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The risks to the unborn child, when a pregnant woman smokes, are well-documented1 and most pregnant women are aware of, at least some, risks.2, 3 Despite this, not all pregnant women cease or reduce smoking.3 Commonly women, who smoke during pregnancy, have a partner who smokes,4,5 and, come from a lower socioeconomic area where high smoking prevalence is more common.6In New Zealand, smoking is clearly patterned by socioeconomic position: the most disadvantaged groups have the highest smoking prevalence.7 M ori women are one of the most socially deprived groups in New Zealand8 and they have the highest smoking prevalence rates. Surveys have put smoking among M ori women aged 15-24 years old as high as nearly 61%; 39% among M ori women aged 25-29 years, and 57% of 30-39 year olds.9In 2007, at first registration with a midwife, 19% of New Zealand pregnant women were smoking and this dropped a little to 15% still smoking when discharged from midwife care.10 The prevalence was substantially higher for M ori women, with 43% smoking at first registration with a midwife and 34% still smoking at discharge.10From conception, M ori are disproportionally affected by the ill-consequences of tobacco use. Smoking during pregnancy contributes to higher rates of miscarriage, preterm births, low birth weight babies and difficulties during childbirth.11 Sudden Unexplained Deaths in Infancy (SUDI), asthma, glue ear, and increased rates of chest infections, all associated with maternal smoking, are commonplace among M ori children.12 Maternal smoking also sets M ori up for higher rates than non-M ori of cardiovascular disease, many cancers and respiratory diseases later in life.Quitting in the first 3-4 months of pregnancy and remaining abstinent protects the fetus from some of the adverse effects of smoking.13 Serendipitously, pregnancy is a powerful motivator to quit smoking.3 In New Zealand, Ford et al14 found that whilst 64% of pregnant smokers wished to quit and 30% wished to cut down, this contrasted with what they actually achieved: 34% quit and 50% cut down. In another study, 40% of M ori pregnant women cut down and 23% stopped smoking altogether.15There are several barriers undermining reduction or cessation of smoking when pregnant, including loss of the role and meaning of smoking and negative influence from family or friends.2, 16Women who continue smoking during pregnancy are likely to live in a household with other smokers,17-19 and have partners, family and friends who smoke.16 Similar results have been found for M ori: living with other smokers effects smoking cessation success M ori.20 Further, a qualitative study found that addiction, habit and stress were reasons why pregnant women continued smoking.21Reducing smoking among pregnant women remains a challenge. Whilst several qualitative studies have investigated pregnant womens smoking during pregnancy, no previous study has focused on pregnant M ori smokers attitudes towards smoking and barriers to cessation. Previous studies into M ori smoking have involved few pregnant participants.20 The high smoking prevalence among M ori women warrants research specifically focused on this group.Reducing smoking during pregnancy has been a New Zealand and international priority for over a decade16, 22 and closing the health inequality gaps are a key public health agenda,22 adding to the rationale for reducing smoking during pregnancy among M ori women. The New Zealand tobacco control programme could usefully be informed by a study identifying barriers to smoking cessation for pregnant M ori women. Thus, this research aimed to determine: The attitudes of M ori pregnant smokers towards smoking during pregnancy; The factors influencing continued smoking during pregnancy; and Family (wh nau) support to quit received by the women. Method This was an exploratory qualitative study using semi-structured face-to-face interviews. Purposive sampling was used to find a diverse range of women who varied across age, stage of pregnancy, number of pregnancies, socioeconomic level and place of residence. Random selection was, therefore, not used. Pregnant M ori self-identified smokers, aged 16 and over, were invited to take part. Participants were recruited through primary health care services, for example, M ori midwives, M ori community health workers, M ori health clinics, the researchers networks, a circulated invite and newspaper advertisement. Interviews were conducted during October 2002 to November 2003 with 60 women from Auckland, Wellington, Hamilton, Kawakawa and around the Hokianga. The questionnaire included questions relating to pregnancy status, tobacco consumption, attitudes to quitting, beliefs about smoking during pregnancy and support to quit. The questionnaire contained both qualitative open-ended questions and quantitative agree-disagree questions. Responses were manually recorded on the questionnaire in full view of the participant. Transcripts were not produced, thus women were not asked to check the written responses. Interviews took from 30-45 minutes. Ethical approval for the study was given by the University of Auckland Human Participants Ethics Committee. Where possible, questionnaire responses were quantified. Quantitative data was entered into Excel and standard frequencies were calculated for descriptive purposes. Free text responses were entered into Microsoft Word and manually sorted using the themes covered in the questionnaire. Thematic analysis within categories enabled coding sets to be developed, for example, for reasons for stopping smoking. Te Whare Tapa Wha23 was used as the primary organising framework for grouping the findings into sections. The demographics, pregnancy status and nicotine dependency factors were grouped under Te Taha Tinana (the physical or bodily aspect of health). Attitudes towards and beliefs about smoking while pregnant and motivation to stop smoking were included under Te Taha Hinengaro (the mental realm). The home and social environment and smoking and attitudes of others fitted into in to the realm of Te Taha Wh nau (the family and social realm). No data emerged that fitted under Te Taha Wairua (the spiritual realm). The data was quantified in order to illustrate how common a particular response was and the qualitative narrative was used to describe or explain the findings. Results Participants ranged in age from 17 to 43 years old. The average age was 26. Most of the women (88%) had a partner. Twenty-three percent of participants had no educational qualifications and only 38% had some employment. Over half (68%) of the participants lived in urban centres. They listed membership of from one to three iwi (tribe) each. Almost equal numbers of participants were in to the second (43%) or third (40%) trimester of their pregnancy and 38% of the women were having their first baby. Te Taha Tinana: biological and physical aspects of smokingThe average stated number of cigarettes smoked per day was nine, ranging from 1 to 28 (Table 1a). Nineteen (32%) of the participants smoked their first cigarette within 5 minutes of waking (Table 1b). Table 1. a) Number of cigarettes smoked per day; and b) time to first cigarette upon waking The majority of participants (77%) were healthy and reported that they had not suffered any smoking-related illnesses in the previous 6 months. Even the women who reported having asthma, bronchitis or low or high blood pressure, reported mild or seasonal symptoms. As one woman said cthats the only time I go to a doctor usuallypregnancy.d Te Taha Hinengaro: beliefs and reasons for smoking and quittingOf the reasons given for smoking 50% of participants said they smoked because of habit (Table 2), as illustrated by the following quote: cJust got to have something in my hands. Its not that I like it.d The second most common reason for smoking was due to stress. cStress and my partner and arguing and stress and my mother and stress.d cStops me from stressing out. Stops me from worrying about things.d Table 2. Reasons for smoking Reason N=60 % Habit Stress Addiction Calms\/relaxes Satisfaction\/like it Social\/company Boredom\/something to do Time out Depression Dont know 30 18 15 14 10 8 7 2 1 2 50 30 25 23 17 13 12 3 2 3 Participants cited multiple reasons motivating them to quit smoking (Table 3). The two most common cited reasons for contemplating quitting were for their babys and own health. For example: cIf I could give it up, it would do me world of good.d Several previous quit attempts had been cfor my health.d For example, these women said, cI got sick,d csmokers cough and the effects.d cI had the flu actually. I just couldnt smoke.d However, only 12 women said they wanted to quit because of the pregnancy and only twelve women had tried to stop or succeeded at stopping smoking for their first pregnancy. One woman managed to stay smokefree until her baby was about 1 year old. Table 3. Reasons for wanting to quit Reason N=37 % For babys health Their own health Cost Pregnancy Other children Sport\/fitness Its time Role model Nausea Its yuk\/stinks Longevity Breastfeeding 29 20 16 12 7 5 4 4 3 2 1 1 78 54 43 32 19 13.5 11 11 8 5 3 3 Most of the participants (92%) had thought about quitting and many (78%) had tried to quit. The number of quit attempts ranged from 0 to cmany timesd, with an average of two. Thirty-five percent had managed to give up smoking before, though some women counted periods as short as a few days as 8having given up. Eleven, of the women who had previously quit stayed smokefree for 3 months or longer, while the other ten stayed smokefree from 1 week up to 3 months. Attitudes towards smoking during pregnancyMost of the women were concerned about their unborn childs health and 45% (27) worried ca lotd. Most of the women agreed that if they stopped smoking while they were still pregnant it was likely their baby would be healthier. Many thought other people smoking around them had an effect on their unborn babys health (Table 4). Contradicting this result, many agreed or answered 8dont know to the questions that the amount they smoked was too little to cause harm to their baby and there was no need to quit completely if they cut down. The statement cif I cut down on my smoking there is no need to quit completelyd was used to rationalise continued smoking. One woman explained that she believed this ccos [because] they said even cutting down would be beneficial. Quitting would be better but cutting down better - every hour or two you dont smoke baby is getting more oxygenthat is why I cut out last one at night and first two in morning so baby has more time smokefree.d Of concern, 33% agreed that they may as well keep smoking themselves as they were exposed to so much smoke from others. One woman acknowledged that it was a thought that supported her to continue smoking even though she knew it wasnt true and another said cthey say nowadays secondhand smoke worse than first hand.d Table 4. Belief statements about smoking during pregnancy Statement Agree % Disagree % Dont know % Its good to have a smaller baby 2 3.3 52 87 6 10 The amount I smoke is too little to cause harm to this baby inside me 9 15 43 72 8 13 If I stop smoking while Im still pregnant, it is likely that this baby will be healthier 57 95 0 0 3 5 Smoking low tar (ultra mild) cigarettes is less harmful to my unborn baby 6 10 39 65 15 25 If I cut down on my smoking there is no need to quit completely 14 23 38 63 8 13 I am exposed to so much smoke from other people I might as well keep smoking myself 20 33 38 63 2 3 Other people smoking in the house has an effect on my unborn babys health 53 88 4 7 3 5 Nicotine passes through breast milk 33 55 4 7 23 38 Te Taha Wh nau: familial and social influencesAll of the women lived with other smokers and nearly half (47%) of the women lived with a partner who smoked. Nearly half (48%) said their house was totally smokefree. Eleven participants (18%) lived in homes with no restrictions on smoking. Twenty participants (33%) lived in households that allowed smoking inside; however, many of those households had made rooms smokefree or had a designated smoking area. Thirty seven (62%) participants said that the people they socialise most frequently with smoke (Table 5a) and only two participants mixed with mainly non-smokers. Most participants (93%) said it was easy to smoke in their social venues (Table 5a). Table 5. Environments - a) Social and b) Work Nearly all of the women who worked said it was easy to smoke at work and 30 smoked with others at work (Table 5b). Smoking at work was easy because as participants said they could cjust go out whenever want tod or ctheres a designated smoking area outsided and because a cmajority of staff smoked. Even participants who worked or were students at schools, an environment designated smokefree under legislation, still smoked while there. Similar to other workplaces, cpractically everyoned smoked or they were callowed to during breaksd and there was a cdesignated [smoking] area out

Summary

Abstract

Aim

To investigate why some M ori women continue smoking during pregnancy.

Method

An exploratory qualitative study was conducted with 60 pregnant M ori women aged from 17-43. A questionnaire was used to guide the interviews. Responses were categorised using Te Whare Tapa Wha (the four-sided house), an Indigenous theoretical framework.

Results

The women smoked on average 9 cigarettes per day. Many (45%) were very concerned for their babys health. The main reasons for quitting were for their own and their babys health. The majority (77%) reported no smoking-related health problems. All the women lived with at least one other smoker. Over half of the participants (62%) predominantly socialised with people who smoked and nearly all said it was easy to smoke in their socialising and work environments. Partners and mothers were the most common source of support or advice to quit, however, often that support person also smoked. There was a lack of understanding of the harms associated with maternal smoking.

Conclusion

Motivation to quit smoking was low. The women all lived with smokers which reportedly made it harder to quit; most of them lived in a smoky environment, where family, friends and coworkers smoked. This highlights the need to include family in cessation interventions.

Author Information

Marewa Glover, Director; Anette Kira, Research Fellow; Centre for Tobacco Control Research, University of Auckland

Acknowledgements

Correspondence

Marewa Glover, Social and Community Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland, New Zealand. Fax: +64 (0)9 3035932

Correspondence Email

m.glover@auckland.ac.nz

Competing Interests

None.

Einarson A, Riordan S. Smoking in pregnancy and lactation: A review of risks and cessation strategies. Eur J Clin Pharmacol 2009;65(4):325-330.Ingall G, Cropley M. Exploring the barriers of quitting smoking during pregnancy: A systematic review of qualitative studies. Women and Birth 2010;23(2):45-52.Haslam C, Draper ES, Goyder E. The pregnant smoker: a preliminary investigation of the social and psychological influences. Journal of Public Health 1997;19(2):187-192.Ebert LM, Fahy K. Why do women continue to smoke in pregnancy? Women and Birth 2007;20(4):161-168.McLeod D, Pullon S, Cookson T. Factors that influence changes in smoking behaviour during pregnancy. N Z Med J 2003;116(1173). http://www.nzma.org.nz:8080/journal/116-1173/418/content.pdfBull L, Burke R, Walsh S, Whitehead E. Social attitudes towards smoking in pregnancy in East Surrey: A qualitative study of smokers, former smokers and non-smokers. Journal of Neonatal Nursing 2007;13(3):100-106.Hill S, Blakely T, Howden-Chapman P. Smoking inequalities: Policies and patterns of tobacco use in New Zealand, 1981-1996. Wellington: University of Otago, Wellington School of Medicine, 2003.Ministry of Womens Affairs. Indicators for Change 2009: Tracking the progress of New Zealand women. Wellington: Ministry of Womens Affairs, 2010.Ministry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health, 2007.Dixon L, Aimer P, Fletcher L, Guilliland K, Hendry C. Smoke free Outcomes with Midwife Lead Maternity Carers: An analysis of smoking during pregnancy from the New Zealand College of Midwives midwifery database information 2004 - 2007. New Zealand College of Midwives Journal 2009;40:13-19.Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine and Tobacco Research 2004;6(SUPPL. 2).Pomare E, Keefe-Ormsby V, Ormsby C, Pearce N, Reid P, Robson B, et al. Hauora: Maori standards of health III. Wellington: Te Ropu Rangahau Hauora a Eru Pomare, Wellington School of Medicine, 1995.McCowan LM, Dekker GA, Chan E, Stewart A, Chappell LC, Hunter M, et al. Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study. BMJ (Clinical research ed.) 2009;338.Ford R, Wild C, Glen M, Price G, Wilson C. Patterns of smoking during pregnancy in Canterbury. NZMJ 1993;106(965):426-9.Te Ropu Rangahau Hauora a Eru Pomare. Benchmark Survey on monitoring the Why Start? Multi-media Campaign to reduce smoking amongst pregnant Maori women smokers: Preliminary results. Wellington: School of Medicine, 1996.Tod AM. Barriers to smoking cessation in pregnancy: a qualitative study. British journal of community nursing 2003;8(2):56-64.Walsh RA, Redman S, Brinsmead MW, Fryer JL. Predictors of smoking in pregnancy and attitudes and knowledge of risks of pregnant smokers. Drug and Alcohol Review 1997;16(1):41-67.Quinn VP, Mullen PD, Ershoff DH. Women who stop smoking spontaneously prior to prenatal care and predictors of relapse before delivery. Addict Behav 1991;16(1-2):29-40.Abrahamsson A, Springett J, Karlsson L, Ottosson T. Making sense of the challenge of smoking cessation during pregnancy: A phenomenographic approach. Health Education Research 2005;20(3):367-378.Glover M. The effectiveness of a Maori Noho Marae Smoking Cessation intervention: Utilising a kaupapa Maori methodology [Doctor of Philosophy Thesis]. The University of Auckland, 2000.McCurry N, Thompson K, Parahoo K, O'Doherty E, Doherty AM. Pregnant women's perception of the implementation of smoking cessation advice. Health Education Journal 2002;61(1):20-31.Ministry of Health. Monitoring Health Inequality Through Neighbourhood Life Expectancy: Public Health Intelligence occasional bulletin Wellington: Ministry of Health, 2005.Glover M. Analysing smoking using Te Whare Tapa Wha. New Zealand Journal of Psychology 2005;34(1):13-19.McCaul KD, Hockemeyer JR, Johnson RJ, Zetocha K, Quinlan K, Glasgow RE. Motivation to quit using cigarettes: A review. Addict Behav 2006;31(1):42-56.Fidler JA, West R. Self-perceived smoking motives and their correlates in a general population sample. Nicotine and Tobacco Research 2009;11(10):1182-1188.Ministry of Health. New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health, 2007.Ministry of Health. Targeting Smokers: Better Help for Smokers to Quit. Wellington: Ministry of Health, 2011.Ministry of Health. Tobacco Use in New Zealand: Key findings from the 2009 New Zealand Tobacco Use Survey. Wellington: Ministry of Health, 2010.National Health Committee. Review of Maternity Services in New Zealand. Wellington: National Health Committee, 1999.Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2009(3).

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The risks to the unborn child, when a pregnant woman smokes, are well-documented1 and most pregnant women are aware of, at least some, risks.2, 3 Despite this, not all pregnant women cease or reduce smoking.3 Commonly women, who smoke during pregnancy, have a partner who smokes,4,5 and, come from a lower socioeconomic area where high smoking prevalence is more common.6In New Zealand, smoking is clearly patterned by socioeconomic position: the most disadvantaged groups have the highest smoking prevalence.7 M ori women are one of the most socially deprived groups in New Zealand8 and they have the highest smoking prevalence rates. Surveys have put smoking among M ori women aged 15-24 years old as high as nearly 61%; 39% among M ori women aged 25-29 years, and 57% of 30-39 year olds.9In 2007, at first registration with a midwife, 19% of New Zealand pregnant women were smoking and this dropped a little to 15% still smoking when discharged from midwife care.10 The prevalence was substantially higher for M ori women, with 43% smoking at first registration with a midwife and 34% still smoking at discharge.10From conception, M ori are disproportionally affected by the ill-consequences of tobacco use. Smoking during pregnancy contributes to higher rates of miscarriage, preterm births, low birth weight babies and difficulties during childbirth.11 Sudden Unexplained Deaths in Infancy (SUDI), asthma, glue ear, and increased rates of chest infections, all associated with maternal smoking, are commonplace among M ori children.12 Maternal smoking also sets M ori up for higher rates than non-M ori of cardiovascular disease, many cancers and respiratory diseases later in life.Quitting in the first 3-4 months of pregnancy and remaining abstinent protects the fetus from some of the adverse effects of smoking.13 Serendipitously, pregnancy is a powerful motivator to quit smoking.3 In New Zealand, Ford et al14 found that whilst 64% of pregnant smokers wished to quit and 30% wished to cut down, this contrasted with what they actually achieved: 34% quit and 50% cut down. In another study, 40% of M ori pregnant women cut down and 23% stopped smoking altogether.15There are several barriers undermining reduction or cessation of smoking when pregnant, including loss of the role and meaning of smoking and negative influence from family or friends.2, 16Women who continue smoking during pregnancy are likely to live in a household with other smokers,17-19 and have partners, family and friends who smoke.16 Similar results have been found for M ori: living with other smokers effects smoking cessation success M ori.20 Further, a qualitative study found that addiction, habit and stress were reasons why pregnant women continued smoking.21Reducing smoking among pregnant women remains a challenge. Whilst several qualitative studies have investigated pregnant womens smoking during pregnancy, no previous study has focused on pregnant M ori smokers attitudes towards smoking and barriers to cessation. Previous studies into M ori smoking have involved few pregnant participants.20 The high smoking prevalence among M ori women warrants research specifically focused on this group.Reducing smoking during pregnancy has been a New Zealand and international priority for over a decade16, 22 and closing the health inequality gaps are a key public health agenda,22 adding to the rationale for reducing smoking during pregnancy among M ori women. The New Zealand tobacco control programme could usefully be informed by a study identifying barriers to smoking cessation for pregnant M ori women. Thus, this research aimed to determine: The attitudes of M ori pregnant smokers towards smoking during pregnancy; The factors influencing continued smoking during pregnancy; and Family (wh nau) support to quit received by the women. Method This was an exploratory qualitative study using semi-structured face-to-face interviews. Purposive sampling was used to find a diverse range of women who varied across age, stage of pregnancy, number of pregnancies, socioeconomic level and place of residence. Random selection was, therefore, not used. Pregnant M ori self-identified smokers, aged 16 and over, were invited to take part. Participants were recruited through primary health care services, for example, M ori midwives, M ori community health workers, M ori health clinics, the researchers networks, a circulated invite and newspaper advertisement. Interviews were conducted during October 2002 to November 2003 with 60 women from Auckland, Wellington, Hamilton, Kawakawa and around the Hokianga. The questionnaire included questions relating to pregnancy status, tobacco consumption, attitudes to quitting, beliefs about smoking during pregnancy and support to quit. The questionnaire contained both qualitative open-ended questions and quantitative agree-disagree questions. Responses were manually recorded on the questionnaire in full view of the participant. Transcripts were not produced, thus women were not asked to check the written responses. Interviews took from 30-45 minutes. Ethical approval for the study was given by the University of Auckland Human Participants Ethics Committee. Where possible, questionnaire responses were quantified. Quantitative data was entered into Excel and standard frequencies were calculated for descriptive purposes. Free text responses were entered into Microsoft Word and manually sorted using the themes covered in the questionnaire. Thematic analysis within categories enabled coding sets to be developed, for example, for reasons for stopping smoking. Te Whare Tapa Wha23 was used as the primary organising framework for grouping the findings into sections. The demographics, pregnancy status and nicotine dependency factors were grouped under Te Taha Tinana (the physical or bodily aspect of health). Attitudes towards and beliefs about smoking while pregnant and motivation to stop smoking were included under Te Taha Hinengaro (the mental realm). The home and social environment and smoking and attitudes of others fitted into in to the realm of Te Taha Wh nau (the family and social realm). No data emerged that fitted under Te Taha Wairua (the spiritual realm). The data was quantified in order to illustrate how common a particular response was and the qualitative narrative was used to describe or explain the findings. Results Participants ranged in age from 17 to 43 years old. The average age was 26. Most of the women (88%) had a partner. Twenty-three percent of participants had no educational qualifications and only 38% had some employment. Over half (68%) of the participants lived in urban centres. They listed membership of from one to three iwi (tribe) each. Almost equal numbers of participants were in to the second (43%) or third (40%) trimester of their pregnancy and 38% of the women were having their first baby. Te Taha Tinana: biological and physical aspects of smokingThe average stated number of cigarettes smoked per day was nine, ranging from 1 to 28 (Table 1a). Nineteen (32%) of the participants smoked their first cigarette within 5 minutes of waking (Table 1b). Table 1. a) Number of cigarettes smoked per day; and b) time to first cigarette upon waking The majority of participants (77%) were healthy and reported that they had not suffered any smoking-related illnesses in the previous 6 months. Even the women who reported having asthma, bronchitis or low or high blood pressure, reported mild or seasonal symptoms. As one woman said cthats the only time I go to a doctor usuallypregnancy.d Te Taha Hinengaro: beliefs and reasons for smoking and quittingOf the reasons given for smoking 50% of participants said they smoked because of habit (Table 2), as illustrated by the following quote: cJust got to have something in my hands. Its not that I like it.d The second most common reason for smoking was due to stress. cStress and my partner and arguing and stress and my mother and stress.d cStops me from stressing out. Stops me from worrying about things.d Table 2. Reasons for smoking Reason N=60 % Habit Stress Addiction Calms\/relaxes Satisfaction\/like it Social\/company Boredom\/something to do Time out Depression Dont know 30 18 15 14 10 8 7 2 1 2 50 30 25 23 17 13 12 3 2 3 Participants cited multiple reasons motivating them to quit smoking (Table 3). The two most common cited reasons for contemplating quitting were for their babys and own health. For example: cIf I could give it up, it would do me world of good.d Several previous quit attempts had been cfor my health.d For example, these women said, cI got sick,d csmokers cough and the effects.d cI had the flu actually. I just couldnt smoke.d However, only 12 women said they wanted to quit because of the pregnancy and only twelve women had tried to stop or succeeded at stopping smoking for their first pregnancy. One woman managed to stay smokefree until her baby was about 1 year old. Table 3. Reasons for wanting to quit Reason N=37 % For babys health Their own health Cost Pregnancy Other children Sport\/fitness Its time Role model Nausea Its yuk\/stinks Longevity Breastfeeding 29 20 16 12 7 5 4 4 3 2 1 1 78 54 43 32 19 13.5 11 11 8 5 3 3 Most of the participants (92%) had thought about quitting and many (78%) had tried to quit. The number of quit attempts ranged from 0 to cmany timesd, with an average of two. Thirty-five percent had managed to give up smoking before, though some women counted periods as short as a few days as 8having given up. Eleven, of the women who had previously quit stayed smokefree for 3 months or longer, while the other ten stayed smokefree from 1 week up to 3 months. Attitudes towards smoking during pregnancyMost of the women were concerned about their unborn childs health and 45% (27) worried ca lotd. Most of the women agreed that if they stopped smoking while they were still pregnant it was likely their baby would be healthier. Many thought other people smoking around them had an effect on their unborn babys health (Table 4). Contradicting this result, many agreed or answered 8dont know to the questions that the amount they smoked was too little to cause harm to their baby and there was no need to quit completely if they cut down. The statement cif I cut down on my smoking there is no need to quit completelyd was used to rationalise continued smoking. One woman explained that she believed this ccos [because] they said even cutting down would be beneficial. Quitting would be better but cutting down better - every hour or two you dont smoke baby is getting more oxygenthat is why I cut out last one at night and first two in morning so baby has more time smokefree.d Of concern, 33% agreed that they may as well keep smoking themselves as they were exposed to so much smoke from others. One woman acknowledged that it was a thought that supported her to continue smoking even though she knew it wasnt true and another said cthey say nowadays secondhand smoke worse than first hand.d Table 4. Belief statements about smoking during pregnancy Statement Agree % Disagree % Dont know % Its good to have a smaller baby 2 3.3 52 87 6 10 The amount I smoke is too little to cause harm to this baby inside me 9 15 43 72 8 13 If I stop smoking while Im still pregnant, it is likely that this baby will be healthier 57 95 0 0 3 5 Smoking low tar (ultra mild) cigarettes is less harmful to my unborn baby 6 10 39 65 15 25 If I cut down on my smoking there is no need to quit completely 14 23 38 63 8 13 I am exposed to so much smoke from other people I might as well keep smoking myself 20 33 38 63 2 3 Other people smoking in the house has an effect on my unborn babys health 53 88 4 7 3 5 Nicotine passes through breast milk 33 55 4 7 23 38 Te Taha Wh nau: familial and social influencesAll of the women lived with other smokers and nearly half (47%) of the women lived with a partner who smoked. Nearly half (48%) said their house was totally smokefree. Eleven participants (18%) lived in homes with no restrictions on smoking. Twenty participants (33%) lived in households that allowed smoking inside; however, many of those households had made rooms smokefree or had a designated smoking area. Thirty seven (62%) participants said that the people they socialise most frequently with smoke (Table 5a) and only two participants mixed with mainly non-smokers. Most participants (93%) said it was easy to smoke in their social venues (Table 5a). Table 5. Environments - a) Social and b) Work Nearly all of the women who worked said it was easy to smoke at work and 30 smoked with others at work (Table 5b). Smoking at work was easy because as participants said they could cjust go out whenever want tod or ctheres a designated smoking area outsided and because a cmajority of staff smoked. Even participants who worked or were students at schools, an environment designated smokefree under legislation, still smoked while there. Similar to other workplaces, cpractically everyoned smoked or they were callowed to during breaksd and there was a cdesignated [smoking] area out

Summary

Abstract

Aim

To investigate why some M ori women continue smoking during pregnancy.

Method

An exploratory qualitative study was conducted with 60 pregnant M ori women aged from 17-43. A questionnaire was used to guide the interviews. Responses were categorised using Te Whare Tapa Wha (the four-sided house), an Indigenous theoretical framework.

Results

The women smoked on average 9 cigarettes per day. Many (45%) were very concerned for their babys health. The main reasons for quitting were for their own and their babys health. The majority (77%) reported no smoking-related health problems. All the women lived with at least one other smoker. Over half of the participants (62%) predominantly socialised with people who smoked and nearly all said it was easy to smoke in their socialising and work environments. Partners and mothers were the most common source of support or advice to quit, however, often that support person also smoked. There was a lack of understanding of the harms associated with maternal smoking.

Conclusion

Motivation to quit smoking was low. The women all lived with smokers which reportedly made it harder to quit; most of them lived in a smoky environment, where family, friends and coworkers smoked. This highlights the need to include family in cessation interventions.

Author Information

Marewa Glover, Director; Anette Kira, Research Fellow; Centre for Tobacco Control Research, University of Auckland

Acknowledgements

Correspondence

Marewa Glover, Social and Community Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland, New Zealand. Fax: +64 (0)9 3035932

Correspondence Email

m.glover@auckland.ac.nz

Competing Interests

None.

Einarson A, Riordan S. Smoking in pregnancy and lactation: A review of risks and cessation strategies. Eur J Clin Pharmacol 2009;65(4):325-330.Ingall G, Cropley M. Exploring the barriers of quitting smoking during pregnancy: A systematic review of qualitative studies. Women and Birth 2010;23(2):45-52.Haslam C, Draper ES, Goyder E. The pregnant smoker: a preliminary investigation of the social and psychological influences. Journal of Public Health 1997;19(2):187-192.Ebert LM, Fahy K. Why do women continue to smoke in pregnancy? Women and Birth 2007;20(4):161-168.McLeod D, Pullon S, Cookson T. Factors that influence changes in smoking behaviour during pregnancy. N Z Med J 2003;116(1173). http://www.nzma.org.nz:8080/journal/116-1173/418/content.pdfBull L, Burke R, Walsh S, Whitehead E. Social attitudes towards smoking in pregnancy in East Surrey: A qualitative study of smokers, former smokers and non-smokers. Journal of Neonatal Nursing 2007;13(3):100-106.Hill S, Blakely T, Howden-Chapman P. Smoking inequalities: Policies and patterns of tobacco use in New Zealand, 1981-1996. Wellington: University of Otago, Wellington School of Medicine, 2003.Ministry of Womens Affairs. Indicators for Change 2009: Tracking the progress of New Zealand women. Wellington: Ministry of Womens Affairs, 2010.Ministry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health, 2007.Dixon L, Aimer P, Fletcher L, Guilliland K, Hendry C. Smoke free Outcomes with Midwife Lead Maternity Carers: An analysis of smoking during pregnancy from the New Zealand College of Midwives midwifery database information 2004 - 2007. New Zealand College of Midwives Journal 2009;40:13-19.Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine and Tobacco Research 2004;6(SUPPL. 2).Pomare E, Keefe-Ormsby V, Ormsby C, Pearce N, Reid P, Robson B, et al. Hauora: Maori standards of health III. Wellington: Te Ropu Rangahau Hauora a Eru Pomare, Wellington School of Medicine, 1995.McCowan LM, Dekker GA, Chan E, Stewart A, Chappell LC, Hunter M, et al. Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study. BMJ (Clinical research ed.) 2009;338.Ford R, Wild C, Glen M, Price G, Wilson C. Patterns of smoking during pregnancy in Canterbury. NZMJ 1993;106(965):426-9.Te Ropu Rangahau Hauora a Eru Pomare. Benchmark Survey on monitoring the Why Start? Multi-media Campaign to reduce smoking amongst pregnant Maori women smokers: Preliminary results. Wellington: School of Medicine, 1996.Tod AM. Barriers to smoking cessation in pregnancy: a qualitative study. British journal of community nursing 2003;8(2):56-64.Walsh RA, Redman S, Brinsmead MW, Fryer JL. Predictors of smoking in pregnancy and attitudes and knowledge of risks of pregnant smokers. Drug and Alcohol Review 1997;16(1):41-67.Quinn VP, Mullen PD, Ershoff DH. Women who stop smoking spontaneously prior to prenatal care and predictors of relapse before delivery. Addict Behav 1991;16(1-2):29-40.Abrahamsson A, Springett J, Karlsson L, Ottosson T. Making sense of the challenge of smoking cessation during pregnancy: A phenomenographic approach. Health Education Research 2005;20(3):367-378.Glover M. The effectiveness of a Maori Noho Marae Smoking Cessation intervention: Utilising a kaupapa Maori methodology [Doctor of Philosophy Thesis]. The University of Auckland, 2000.McCurry N, Thompson K, Parahoo K, O'Doherty E, Doherty AM. Pregnant women's perception of the implementation of smoking cessation advice. Health Education Journal 2002;61(1):20-31.Ministry of Health. Monitoring Health Inequality Through Neighbourhood Life Expectancy: Public Health Intelligence occasional bulletin Wellington: Ministry of Health, 2005.Glover M. Analysing smoking using Te Whare Tapa Wha. New Zealand Journal of Psychology 2005;34(1):13-19.McCaul KD, Hockemeyer JR, Johnson RJ, Zetocha K, Quinlan K, Glasgow RE. Motivation to quit using cigarettes: A review. Addict Behav 2006;31(1):42-56.Fidler JA, West R. Self-perceived smoking motives and their correlates in a general population sample. Nicotine and Tobacco Research 2009;11(10):1182-1188.Ministry of Health. New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health, 2007.Ministry of Health. Targeting Smokers: Better Help for Smokers to Quit. Wellington: Ministry of Health, 2011.Ministry of Health. Tobacco Use in New Zealand: Key findings from the 2009 New Zealand Tobacco Use Survey. Wellington: Ministry of Health, 2010.National Health Committee. Review of Maternity Services in New Zealand. Wellington: National Health Committee, 1999.Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2009(3).

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The risks to the unborn child, when a pregnant woman smokes, are well-documented1 and most pregnant women are aware of, at least some, risks.2, 3 Despite this, not all pregnant women cease or reduce smoking.3 Commonly women, who smoke during pregnancy, have a partner who smokes,4,5 and, come from a lower socioeconomic area where high smoking prevalence is more common.6In New Zealand, smoking is clearly patterned by socioeconomic position: the most disadvantaged groups have the highest smoking prevalence.7 M ori women are one of the most socially deprived groups in New Zealand8 and they have the highest smoking prevalence rates. Surveys have put smoking among M ori women aged 15-24 years old as high as nearly 61%; 39% among M ori women aged 25-29 years, and 57% of 30-39 year olds.9In 2007, at first registration with a midwife, 19% of New Zealand pregnant women were smoking and this dropped a little to 15% still smoking when discharged from midwife care.10 The prevalence was substantially higher for M ori women, with 43% smoking at first registration with a midwife and 34% still smoking at discharge.10From conception, M ori are disproportionally affected by the ill-consequences of tobacco use. Smoking during pregnancy contributes to higher rates of miscarriage, preterm births, low birth weight babies and difficulties during childbirth.11 Sudden Unexplained Deaths in Infancy (SUDI), asthma, glue ear, and increased rates of chest infections, all associated with maternal smoking, are commonplace among M ori children.12 Maternal smoking also sets M ori up for higher rates than non-M ori of cardiovascular disease, many cancers and respiratory diseases later in life.Quitting in the first 3-4 months of pregnancy and remaining abstinent protects the fetus from some of the adverse effects of smoking.13 Serendipitously, pregnancy is a powerful motivator to quit smoking.3 In New Zealand, Ford et al14 found that whilst 64% of pregnant smokers wished to quit and 30% wished to cut down, this contrasted with what they actually achieved: 34% quit and 50% cut down. In another study, 40% of M ori pregnant women cut down and 23% stopped smoking altogether.15There are several barriers undermining reduction or cessation of smoking when pregnant, including loss of the role and meaning of smoking and negative influence from family or friends.2, 16Women who continue smoking during pregnancy are likely to live in a household with other smokers,17-19 and have partners, family and friends who smoke.16 Similar results have been found for M ori: living with other smokers effects smoking cessation success M ori.20 Further, a qualitative study found that addiction, habit and stress were reasons why pregnant women continued smoking.21Reducing smoking among pregnant women remains a challenge. Whilst several qualitative studies have investigated pregnant womens smoking during pregnancy, no previous study has focused on pregnant M ori smokers attitudes towards smoking and barriers to cessation. Previous studies into M ori smoking have involved few pregnant participants.20 The high smoking prevalence among M ori women warrants research specifically focused on this group.Reducing smoking during pregnancy has been a New Zealand and international priority for over a decade16, 22 and closing the health inequality gaps are a key public health agenda,22 adding to the rationale for reducing smoking during pregnancy among M ori women. The New Zealand tobacco control programme could usefully be informed by a study identifying barriers to smoking cessation for pregnant M ori women. Thus, this research aimed to determine: The attitudes of M ori pregnant smokers towards smoking during pregnancy; The factors influencing continued smoking during pregnancy; and Family (wh nau) support to quit received by the women. Method This was an exploratory qualitative study using semi-structured face-to-face interviews. Purposive sampling was used to find a diverse range of women who varied across age, stage of pregnancy, number of pregnancies, socioeconomic level and place of residence. Random selection was, therefore, not used. Pregnant M ori self-identified smokers, aged 16 and over, were invited to take part. Participants were recruited through primary health care services, for example, M ori midwives, M ori community health workers, M ori health clinics, the researchers networks, a circulated invite and newspaper advertisement. Interviews were conducted during October 2002 to November 2003 with 60 women from Auckland, Wellington, Hamilton, Kawakawa and around the Hokianga. The questionnaire included questions relating to pregnancy status, tobacco consumption, attitudes to quitting, beliefs about smoking during pregnancy and support to quit. The questionnaire contained both qualitative open-ended questions and quantitative agree-disagree questions. Responses were manually recorded on the questionnaire in full view of the participant. Transcripts were not produced, thus women were not asked to check the written responses. Interviews took from 30-45 minutes. Ethical approval for the study was given by the University of Auckland Human Participants Ethics Committee. Where possible, questionnaire responses were quantified. Quantitative data was entered into Excel and standard frequencies were calculated for descriptive purposes. Free text responses were entered into Microsoft Word and manually sorted using the themes covered in the questionnaire. Thematic analysis within categories enabled coding sets to be developed, for example, for reasons for stopping smoking. Te Whare Tapa Wha23 was used as the primary organising framework for grouping the findings into sections. The demographics, pregnancy status and nicotine dependency factors were grouped under Te Taha Tinana (the physical or bodily aspect of health). Attitudes towards and beliefs about smoking while pregnant and motivation to stop smoking were included under Te Taha Hinengaro (the mental realm). The home and social environment and smoking and attitudes of others fitted into in to the realm of Te Taha Wh nau (the family and social realm). No data emerged that fitted under Te Taha Wairua (the spiritual realm). The data was quantified in order to illustrate how common a particular response was and the qualitative narrative was used to describe or explain the findings. Results Participants ranged in age from 17 to 43 years old. The average age was 26. Most of the women (88%) had a partner. Twenty-three percent of participants had no educational qualifications and only 38% had some employment. Over half (68%) of the participants lived in urban centres. They listed membership of from one to three iwi (tribe) each. Almost equal numbers of participants were in to the second (43%) or third (40%) trimester of their pregnancy and 38% of the women were having their first baby. Te Taha Tinana: biological and physical aspects of smokingThe average stated number of cigarettes smoked per day was nine, ranging from 1 to 28 (Table 1a). Nineteen (32%) of the participants smoked their first cigarette within 5 minutes of waking (Table 1b). Table 1. a) Number of cigarettes smoked per day; and b) time to first cigarette upon waking The majority of participants (77%) were healthy and reported that they had not suffered any smoking-related illnesses in the previous 6 months. Even the women who reported having asthma, bronchitis or low or high blood pressure, reported mild or seasonal symptoms. As one woman said cthats the only time I go to a doctor usuallypregnancy.d Te Taha Hinengaro: beliefs and reasons for smoking and quittingOf the reasons given for smoking 50% of participants said they smoked because of habit (Table 2), as illustrated by the following quote: cJust got to have something in my hands. Its not that I like it.d The second most common reason for smoking was due to stress. cStress and my partner and arguing and stress and my mother and stress.d cStops me from stressing out. Stops me from worrying about things.d Table 2. Reasons for smoking Reason N=60 % Habit Stress Addiction Calms\/relaxes Satisfaction\/like it Social\/company Boredom\/something to do Time out Depression Dont know 30 18 15 14 10 8 7 2 1 2 50 30 25 23 17 13 12 3 2 3 Participants cited multiple reasons motivating them to quit smoking (Table 3). The two most common cited reasons for contemplating quitting were for their babys and own health. For example: cIf I could give it up, it would do me world of good.d Several previous quit attempts had been cfor my health.d For example, these women said, cI got sick,d csmokers cough and the effects.d cI had the flu actually. I just couldnt smoke.d However, only 12 women said they wanted to quit because of the pregnancy and only twelve women had tried to stop or succeeded at stopping smoking for their first pregnancy. One woman managed to stay smokefree until her baby was about 1 year old. Table 3. Reasons for wanting to quit Reason N=37 % For babys health Their own health Cost Pregnancy Other children Sport\/fitness Its time Role model Nausea Its yuk\/stinks Longevity Breastfeeding 29 20 16 12 7 5 4 4 3 2 1 1 78 54 43 32 19 13.5 11 11 8 5 3 3 Most of the participants (92%) had thought about quitting and many (78%) had tried to quit. The number of quit attempts ranged from 0 to cmany timesd, with an average of two. Thirty-five percent had managed to give up smoking before, though some women counted periods as short as a few days as 8having given up. Eleven, of the women who had previously quit stayed smokefree for 3 months or longer, while the other ten stayed smokefree from 1 week up to 3 months. Attitudes towards smoking during pregnancyMost of the women were concerned about their unborn childs health and 45% (27) worried ca lotd. Most of the women agreed that if they stopped smoking while they were still pregnant it was likely their baby would be healthier. Many thought other people smoking around them had an effect on their unborn babys health (Table 4). Contradicting this result, many agreed or answered 8dont know to the questions that the amount they smoked was too little to cause harm to their baby and there was no need to quit completely if they cut down. The statement cif I cut down on my smoking there is no need to quit completelyd was used to rationalise continued smoking. One woman explained that she believed this ccos [because] they said even cutting down would be beneficial. Quitting would be better but cutting down better - every hour or two you dont smoke baby is getting more oxygenthat is why I cut out last one at night and first two in morning so baby has more time smokefree.d Of concern, 33% agreed that they may as well keep smoking themselves as they were exposed to so much smoke from others. One woman acknowledged that it was a thought that supported her to continue smoking even though she knew it wasnt true and another said cthey say nowadays secondhand smoke worse than first hand.d Table 4. Belief statements about smoking during pregnancy Statement Agree % Disagree % Dont know % Its good to have a smaller baby 2 3.3 52 87 6 10 The amount I smoke is too little to cause harm to this baby inside me 9 15 43 72 8 13 If I stop smoking while Im still pregnant, it is likely that this baby will be healthier 57 95 0 0 3 5 Smoking low tar (ultra mild) cigarettes is less harmful to my unborn baby 6 10 39 65 15 25 If I cut down on my smoking there is no need to quit completely 14 23 38 63 8 13 I am exposed to so much smoke from other people I might as well keep smoking myself 20 33 38 63 2 3 Other people smoking in the house has an effect on my unborn babys health 53 88 4 7 3 5 Nicotine passes through breast milk 33 55 4 7 23 38 Te Taha Wh nau: familial and social influencesAll of the women lived with other smokers and nearly half (47%) of the women lived with a partner who smoked. Nearly half (48%) said their house was totally smokefree. Eleven participants (18%) lived in homes with no restrictions on smoking. Twenty participants (33%) lived in households that allowed smoking inside; however, many of those households had made rooms smokefree or had a designated smoking area. Thirty seven (62%) participants said that the people they socialise most frequently with smoke (Table 5a) and only two participants mixed with mainly non-smokers. Most participants (93%) said it was easy to smoke in their social venues (Table 5a). Table 5. Environments - a) Social and b) Work Nearly all of the women who worked said it was easy to smoke at work and 30 smoked with others at work (Table 5b). Smoking at work was easy because as participants said they could cjust go out whenever want tod or ctheres a designated smoking area outsided and because a cmajority of staff smoked. Even participants who worked or were students at schools, an environment designated smokefree under legislation, still smoked while there. Similar to other workplaces, cpractically everyoned smoked or they were callowed to during breaksd and there was a cdesignated [smoking] area out

Summary

Abstract

Aim

To investigate why some M ori women continue smoking during pregnancy.

Method

An exploratory qualitative study was conducted with 60 pregnant M ori women aged from 17-43. A questionnaire was used to guide the interviews. Responses were categorised using Te Whare Tapa Wha (the four-sided house), an Indigenous theoretical framework.

Results

The women smoked on average 9 cigarettes per day. Many (45%) were very concerned for their babys health. The main reasons for quitting were for their own and their babys health. The majority (77%) reported no smoking-related health problems. All the women lived with at least one other smoker. Over half of the participants (62%) predominantly socialised with people who smoked and nearly all said it was easy to smoke in their socialising and work environments. Partners and mothers were the most common source of support or advice to quit, however, often that support person also smoked. There was a lack of understanding of the harms associated with maternal smoking.

Conclusion

Motivation to quit smoking was low. The women all lived with smokers which reportedly made it harder to quit; most of them lived in a smoky environment, where family, friends and coworkers smoked. This highlights the need to include family in cessation interventions.

Author Information

Marewa Glover, Director; Anette Kira, Research Fellow; Centre for Tobacco Control Research, University of Auckland

Acknowledgements

Correspondence

Marewa Glover, Social and Community Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland, New Zealand. Fax: +64 (0)9 3035932

Correspondence Email

m.glover@auckland.ac.nz

Competing Interests

None.

Einarson A, Riordan S. Smoking in pregnancy and lactation: A review of risks and cessation strategies. Eur J Clin Pharmacol 2009;65(4):325-330.Ingall G, Cropley M. Exploring the barriers of quitting smoking during pregnancy: A systematic review of qualitative studies. Women and Birth 2010;23(2):45-52.Haslam C, Draper ES, Goyder E. The pregnant smoker: a preliminary investigation of the social and psychological influences. Journal of Public Health 1997;19(2):187-192.Ebert LM, Fahy K. Why do women continue to smoke in pregnancy? Women and Birth 2007;20(4):161-168.McLeod D, Pullon S, Cookson T. Factors that influence changes in smoking behaviour during pregnancy. N Z Med J 2003;116(1173). http://www.nzma.org.nz:8080/journal/116-1173/418/content.pdfBull L, Burke R, Walsh S, Whitehead E. Social attitudes towards smoking in pregnancy in East Surrey: A qualitative study of smokers, former smokers and non-smokers. Journal of Neonatal Nursing 2007;13(3):100-106.Hill S, Blakely T, Howden-Chapman P. Smoking inequalities: Policies and patterns of tobacco use in New Zealand, 1981-1996. Wellington: University of Otago, Wellington School of Medicine, 2003.Ministry of Womens Affairs. Indicators for Change 2009: Tracking the progress of New Zealand women. Wellington: Ministry of Womens Affairs, 2010.Ministry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health, 2007.Dixon L, Aimer P, Fletcher L, Guilliland K, Hendry C. Smoke free Outcomes with Midwife Lead Maternity Carers: An analysis of smoking during pregnancy from the New Zealand College of Midwives midwifery database information 2004 - 2007. New Zealand College of Midwives Journal 2009;40:13-19.Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine and Tobacco Research 2004;6(SUPPL. 2).Pomare E, Keefe-Ormsby V, Ormsby C, Pearce N, Reid P, Robson B, et al. Hauora: Maori standards of health III. Wellington: Te Ropu Rangahau Hauora a Eru Pomare, Wellington School of Medicine, 1995.McCowan LM, Dekker GA, Chan E, Stewart A, Chappell LC, Hunter M, et al. Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study. BMJ (Clinical research ed.) 2009;338.Ford R, Wild C, Glen M, Price G, Wilson C. Patterns of smoking during pregnancy in Canterbury. NZMJ 1993;106(965):426-9.Te Ropu Rangahau Hauora a Eru Pomare. Benchmark Survey on monitoring the Why Start? Multi-media Campaign to reduce smoking amongst pregnant Maori women smokers: Preliminary results. Wellington: School of Medicine, 1996.Tod AM. Barriers to smoking cessation in pregnancy: a qualitative study. British journal of community nursing 2003;8(2):56-64.Walsh RA, Redman S, Brinsmead MW, Fryer JL. Predictors of smoking in pregnancy and attitudes and knowledge of risks of pregnant smokers. Drug and Alcohol Review 1997;16(1):41-67.Quinn VP, Mullen PD, Ershoff DH. Women who stop smoking spontaneously prior to prenatal care and predictors of relapse before delivery. Addict Behav 1991;16(1-2):29-40.Abrahamsson A, Springett J, Karlsson L, Ottosson T. Making sense of the challenge of smoking cessation during pregnancy: A phenomenographic approach. Health Education Research 2005;20(3):367-378.Glover M. The effectiveness of a Maori Noho Marae Smoking Cessation intervention: Utilising a kaupapa Maori methodology [Doctor of Philosophy Thesis]. The University of Auckland, 2000.McCurry N, Thompson K, Parahoo K, O'Doherty E, Doherty AM. Pregnant women's perception of the implementation of smoking cessation advice. Health Education Journal 2002;61(1):20-31.Ministry of Health. Monitoring Health Inequality Through Neighbourhood Life Expectancy: Public Health Intelligence occasional bulletin Wellington: Ministry of Health, 2005.Glover M. Analysing smoking using Te Whare Tapa Wha. New Zealand Journal of Psychology 2005;34(1):13-19.McCaul KD, Hockemeyer JR, Johnson RJ, Zetocha K, Quinlan K, Glasgow RE. Motivation to quit using cigarettes: A review. Addict Behav 2006;31(1):42-56.Fidler JA, West R. Self-perceived smoking motives and their correlates in a general population sample. Nicotine and Tobacco Research 2009;11(10):1182-1188.Ministry of Health. New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health, 2007.Ministry of Health. Targeting Smokers: Better Help for Smokers to Quit. Wellington: Ministry of Health, 2011.Ministry of Health. Tobacco Use in New Zealand: Key findings from the 2009 New Zealand Tobacco Use Survey. Wellington: Ministry of Health, 2010.National Health Committee. Review of Maternity Services in New Zealand. Wellington: National Health Committee, 1999.Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2009(3).

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