Using nicotine replacement therapy for smoking reduction in pregnancy: a qualitative study of pregnant women in the UK who smoke

Discussion

This study reports the exploration of the acceptability, in reducing the number of daily cigarettes smoked in pregnancy, rather than for stopping smoking completely and the potential role NRT may have in this process. The analysis identified an appreciation for a ‘cutting down’ approach to smoking harm reduction while highlighting associated difficulties. Half of interviewees reported using NRT to help them reduce their smoking in this current pregnancy, while the perceived stigma associated with purchasing or using NRT were seen as problematic. When presented with the suggestion that NRT could be used to help women reduce their smoking, issues associated with using NRT in this way were discussed.

A key strength of our study is that we are unaware of any others that have qualitatively explored the views of pregnant women on whether NRT should, or could, be used to help reduce the number of cigarettes smoked when complete cessation was not likely, and the kind of support needed for this approach. Online recruitment using Facebook adverts and social media posts allowed researchers to identify and interview women from across the UK who might be disengaged from SSS (ie, those who were unable or unwilling to stop smoking).38

The main study limitation was the reliance on telephone, rather than face-to-face, interviews. While it is more difficult to develop rapport with interviewees over the phone, this approach is known to have advantages when discussing topics of a potentially sensitive nature.39 Furthermore, the use of social media recruitment, while advantageous in terms of geographical reach, may have excluded representation from those who do not use social media regularly or use platforms other than Facebook.40

For interviewees in this study reducing their smoking seemed to be an intuitively adopted behaviour and is congruent with the idea that particular health behaviours such as smoking, drinking alcohol and healthy eating may change as a result of pregnancy and without intervention from health professionals.41 Interviewees in this study understood the opportunities afforded by adopting a cutting down approach, not only because abrupt stopping was seen as particularly difficult but also because smoking reduction was seen as a way of reducing the harms related to continuing to smoke at pre-pregnancy levels. While most pregnant smokers recognise the risks to their unborn child,42 the findings of this study echo the sentiments expressed in other qualitative work, in that, while quitting smoking was judged to be the ideal, cutting down was seen as an important strategy in reducing the harm to the unborn fetus that should be considered.28

This study identified different strategies employed by women to reduce their smoking such as increasing the time between cigarettes or only smoking at certain times of the day which have been shown to be effective means of smoking reduction43 44; however, there seemed to be a lack of clear goal setting, which is an important aspect in behavioural changes.45 Having access to professional support that could assist women in distinct, realistic, goal setting and clear feedback may increase successful reduction.46 The lack of praise women received from healthcare professionals for any cigarette reduction was a concern raised by our Patient and Public Involvement and Engagement (PPIE) group when they reviewed interview transcripts and assisted in initial coding. They felt that in general these women were not receiving adequate support which could be a reflection of the current focus on cessation above harm reduction.

One difficulty with this approach was the stigma surrounding continued smoking. Women seemed concerned that other people would judge them negatively if they were seen buying or using NRT without understanding that they had worked hard to reduce the amount they smoked. Stigma around smoking during pregnancy has long been recognised and is considered to be less to do with the level of risk to the fetus and more of a moral judgement.47 The stigmatisation of pregnant women who smoke may lead to women hiding their smoking and a hesitancy to engage with professional smoking cessation support.48 49

We sought women who had experience of smoking in pregnancy but did not seek those who were trying to stop or to cut down smoking at all. Nevertheless, half of the women enrolled in this study were using NRT to cut down their smoking, and over half were not actively engaged with stop smoking services. This suggests that using NRT to cut down daily smoking may already be a widely adopted practice. It was unclear why the women were not using stop smoking services. A possible explanation could be that cessation services only work with women who are committed to trying to quit, and it has been shown that stop smoking practitioners (SSPs) hold particularly negative views towards using NRT for cutting down smoking in pregnancy and would only ever advise NRT use and concurrent smoking for anything but the briefest of smoking lapses during a quit attempt.50 Women who felt that they were unable or not willing to commit to a stop smoking attempt would find their access to free NRT products from stop smoking services restricted and may have resulted in women buying their own NRT or nicotine products themselves. Buying their own NRT without the associated support and education provided by healthcare professionals may lead to women being less informed around what to expect in terms of possible side effects, such as nausea, which may impact better tolerance and adherence to different NRT products.51 The cost of buying NRT to support cutting down their smoking alongside the potential for embarrassment reported by some women by buying NRT in public was seen as a barrier to this approach. Only organisational changes that would allow the prescription of NRT to support smoking reduction in pregnancy, as it is in the general population of smokers who are unable to quit, would reduce the burden on an already socially and economically disadvantaged population.52

Stigma was also cited as a barrier by the interviewees in our study when purchasing or using NRT to help them reduce their smoking. This finding emphasises other work that pregnant smokers who feel stigmatised may be particularly attracted to products that can be used discreetly53 such as patches that can easily be hidden under clothing or nicotine gum that looks like an ordinary product. It was reported that purchasing nicotine products over the counter offered more opportunities for them to feel judged by others. Unless women were able to procure NRT to cut down their smoking on prescription or directly from a stop smoking service, perhaps using an online delivery service may help alleviate these concerns; however, this may add an additional cost to these products.

Some women reported being concerned about getting too much nicotine from using NRT and smoking at the same time; however, a recent review and meta-analysis should provide reassurance that using NRT alongside smoking in the context of smoking reduction is unlikely to result in dangerous levels of nicotine exposure.54 This may be because most smokers are able to self-titrate their nicotine intake, through smoking and NRT, to maintain plasma nicotine levels without adverse physical or subjective effects.55

Similar qualitative work is needed with health professionals to assess their views on this topic. Given that stop smoking practitioners have previously reported not feeling comfortable promoting a harm reduction approach to pregnant women, it was not compatible with their aims of promoting a smoke-free pregnancy and healthy baby50 and that stopping smoking completely is the only way of ensuring that the unborn baby is not at risk from smoking harms.13 Health professionals might need to consider how they balance communicating the risks of reduced but continued exposure to tobacco smoke and the use of NRT to promote smoking reduction as a possible treatment option without undermining cessation as the aim of a stop smoking service. This is particularly important when pregnant women are often confused about the need for the safety of NRT and clear, consistent messages from healthcare professionals.51

There was a distinct preference for offering NRT to support smoking reduction as early as possible in pregnancy in an attempt to minimise the effects of smoking. There is a suggestion that women may be more motivated to quit earlier on in pregnancy,14 so it seems reasonable to suggest that women may also be more motivated to reduce their smoking during this time frame. As midwives play a particularly pivotal role in providing SSS to pregnant women,56 any steps to reduce stigma around reduced smoking, procurement of NRT and the provision of empathetic support would require meaningful co-development involving both midwives and pregnant women.47