnancy may be unplanned, women are often in adolescence and urgent social situations have a high priority, such as domestic violence and homelessness. Comprehensive primary care will involve helping women tackle these issues and underlying social determinants of smoking (Gould et al. 2015a). Alternately, pregnant women who do quit are highly regarded as role models by other Indigenous women (Gould et al. 2013c).

Intention to quit by Indigenous smokers can be affected by perceptions of threat and efficacy. A community-based study revealed that a majority (77%) of Indigenous smokers of reproductive age perceived smoking to be highly threatening to physical health, implying that reflective motivation is occurring (Gould et al. 2015c). Psychological threats of disgust, regret and stigma about smoking have also been reported (Gould et al. 2015c). Those who consider the threat to lack immediacy, believing ‘smoking is not doing me any harm right now’, are less motivated to quit (OR 0.25; 95% CI 0.08–0.8) (Gould et al. 2015c). High-perceived efficacy (self-efficacy and response efficacy) for quitting was strongly associated with intention to quit (OR 4.8; 95% CI 1.78–12.93) (Gould et al. 2015b), whereas low-perceived efficacy coupled with low-perceived threat (in 16%) was associated with denial, avoidance or reactance to messages (Gould et al. 2015d). In summary, to raise intentions to quit smoking, careful attention needs to be paid to levels of efficacy (by boosting capability in a real sense), coupled with the level of threat messages Indigenous smokers are exposed to. Approaches to build efficacy for quitting are achievable in primary healthcare settings, through counselling and targeted resources.

Indigenous community members are observing home smoking rules to protect their children and babies (Walker et al. 2015), reflecting on consequences of passive smoking and even challenging each other to achieve these aims (Gould et al. 2013c). However, some may believe only new-born babies are susceptible to environmental tobacco smoke (ETS), thus continue to smoke around older children (Gould et al. 2013c). Strategies to avoid third-hand smoke affecting babies and children have been reported in a study involving Australian Indigenous and Maori smokers (Walker et al. 2015), including wearing a smoking shirt and showering. These changes indicate reflective motivation, social and physical opportunities and capacity to restructure the home smoking environment (Gould et al. 2013c).

Smoking by Indigenous women in pregnancy requires special consideration. Anti-tobacco messages effective in other contexts may sometimes be too confronting in pregnancy, leading to disengagement and self-exempting beliefs, as reported in other pregnant populations (Naughton et al. 2013). The ‘Quit for You Quit for Two’ campaign with its gentle references to improving pregnancy outcomes may have messages pitched at the right level or tone (Australian Government 2012). However, we believe that messages targeting Indigenous pregnant smokers require expansion in scope to incorporate the evidence emerging from recent studies. Perceptions about susceptibility to smoking harms could be addressed by using the strategies in Table 2, employed at local, regional and national levels, and developed with appropriate Indigenous community consultation. Many of these messages can be delivered in primary healthcare settings to Indigenous pregnant women who smoke, and her family members. These settings are an excellent conduit for targeted materials, and messages can be delivered one-on-one or in small groups.

Table 2.  Suggested responses to beliefs about smoking identified in studies involving pregnant Indigenous women and smokers of reproductive age
CO, carbon monoxide; ETS, environmental tobacco smoke; NRT, nicotine replacement therapy

National and international guidelines for smoking cessation in pregnancy recommend behavioural counselling, followed by nicotine replacement therapy (NRT) for women unable to quit unaided. NRT is used therapeutically to reduce withdrawal symptoms associated with quitting smoking. It is available as a transdermal patch (slow-acting) and more rapidly acting oral forms such as gum, lozenges, inhaler or a spray. In Australia, oral NRT is the first-line pharmacotherapy in pregnancy, followed by transdermal and then combination NRT (transdermal and oral) if required (Zwar et al. 2014). Effective cessation interventions in pregnancy in the general population include: behaviour change techniques, pregnancy-specific self-help materials, financial incentives, and NRT, often as a combination of a patch and a fast-acting oral form (Brose et al. 2013; Chamberlain et al. 2013; Coleman et al. 2015). NRT is considered safe to use for the pregnant mother and foetus, according to the latest Cochrane review (Coleman et al. 2015). Counselling in pregnancy produces a modest 4–6% increased quit rate compared with no counselling (Chamberlain et al. 2013). Adding NRT to counselling can triple the effectiveness of counselling alone (Pollak et al. 2007).

In a randomised controlled trial in a clinical setting, nicotine patches were efficacious at 4 weeks compared with placebo (21.3 v. 11.7%), but adherence was problematic after this time point (Coleman et al. 2012). In a large non-randomised clinical sample (3500 participants), transdermal NRT combined with an oral form doubled the quit rate compared with no medication or monotherapy (OR = 1.93) (Brose et al. 2013). The accelerated nicotine metabolism in pregnancy gives a physiological basis for higher doses being required (Dempsey et al. 2002). Even short periods of abstinence are beneficial for foetal growth.

Cutting down, as a harm reduction or quitting strategy, in pregnancy is reported in other populations (Graham et al. 2014). Owing to the risk of compensatory smoking, health gains are only realised if cutting down is accompanied with NRT. Preliminary studies involving pregnant smokers suggest that using NRT while cutting down is safe (Berlin et al. 2014), although pre-cessation use has not been addressed in formal guidelines (Zwar et al. 2014).

Counselling and pharmacotherapy are effective in Indigenous smokers generally (relative risk, RR 1.43; 95% CI 1.03–1.98) (Carson et al. 2012a); however, it is unclear what approaches are effective for Indigenous women in pregnancy (Passey et al. 2013). Indigenous pregnant women sometimes interpret the discomfort they experience from ‘cutting down’ or quitting as psychological stress, and are unaware that these symptoms could be nicotine withdrawal, so educational approaches may be required (Passey et al. 2012a; Gould et al. 2013c). Similar considerations are seen in other vulnerable populations. Pre-cessation NRT may provide a bridge between cutting down and complete cessation, possibly assisting to ameliorate stress-inducing symptoms and increasing physical and psychological capabilities. However, it is not known how acceptable NRT is to Indigenous pregnant smokers (Gould et al. 2013b, 2013c). Educational and social marketing approaches could promote the use of NRT, increase client understanding about why NRT is safer than smoking in pregnancy and how it works (Gould et al. 2015a).

Translational strategies relate to service provision on the outer ring of the BCW and are recommended in primary care. Clinician training and enabling providers to offer evidence-based therapies can achieve these approaches. Intentions to change smoking behaviour need to become a reality by health professionals giving practical assistance to enable and empower pregnant women to quit smoking. Best practice includes a range of behaviour change techniques addressing the psychosocial issues that Indigenous women encounter. Enhancing self-efficacy may lead to more quit attempts, but these attempts also need to be of a ‘better quality’ in order to give people the best chances to successfully quit. In the general population, it has been shown that providing practical assistance, such as offering NRT, has a significant influence on cessation outcomes (Aveyard et al. 2012).

Several studies draw attention to the barriers for Indigenous pregnant smokers to receiving evidence-based therapies (Passey et al. 2012b; Gould et al. 2013b; Passey et al. 2013; Gould 2014). Barriers that are largely remediable and should be targeted strenuously include lack of knowledge and expertise by clinicians, lack of access to culturally appropriate programs and lack of access to subsidised oral and combination forms of NRT for pregnant women. These barriers impinge on individuals’ capacity, opportunity and motivation to change, as indicated by the three central segments of the BCW. In NSW, a targeted Quit For New Life program uses a translational approach by providing a family-orientated program, cessation support for Indigenous pregnant mothers and free oral forms of NRT (currently under evaluation).

Clinicians commonly have concerns about prescribing NRT for pregnant women, and may miss opportunities to intervene. UK general practitioners (GPs) reported safety concerns and low confidence in prescribing NRT, despite the majority agreeing that NRT was safer than smoking when pregnant (Herbert et al. 2005). In Australia, knowledge of cessation strategies is poor among Australian antenatal health providers caring for Indigenous women (Passey et al. 2012b). Some health workers considered it not worthwhile to offer cessation advice to Indigenous pregnant women due to low perceived success (Passey et al. 2012b). Preliminary findings from Australian GPs working in Indigenous health show a similar lack of optimism and inadequate follow up (Gould et al. 2015e). A study of Indigenous smokers of reproductive age showed that 40% of smokers, who had consulted their health provider about quitting, rated the assistance they received as poor, thus limiting their physical opportunity and capacity for change (Gould et al. 2015c). Researchers conclude that the support offered to Indigenous women has hitherto been insufficient, and 38% are offered no assistance (Passey and Sanson-Fisher 2015).

Improving the skills of ante-natal and primary care providers for smoking cessation, through training and incentivisation, has the potential to improve Indigenous health and cessation outcomes (Carson et al. 2012b; Passey et al. 2013; Passey and Sanson-Fisher 2015). GPs and multidisciplinary teams have opportunities to engage with Indigenous women when confirming pregnancy, and often provide shared antenatal care for rural and remote Indigenous women.

The recently updated Royal Australian College of General Practitioners (RACGP) guidelines include combination NRT if required in pregnancy (Zwar et al. 2014). The management of smoking cessation in Indigenous pregnant women can be complex. Concern about the lack of knowledge of effective cessation approaches specific to Indigenous pregnant women led to the recent publication of interim pragmatic guidelines (Gould et al. 2015a, 2015b). This approach is aimed at primary healthcare professionals. These guidelines, based on an ABCD mnemonic (Ask, Brief advice, Cessation support, Discuss the psychosocial context), encourage a proactive translational approach. The ABCD approach includes culturally competent behavioural counselling using the ‘teachable moment’ of pregnancy (McBride et al. 2003), a visual aid to educate on the issue of stress and withdrawal symptoms, a quit plan to engage the client in goal setting and problem-solving, and an algorithm to guide the expedited use of NRT including combination forms if required (Gould et al. 2015a).

A significant barrier to capability and opportunity for smoking cessation in pregnant women, and hampering the service provision by providers, is the lack of subsidy for oral or combination NRT on Australia’s Pharmaceutical Benefits Scheme (PBS). The Australian Association of Smoking Cessation Professionals has lobbied for 3 years to correct this inequity. Access would be facilitated, should the PBS agree to extend the NRT listing. So far, pharmaceutical companies are reluctant to supply oral NRT to the PBS or apply for it to be listed – an essential first step for putting in an application for listing extension. The Australian Government may need to consider alternatively funded supplies under a scheme tailored specifically to this vulnerable population.

The views of Indigenous women should be further explored to determine the most effective approaches. Such a study could determine what support and counselling techniques would be preferred, and who should deliver them; and also assess willingness to use evidence-based approaches, such as NRT in pregnancy.

Primary care approaches that could be strengthened include counselling using behaviour change techniques known to be effective in pregnancy, routine discussion of the psychosocial context for smoking, educational approaches to improve health promotion messages, appropriate use of NRT in pregnancy, culturally competent practices, and following up women throughout their term. These approaches can be improved by investing in training for GPs and other health professionals in primary care settings, who have contact with pregnant women from the earliest stages of their pregnancies and routinely consult them in their reproductive years. Training could up-skill providers in culturally competent approaches, aid the translation of evidence into action and promote the uptake of evidence-based guidelines.

Pregnancy is both a risk for persistent smoking and an opportunity for behaviour change in Indigenous Australian women. Indigenous women, however, face intrinsic and extrinsic barriers in accessing evidence-based cessation therapy during pregnancy, including the lack of suitable services and access to NRT, and few culturally appropriate programs. Areas for immediate action have been outlined to refine anti-tobacco messages and provide cessation support, with reference to the BCW. These approaches have potential to hasten the reduction in prevalence of smoking among Indigenous pregnant women, and aid in achieving state and national Indigenous health goals.

No conflicts of interest to declare.