Introduction
In Canada, the prevalence of women who smoke cigarettes during pregnancy is approximately 10.5 per cent (Al-Sahab, Saqib, Hauser & Tamim, Reference Al-Sahab, Saqib, Hauser and Tamim2010). Current smoking cessation/reduction interventions are fairly successful in helping women quit during pregnancy but less successful in supporting them to abstain from smoking long-term (Lumley et al., Reference Lumley, Chamberlain, Dowswell, Oliver, Oakley and Watson2009). In fact, 70–90 per cent of women who have quit smoking during pregnancy resume within one year postpartum (Johnson, Ward & Barnard, 2001).
There is an unmet need for smoking cessation/reduction interventions among younger women. Such initiatives are significant since younger women, who lack social support and experience stressful life events, are more likely to relapse into smoking in the postpartum period (Fang et al., Reference Fang, Goldstein, Butzen, Hartstock, Hartmann, Helton and Lohr2004; Lowe, Barnes, Teo & Suthers, Reference Lowe, Barnes, Teo and Suthers2012; May, West, Hajek, McEwen & McRobbie, Reference May, West, Hajek, McEwen and McRobbie2006). Innovative smoking cessation/reduction interventions are therefore required to engage younger pregnant and postpartum women to provide them with support and assistance.
One innovative intervention is text messaging (TM), in which up to 160 characters of text are sent between two or more mobile phones or fixed or portable devices to a phone. Mobile phone use is very common within developed countries regardless of socioeconomic status (Kenyon, Poropatich & Holtel, Reference Kenyon, Poropatich and Holtel2011; Thomas, Heinrich, Kuhnlein & Radon, Reference Thomas, Heinrich, Kuhnlein and Radon2009), with usage rates for texting most common among younger age groups (Lenhart, Reference Lenhart2010). Texting provides an anonymous, low-cost means for delivering messages that avoids some of the barriers of face-to-face support. Furthermore, pregnant and postpartum women have expressed interest in smoking cessation/reduction programmes that deliver TM (Lowe et al., Reference Lowe, Barnes, Teo and Suthers2012; Ussher et al., Reference Ussher, West and Hibbs2004).
A recent systematic review provided an overview of TM as a tool for behaviour change, health promotion and health management in areas including smoking cessation/reduction, weight loss, physical activity, diabetes, asthma and medication adherence (Cole-Lewis & Kershaw, Reference Cole-Lewis and Kershaw2010). Study results consistently report this method as an acceptable and effective way to communicate and provide advice and support to service users (Cole-Lewis & Kershaw, Reference Cole-Lewis and Kershaw2010). Research evaluating TM interventions among non-pregnant individuals who smoke has demonstrated their effectiveness and success in increasing cessation rates, improving adherence to pharmacotherapy, and maintaining high participation (Brendryen & Kraft, Reference Brendryen and Kraft2008; Free et al., Reference Free, Whittaker, Knight, Abramsky, Rodgers and Roberts2009; Free et al., Reference Free, Knight, Robertson, Whittaker, Edwards, Zhou, Rodgers, Cairns, Kenward and Roberts2011; Haug, Meyer, Schorr, Bauer & John, Reference Haug, Meyer, Schorr, Bauer and John2009; Haug et al., Reference Haug, Bitter, Hanke, Ulbricht, Meyer and John2013; Obermayer, Riley, Asif & Jean-Mary, Reference Obermayer, Riley, Asif and Jean-Mary2004; Rodgers et al., Reference Rodgers, Corbett, Bramley, Riddell, Wills, Lin and Jones2005; Whittaker et al., Reference Whittaker, Borland, Bullen, Lin, McRobbie and Rodgers2009; Ybarra et al., Reference Ybarra, Holtrop, Prescott, Rahbar and Strong2013).
A recent investigation on the effectiveness of a TM intervention for pregnant and postpartum women who smoke found that compared with controls, women who participated in a TM programme were more likely to set a quit date and reported higher levels of self-efficacy and determination to quit (Naughton, Prevost, Gilbert & Sutton, Reference Naughton, Prevost, Gilbert and Sutton2012). Current literature promotes the continued use of texting as a behaviour change intervention tool, however more research is needed to determine the appropriate content, frequency, duration and unique features needed for different targeted groups and outcomes.
Despite a growing body of literature showing promising results for TM programmes, very little is available about the design decisions that texting services are based on or how content and protocol are developed. This is an important area of focus that has been overlooked and may stem from providers seeing texting itself as the intervention rather than the mode of message delivery (Ybarra, Holtrop, Bosi & Emri, Reference Ybarra, Holtrop, Bosi and Emri2012).
The [name of programme] was initiated at the [name of hospital] in [name of geographic location]. [Name of programme] aims to improve the health of women and their babies by offering information, resources and support related to smoking for pregnant and postpartum women and their healthcare providers. The current article focuses on the mobile communication (TM) study within the larger [name of programme] project. The purpose of the TM study was to gain an in-depth understanding of the experiences and unique needs of younger pregnant and postpartum women to develop appropriate TM messages.
Methods
We undertook a qualitative grounded theory approach (Guba & Lincoln, Reference Guba, Lincoln, Denzin and Lincoln1994) to explore the use of TM as an intervention to assist pregnant and postpartum women to quit/reduce smoking. A qualitative research approach is valuable when conducting initial explorations that illuminate individuals’ experiences and interpretations of phenomena. There is a lacuna of research on the use of TM as a smoking cessation/reduction intervention for pregnant and postpartum women; therefore this approach was suitable for this exploratory and descriptive study. This study was reviewed and approved by the research ethics board at the institution with which the first author of this paper is affiliated.
Recruitment
The study was advertised for recruitment purposes using flyers and posters in public health units (PHU) across Ontario. A Public Health Unit is an official health agency established by a group of urban and rural municipalities throughout the province to provide a more efficient community health programme. There are 36 public health units in Ontario. The manager of each PHU was approached regarding the study, provided with a verbal description, given an opportunity to ask questions and was asked whether they wished to assist with recruitment. Participating PHU staff was asked to provide flyers to pregnant and postpartum women who smoke during their visit to the PHU and during specific programmes for pregnant and postpartum women hosted by the PHU or local organisations. An honorarium ($30 gift certificate) and childcare was provided for study participation.
Interested participants were asked to call a toll-free number to schedule a telephone screening interview. If the inclusion criteria were met, an overview of the study was provided. If after hearing about the study the potential participant was still interested in participating, she was scheduled for either a focus group session or telephone interview based on the number of similarly interested women from her geographic area.
The study included women who:
• were 16 years of age or older (no upper limit specified);
• smoked daily;
• spoke English;
• were planning a pregnancy, pregnant or less than one year postpartum.
Data Collection
Six telephone interviews and six focus groups were convened for the purpose of this study. During the focus groups, respondents were encouraged and guided to have dynamic conversations with one another and the interviewer with the aim of eliciting a variety of opinions and views regarding TM. We conducted the telephone interviews as a way of potentially capturing sensitive information that respondents in a focus group setting may not feel comfortable revealing. They were also conducted as a way of including interested participants who were from geographic locations where there were not enough women recruited to convene a focus group. Participants took part in either a focus group or telephone interview but not both. We discovered no differences between the focus group and individual interview data regarding the topic of TM intervention after analysing them separately and therefore combined the results for the purpose of this study.
In qualitative research, guidelines for determining non-probabilistic sample sizes are virtually non-existent. Thus, the researcher typically relies on the concept of saturation, that is, the point at which no new information or themes are observed in the data. For this study, we did not set a specific target for recruitment and instead stopped seeking new participants at the point of saturation.
The interview guide facilitated the discussion and the interviewer encouraged all respondents to participate and express their opinions freely and openly. The discussions concentrated on the following key questions:
1. Is there a role for TM when trying to reduce/quit smoking? In what ways do feel TM may or may not be able help you?
2. What kind of messages would be helpful/not helpful? How might the kind of messages you would want change as you moved forward with quitting/reducing smoking?
3. Are there certain times of the day when you would want to receive TM? How often would you like to receive TM?
4. What are some of the key things we need to know to make the TM intervention successful? What do you think would help you quit smoking the most?
Data Analysis
The focus groups were recorded and transcribed verbatim. The telephone interviews were not taped or transcribed due to budgetary constraints but detailed notes were taken and direct quotes recorded by the interviewer. The transcripts and notes from the focus groups and interviews were analysed using the process of inductive coding (Strauss & Corbin Reference Strauss and Corbin1990). A sub-sample of transcripts were read independently and notes were made in the margins that were identified as potential themes by the first, second and third authors. These authors compared the notes they independently documented on the first three transcripts. Through this comparison and discussion, a coding frame was developed which was then applied to all the data by the first and second authors. The first and second authors then organised each theme or topic into larger categories as the research proceeded. Finally, the codes were grouped together into themes with various subthemes which constituted the foundation of synthesising and conceptualising the data.
Results
Sample Characteristics
In total, there were six focus groups with four–seven participants in each and six individual interviews conducted. Of the 36 women who participated in the study, 29% (n = 9) were pregnant, 68% (n = 21) were postpartum and 3% (n = 1) were planning a pregnancy. The mean age was 23 (SD 3.78) years, ranging from 16–30 years. Among those who were postpartum, the mean age of their most recent child was 10 months (SD 7.60) with a range of one to 33 months. Only two women who were interested in participating in the study did not meet the inclusion criteria and therefore could not participate: one woman who called was not pregnant, postpartum or planning a pregnancy and another woman did not smoke. One woman who met the inclusion criteria based on her initial responses to the screening questions revealed during the focus group that she did not meet the criteria since her child was 33 months old rather than 12 months or younger. We included her in the study because of her younger age and because she was from a small Northern community and had expressed great enthusiasm in participating.
Findings
Three main themes with various subthemes were identified. First, the respondents identified topic areas that they would be interested in hearing more about. Second, these topical areas needed to be tailored to their quit/reduction process and address specific concerns of pregnant and postpartum women. Lastly, to be well-received, the tone of the TM needed to indicate an understanding of the diversity and complexity of women's lives.
Topic areas
Respondents were interested in receiving TM about the financial considerations of smoking, tips or advice on smoking cessation/reduction, as well as addressing myths and misconceptions about tobacco use.
Several respondents stated that they would be interested in receiving messages regarding the financial costs of smoking. According to this respondent:
For me, it's the money thing ‘cause right now, everything's about money. Especially at our age and with everything our situations like money's our biggest thing so like even just texting us and be like okay like this is how much you guys are pretty much spending a month or a year.
Other respondents thought it might be useful to compare the cost of smoking to the cost of something else, such as a holiday or a car payment as a means of putting the cost of smoking into perspective. That said, caution is duly noted in that the intent of the messages would not be to induce guilt or shame about spending money on smoking. Therefore, TM on the financial costs of smoking would have to be developed with care and sensitivity with regards to these concerns.
Several respondents were interested in ‘tips’ or advice on smoking cessation/reduction. They wanted TM on how to avoid cravings and triggers. General tips on how to quit/reduce smoking were also seen as valuable:‘Tips would definitely help because I am often like, How do I do this?’
The majority of respondents believed that TM could be used to dispel myths and correct misconceptions about smoking. For example, several respondents described how they received mixed messages from their healthcare providers, friends and family about whether or not it was healthy to quit/reduce smoking during their pregnancy. Some respondents believed that if women quit/reduce smoking while pregnant, it would cause the baby to go into a state of ‘shock’. TM can help dispel that and other myths as this respondent describes:
For the pregnant women, text them telling them like ‘you are allowed to quit while you're pregnant’. Because that's a huge misconception. I didn't know . . . Like my doctor told me not to quit and then a different one told me I should've quit. And then like I just felt so confused.
TM could also address misconceptions about the use of pharmacotherapy for smoking cessation/reduction. For example, messages that describe how to properly chew nicotine gum, and information on the difference between the side effects of smoking cessation/reduction versus side effects of nicotine replacement therapies were identified as being important for facilitating smoking cessation/reduction.
Tailored approach to smoking cessation/reduction
According to the respondents, TM needed to be tailored to the individual. As this respondent explains:‘Every person's different. Like people that I know that have quit. . . didn't do it the same way. Every person I know always did it differently’.
This statement highlights two forms of tailoring: logistical and staged.
Logistical tailoring
Logistical tailoring refers to the timing, frequency and initiation of the TM. When we asked respondents about timing, we received a variety of responses ranging from first thing in the morning, after meals, during cravings etc. We also received a variety of responses when asked how many TM they would like to receive. Some respondents thought one message per day was sufficient while others preferred three or more. These dialogues lead to the suggestion of a ‘sign up’ process that would allow each woman to indicate her preferences so that messages could be tailored to her social context. As described by this respondent:
When you do the initial sign up you should give information about how long you've quit and stuff like that. How long you've been smoking, if you are around people who smoke, if you live with people who smoke, whether or not you are breastfeeding, whether or not you smoke in your house, the things that make you want to smoke. It should determine the amount of texts you get and the amount of support you are going to need.
Understanding a woman's social context would make the TM seem more personalised and timely, and therefore potentially more effective. In fact, mass or repetitive messages, according to the majority of respondents, were to be avoided:
‘General messages that you know that everybody gets wouldn't be as helpful as a personal message’.
Other features that were considered important were the ability to track progress, texting with a live person and the ability for participants to initiate TM. TM that would provide information or feedback on the progress of a woman's quit/reduction journey such as how much time has passed, quantifying how much a woman has been able to reduce and the health benefits associated with time-related milestones were viewed as effective messages. Of particular importance would be the ability to live chat with a person in addition to receiving automated messages. As this respondent explains:
You don't wanna be sitting there thinking that you're talking to a computer when you know you're talking to a computer. I rather know that I'm actually talking to a human being. And not some machine.
A preference to begin a conversation by sending a TM or to be in control of when a texting conversation occurs was also discussed by respondents:
I have the hardest time when I am alone and I am bored. Because when I am bored, I'm like “I want a cigarette”. I can smoke 4 in a row when I am bored. This happens mostly at night for me because I am busy during the day. If it could be like, I could text in and they could text me back right away. . . I would rather say when I get the messages. Not set times.
An interesting point that one respondent noted was that receiving a TM might in itself trigger a craving for smoking:‘If you weren't thinking about smoking and then you got that text message and it was talking about smoking. . . I would end up wanting a smoke’.
Thus, as suggested above, tailoring text messages that are sensitive to individual women's environmental cues and triggers is of utmost importance for effective implementation.
Staged Tailoring
Messages of support and motivation that would assist a woman in her efforts to quit/reduce smoking would need to be based on where she is in the quit/reduction process. For women who were thinking about quitting/reducing smoking, the messages should be more general and focused on the positive impact of smoking cessation/reduction. As this participant states:
For people thinking about quitting, you should send them positive reasons why they should stop quitting. It can become more dramatic and way more personal later when you have already made progress.
For women who have just begun the process of quitting/reducing, the effective TM would shift from benefits of quitting/reducing to information on cravings:
I wouldn't want to hear reasons to quit or health effects in the beginning of the quitting process. It would be too touchy. The priority would be to deal with the cravings. . . I need reinforcement and positive affirmation.
Women who have quit/reduced for a sustained period of time but still require support would need motivational messages that recognise and celebrate their success:
Look how far you have come- you can do this. Why look back. Little things letting people know how good they are doing and to make people feel good about what they have accomplished.
Messages related to reducing smoking were also deemed as essential by the respondents. Reduction needs to be recognised as a goal and part of the smoking cessation process, particularly for some respondents that are not considering quitting but are ready to reduce. As this respondent states: ‘Cut back, yes. Completely give up, not a hope in hell’.
Several respondents noted that a potential opportunity for effective TM would be during the postpartum period. This respondent described how she was vulnerable during this time and relapsed: ‘Well, when I was pregnant I quit smoking. . . Then once you got to that point where she [baby] stopped breastfeed, everything like that, I started smoking again’.
Overall, TM needs to capture an understanding of the challenges women face when attempting to quit/reduce. Some of these challenges were captured in the above quotes and include the social patterns of behaviour that are strongly tied to smoking (i.e. stress), the respondents’ social network and the power of nicotine dependence.
Understanding the diversity and complexity of women's lives
An underlying theme, as noted above, was the need to provide support without expressing an opinion or judgement. Respondents emphasised the importance of focusing on women's health and safety first to work towards minimising health risks in the long term. As this respondent astutely explains:’It's just like we're trying to help out our babies but in the end . . . We need to help ourselves’.
All respondents agreed that they would not want to receive TM with facts or statistics about the negative health effects of smoking for women and their children. In fact, these messages can often be counterproductive:
Negative messages about the effects of smoking would irritate the heck out of me. I would reply ‘screw off, I know it's bad for me. You are making me want one even more’.
As described in the quote above, feeling patronised could trigger more smoking and this, in turn, could lead to a situation whereby a woman does not feel safe to disclose her smoking status. As this respondent stated, her fear of repercussions prevented her from being honest about smoking when talking to her healthcare provider:
After I found out [I was pregnant], they're [healthcare providers] like “you gotta cut down! Cut down!” I cut down to a pack and they're like [not enough]. . . And then I just started lying after that. I'm like “I only had 5 cigarettes a day” ‘cause then they just started giving me shit, right? So I just started lying: ‘I only have 5 cigarettes a day. That's it’.
Another key barrier to honesty, trust and safety described by respondents was their fear of judgement or condescension from healthcare providers related to their age, pregnancy and smoking status. As described by this participant:
Doctors kinda like look down, especially if you're young. For one, you're young and you're pregnant and two, you're young, pregnant and smoking. They really look down on you. And it is super intimidating.
All respondents described how stress was a common trigger to smoking. The majority of respondents described themselves as lone parents and younger adults. The stress of being pregnant and having a baby can serve as a barrier to making positive changes: ‘I'm 18. Like I'm having a kid at 18. Like obviously I didn't plan this. I'm having a cigarette ‘cause I'm fucking stressed like you know what I mean?’
Respondents emphasised that it is important to understand these barriers when developing a TM programme for pregnant and postpartum women. A range of success outcomes that includes reduction as well as cessation and considers how a woman's social context can act as a barrier to change might be more effective than messages that use ‘shame and blame’ as a strategy.
Discussion
Participants in this study provided valuable data to aid in the development of specific components of a TM programme that would support pregnant and postpartum women in their efforts to quit/reduce smoking. Recommendations were nuanced with issues related to the broader context of young women's greater social context including the effects of marginalisation on mothers who smoke. The strong preference for a woman-centered intervention differentiates the needs of this subpopulation from those of service users of programs aimed generally at adults who smoke. The necessity for messages that reflect an understanding of the diversity and complexity of women's lives, focus on women's health first and foremost and are free of judgement is consistent with other research revealing the foundations that interventions for young pregnant and postpartum women must be built upon (Greaves et al., Reference Greaves, Poole, Okoli, Hemsing, Qu, Bialystok and O'Leary2011). However, these needs have not yet been extended to TM services aimed at supporting smoking cessation/reduction.
The majority of respondents expressed an interest in TM that stated the financial implications of cigarette smoking. However, there are potential unintended negative consequences if these messages are not constructed in a way that considers young women's larger social context. Young pregnant and postpartum women who smoke are often stigmatised and characterised as economically compromised, less responsible, less educated and less aware of the potential health risks to themselves and their babies. This social stigma of smoking is intensified among those young women who are low-income because they are seen as part of an ‘unhealthy underclass or a culture of smoking’ (Oaks, Reference Oaks2001). The respondents of the study described how healthcare providers and others ‘looked down on them’ because in addition to being pregnant or recently pregnant, they were also both young and smoking. Socially disadvantaged women may discontinue accessing healthcare if they feel judged or embarrassed (Ebert & Fahy, Reference Ebert and Fahy2007).Thus, caution is duly noted when developing a TM programme that seeks to financially motivate young women to quit/reduce smoking.
Respondents emphasised that in order for messages to be meaningful and impactful, they would have to be individualised. These preferences are in line with extensive research conducted by Kreuter et al. demonstrating that tailored messages lead to more effective health interventions (for example: Hawkins et al., Reference Hawkins, Kreuter, Resnicow, Fishbein and Dijkstra2008; Kreuter, Strecher & Glassman, Reference Kreuter, Strecher and Glassman1999). Tailored messages are intended to reach one specific person, are based on characteristics that are unique to that person, are related to the outcome of interest and have been derived from an individual assessment (Hawkins, Kreuter, Resnicow, Fishbein & Dijkstra, Reference Hawkins, Kreuter, Resnicow, Fishbein and Dijkstra2008). Targeting messages to a specific subgroup such as young pregnant and postpartum women is not enough as this assumes that sufficient homogeneity exists among members of a demographically defined population, which is often not the case (Hawkins et al., Reference Hawkins, Kreuter, Resnicow, Fishbein and Dijkstra2008). The TM programme must have a component built into the sign up process to assess individual differences and preferences that the subsequent messages will be based upon.
Having control over the timing, type and frequency of TM is also linked to women's empowerment. Empowerment at the individual level focuses on capacity building, fostering personal control and promoting a proactive approach (Zimmerman, Reference Zimmerman1995; Natasi et al., Reference Nastasi, Varjas, Schensul, Silva, Schensul and Ratnayake2000; Zimmerman, Reference Zimmerman, Rappaport and Seidmann2000). Empowerment often serves as a mediating variable between the implementation of a programme and the achievement of desired outcomes (Minkler et al., Reference Minkler, Thompson, Bell and Rose2001). A smoking cessation/reduction TM programme for pregnant and postpartum women, then, should aim to foster women's self-efficacy, incorporate participant involvement and recognise women's unique needs and goals.
The suggestion from participants in this study that TM should be tailored to where women are in their journey of quitting smoking is consistent with the approach to cessation support that follows the Transtheoretical Model of Health Behaviour Change (Prochaska, DiClemente & Norcross, Reference Prochaska, DiClemente and Norcross1993). In this model, change is a process involving progress through a series of six stages that range in terms of readiness to make changes. Interventions matched to the stage people are in are thought to improve recruitment, retention and progress (Prochaska & Velicer, Reference Prochaska and Velicer1997). Research suggests, however, that this model may not map appropriately onto the subpopulation of pregnant and postpartum women. High postpartum relapse rates indicate that women who have quit while pregnant may feel ambivalent about smoking and are suspending rather than quitting their smoking, therefore are more likely to be at an earlier stage in the model than their behaviour suggests (Stotts, DiClemente, Carbonari & Mullen, Reference Stotts, DiClemente, Carbonari and Mullen2000). Participants in the current study emphasised the need for extra support in their efforts to quit/reduce smoking during the postpartum phase, revealing a consistency with the idea of unresolved ambivalence and suspension rather than cessation during pregnancy. The stage-matching suggested by participants in this study was related to both readiness to change and phase of pregnancy, and may contribute to a more appropriate intervention model for this subpopulation of women.
Participants in this study emphasised the importance of smoking reduction as part of the smoking cessation process and many women felt that they would be disinterested in a TM intervention that did not include a reduction component. While complete cessation during pregnancy would have the most positive health outcome for the woman and her foetus, there are also benefits to reducing the number of cigarettes smoked including improved newborn health (Li & Windsor, Reference Li and Windsor1993; Malchodi et al., Reference Malchodi, Oncken, Dornelas, Caramanica, Gregonis and Curry2003; Windsor, Li, Boyd & Hartmann, Reference Windsor, Li, Boyd and Hartmann1999). Research shows that a harm reduction approach to smoking for pregnant and postpartum women may be particularly effective for socially and economically disadvantaged women and those who have been otherwise unable to quit (Greaves et al., Reference Greaves, Poole, Okoli, Hemsing, Qu, Bialystok and O'Leary2011; Hatsukami et al., Reference Hatsukami, Slade, Benowitz, Giovino, Gritz, Leischow and Warner2002). A qualitative study by Nichter and colleagues (Reference Nichter, Nichter, Adrian, Goldade, Tesler and Muramoto2008) suggests that benefits of smoking reduction include increased self-efficacy, decreased nicotine dependency and a greater likelihood of quitting in the future. A recent pilot study investigated a TM intervention where pregnant women who smoked received support messages plus alert messages instructing them to smoke on a schedule that was gradually reduced over time (Pollak et al., Reference Pollak, Lyna, Bilheimer, Farrell, Gao, Swamy and Fish2013). Compared to women receiving only support messages, those on a smoking reduction schedule had a higher rate of biochemically validated cessation at the end of pregnancy. Of those still smoking, women reduced their smoking substantially more in the reduction arm than in the support only arm. Harm reduction is a promising approach to smoking for pregnant and postpartum women which requires more research to further validate its safety and effectiveness and to ascertain the most acceptable methods of delivery for interventions.
An additional area for further research is the exploration of smoking cessation/reduction interventions for pregnant and postpartum women that utilise different or additional mediums and forms of technology. While the results of this study were focused on women's experiences and needs related to a TM programme, several other themes surfaced throughout discussions with participants such as the use of applications (apps). There is a growing body of research on the use of apps as a conduit for smoking cessation (for example, Abroms, Padmanabhan, Thaweethai & Phillips, Reference Abroms, Padmanabhan, Thaweethai and Phillips2011; Valdivieso-Lopez et al., Reference Valdivieso-López, Flores-Mateo, Molina-Gómez, Rey-Reñones, Uriarte, Duch and Valverde2013).With the widespread use of smart phones and tablets and the continuously growing app market, additional research is needed to explore the use and effectiveness of this format to reach pregnant and postpartum women and to support their efforts to quit or reduce smoking.
A limitation of the current study was the use of notes recorded by the interviewer during telephone interviews rather than audiorecordings. While detailed electronic notes were taken in real time and analysis was conducted to ensure congruence with focus group data, notes may not be as reliable as audiorecordings followed by professional transcription.
Conclusion
The purpose of this study is to develop a smoking cessation/reduction TM intervention that maximises empowerment through tailoring the programme to individual women's needs. Smoking cessation/reduction programmes have yielded mixed results thus far (Greaves et al., Reference Greaves, Poole, Okoli, Hemsing, Qu, Bialystok and O'Leary2011). However, with personalised programmes that meet a woman's unique needs and address her concerns through her participation and direction, the study suggests that women will feel more empowered and supported in their quit/reduce attempts.
Acknowledgements
We would like to acknowledge Natalie MacLeod for her work at the beginning stages of this project including the ethics submission and creating recruitment materials.
Financial Support
This work was supported by Echo: Improving Women's Health in Ontario, an agency of the Ministry of Health and Long-Term Care.
Conflict of Interest
None.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
