Pregnant smokers, partners and midwives: Qualitative research on their receptivity to campaign messages

Receptiveness to messages

Three basic facts seem fundamental to the way in which messages about smoking and pregnancy are received.  First, awareness of the fact that it is bad for women to smoke during pregnancy is very high.  Second, understanding of why this is so is very limited.  Third, the dangers of a partner’s secondhand smoke to the unborn baby are not as obvious as the dangers of it to children, who are visible.

These facts combine to create a number of effects.  Almost all women know that they should quit or at least cut down when pregnant, but their lack of understanding of the dangers undermines their resolve.  Men (smokers and non-smokers) also feel that women should quit or cut down, but do not have convincing arguments why they should do so.  Of these, smoking men do not see why they should quit themselves, as they feel that moving away to smoke is sufficient.  Smoking women with partners who smoke and do not want to quit use this as a reason why they should not quit either, creating a vicious circle in which neither partner will quit unless they both try together.

As a result, communications which raise the subject of smoking in pregnancy in a resonant way and provide information about the dangers are likely to be well received by some populations, but not others.  Women who know they should quit but have succumbed to pressure not to do so, and need to be given a push are likely to be receptive, as are non-smoking men with smoking partners, who know that their partners should not be smoking but have no real arguments to make against it, and smoking men with non-smoking partners, who are considerate enough to move away when they smoke but do not appreciate the dangers that remain.  But communications are likely to be less effective among male and female smokers who have smoking partners because of the vicious circle described above.

Target sectors

Three attitude sectors were identified:

• the least engaged, who have given little thought to the dangers to their baby of smoking during pregnancy (and often little thought to the dangers of smoking to themselves)
• the middle ground of women who know that smoking during pregnancy is bad, but who have brushed this fact under the carpet in the face of compelling reasons for smoking and lack of understanding of the effects of smoking.  Also smoking men with non-smoking partners who know that they should not smoke near their partners, but do not feel that they need to quit since moving away is sufficient
• the most engaged, who are well aware that smoking during pregnancy is bad and want to quit or cut down, but need a push in this direction

Based on this sample, it is the middle sector which appears to be largest and most worth targeting.  Smokers in this sector are ‘ripe’ for motivation, but need to reappraise their (often entrenched) attitudes to smoking in pregnancy if they are to change their behaviour.  Communications will need to resonate with and be thought relevant by this audience if they are to force this reappraisal.

By contrast, the most engaged smokers are likely to be relatively easy to motivate, provided that they are interested in the material and learn what they need from it, and the least engaged are likely to be very difficult to motivate at all.

Preferred routes: posters and leaflets

As routes, Scan and Poisons received similar levels of support (in terms of both posters and leaflets) from across the public sample, but it was felt  that Scan has a number of advantages over Poison and, crucially, no gross negatives.

Scan seems to work best among those in the middle of the attitudes spectrum described above; it is clearly related to pregnancy, and therefore immediately relevant and noticeable, and it uses emotional shock to force the issue of smoking and pregnancy to the fore.  It is also equally relevant to men and women, provided that men are engaged enough with their partner’s pregnancy to notice the image. 

Overall, Scan resonates effectively with this audience, and seems to have the potential to force a reappraisal of their attitudes.  It also seems to be more resonant than the other routes among first-time mothers. 

Scan is less successful for the outer two sectors, but it is still likely to be relevant enough to interest the most engaged sector, and therefore to provide them with the information they say they want through the leaflets.  If it is to be effective among the most engaged smokers, its leaflets will need to communicate clearly why smoking during pregnancy is bad, as the creative device does not do this.  But there is a danger that the smoking message in the poster will be missed because the image of the baby is healthy-looking and the reference to smoking is recessively positioned.

Poisons is more successful with the outer two sectors, as it immediately gives them information which is new and shocking, and in some cases relevant and motivating, but it is less successful with the middle sector as it lacks the emotional punch needed to force them to confront their smoking behaviour.  Poisons also has some drawbacks which could be construed as gross negatives: showing supplements in this way may be inappropriate; the link between the ‘contents of smoke’ message and pregnancy may be missed; and it is too busy to attract attention from some, or for some to take it in all at once.

Secrecy does not seem to communicate with enough impact to be effective, and is difficult for many to understand – although its message does resonate with a number of respondents.

Similar tones were preferred for the leaflets for women and dads – a mix of emotive language, bare facts and supportive statements. 

Format of the leaflet

Overall, women and midwives both preferred the visual leaflet format which would be filled in by mothers, to the coupon which would be filled in by midwives.  Basically women wanted something that they could take away, and midwives would prefer not to fill in a form during the booking appointment.  Many women said they would fill in and send off the form, as did a number of male smokers. Most midwives agreed – some said that the women they saw would send off for anything that was clearly free.

Other material

Both the fridge magnet and the wallchart were well liked by women: they were both expected to be motivating and encouraging; neither was seen as patronising or hectoring.  Some women suggested using a calendar-style format for the wallchart, so that development side would be positioned above the tips on a single side.

Midwives’ material

The flashcards concept was widely liked, and expected to be useful for a number of reasons.  Q&A booklets were a little less popular as proposed, but would be better received, and could be used in a wider variety of ways, if they provided a short and a long answer to each question. 

The training guide was difficult for community midwives to assess in the form in which they saw it.  Most imagined a fuller version would be useful, but many wanted to reserve judgement at this stage.  Stop smoking specialist midwives were more enthusiastic, and could imagine that a guide which gave them a structure for training sessions and signposts to further information would be useful.  They had few criticisms of the guide.