“Nobody smokes in the house if there's a new baby in it”: Aboriginal perspectives on tobacco smoking in pregnancy and in the household in regional NSW Australia
Introduction
In Australia the prevalence of smoking in pregnant Aboriginal and Torres Strait Islander women is 49.3% compared with 12.1% for their non-Indigenous counterparts.1 Prenatal and perinatal smoking perpetuates disadvantage2 by being associated with: miscarriage, stillbirth, low birth weight and Sudden Unexpected Death in Infancy (SUDI), hearing and cognitive-behavioural problems in childhood,2 early smoking initiation,3 and inter-generational chronic diseases.4
Antecedents to smoking by Aboriginal and Torres Strait Islanders include the historical use of tobacco,5 colonisation and the impact of Government policies,5, 6 racism,7 socioeconomic inequities,6 the ‘stolen generation’8 and the scarcity of culturally appropriate services.6 Smoking in pregnant Aboriginal and Torres Strait Islander women is influenced by multiple factors such as sociocultural norms, family influences and stressors, limited knowledge of harms, anti-tobacco messages lacking relevance, and unfamiliarity about and access to cessation methods including nicotine replacement therapy (NRT).9 Despite these difficulties, pregnant Aboriginal and Torres Strait Islander smokers acknowledge their ‘protector role’ for the foetus.9, 10
Smoking cessation for pregnant Aboriginal and Torres Strait Islander women is a priority,11, 12 yet evidence about effective interventions is limited for pregnant Indigenous smokers in Australia,10, 11, 13, 14 and internationally.11, 12 Greater insight into the experiences of pregnant women who smoke is needed12 to develop salient health messages,9 culturally-relevant interventions and targeted support.11, 14 There is also a need to address gaps in knowledge related to Aboriginal and Torres Strait Islander women who smoke such as the use of NRT, responses to anti-tobacco mass media and the management of smoke-free homes.9
This study explored the responses of Aboriginal women and family members to issues about smoking in pregnancy and household smoking. The study sought to inform the development of a local cessation program for pregnant Aboriginal women using the views of the women and men involved in the study.
We use the term Aboriginal to refer to the local community and participants as the first peoples of NSW, and Aboriginal and/or Torres Strait Islander peoples when referring to wider Australian research.
Section snippets
Methods
We used focus groups as a way of understanding community perspectives and dialogue.15 Topics for discussion were selected from the literature on Aboriginal and Torres Strait Islanders who smoke when pregnant.9 The importance of family and partners to smoking guided sampling.16 A steering committee including Aboriginal stakeholders oversaw the study. A maternal subcommittee, including Aboriginal members and midwives, assisted in the study design, interview guide, and recruitment process, and
Results
Categories related to tobacco smoking in pregnancy included: social and family influences, knowing and experiencing the health effects of smoking, responses to health messages, craving and stress, giving up and cutting down, managing smoke-free homes and cars and community recommendations. Each researcher-defined theme is allocated a quote as subtitle.
Discussion
This qualitative study explored Aboriginal people's attitudes to and experiences of smoking during pregnancy and household smoking at one Aboriginal maternity service in Australia. Our findings revealed multiple perspectives through interlinking factors that influenced maternal smoking. These factors included: social and family influences, lack of support for quitting, lack of relevance of anti-tobacco and educational messages to participants’ lived experience, protective parental attitudes to
Implications for practice and policy
These findings have implications for the appropriate development of tobacco control strategies at three levels: media messages, behavioural support and pharmacological treatment.
The static rates for smoking in Aboriginal and Torres Strait Islander pregnant women suggest that prevailing anti-tobacco messages may have been ineffective. During this focus group study an Indigenous-targeted National Tobacco Campaign was released,42 and a recent campaign targets smoking by pregnant Aboriginal and
Conclusion
This work builds on knowledge from a previous meta-ethnography of studies on smoking by Aboriginal and/or Torres Strait Islander women9 by bringing greater attention to issues of household smoking, NRT and views about susceptibility to tobacco harms. Anti-tobacco messages and interventions should relate to Aboriginal women's experiences, improve understanding of the quitting process, support efficacy, and capitalise on the positive changes occurring in smoke-free home management.
Declaration of interests
AM receives a personal income from Cancer Research UK via University College London. He has received travel funding, honorariums and consultancy payments from manufacturers of smoking cessation products (Pfizer Ltd, Novartis UK and GSK Consumer Healthcare Ltd). He also receives payment for providing training to smoking cessation specialists; receives royalties from books on smoking cessation and has a share in a patent of a nicotine delivery device.
Acknowledgements
The Australian Government Department of Health and Ageing Indigenous Tobacco Control Initiative funded this work. GG is in receipt of a post-graduate scholarship for Indigenous health research from National Health and Medical Research Council (Australia) and National Heart Foundation (Australia) APP1039759.
For their generous involvement in this study we would like to acknowledge the Aboriginal community and Elders, staff and clients from the Aboriginal Maternal and Infant Health Service, Coffs
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