Qualitative methodology

This research was conducted using the principles of interpretative phenomenological analysis (IPA), [20] an inductive approach that aims to explore how participants interpret and make sense of their world, and formulate their own biographical stories. [20–23] This approach was considered appropriate as it was important to understand smoking behaviour from women’s perspectives; exposure in infants and children is a sensitive, complex and changeable issue, and mother’s experiences of smoking are likely to be unique to the individual. This study is reported using the COREQ guidelines (S1 Table).[24]

Ethical approval

The study received a favourable opinion by Derbyshire Research Ethics Proportionate Review Sub-Committee (reference number 11/EM/0078).

Recruitment

Women were recruited from the Pregnancy Lifestyle (PLS) cohort.[25] The PLS is a longitudinal pregnancy cohort recruited within Nottingham, England, which collected detailed information on smoking behaviour across pregnancy and the early postpartum period. [25] In line with IPA methodology [20] a sample size of up to 10 participants was identified as appropriate. Four recruitment waves of women who had reported that they had stopping smoking for at least some of their pregnancy but were smoking again at 3 months post-delivery were conducted (Fig 1). Women were excluded from participation if they reported themselves to be currently pregnant.

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Fig 1. Recruitment waves and response rates.

https://doi.org/10.1371/journal.pone.0157525.g001

Women were invited to participate by post, and contacted by telephone or text message thereafter. Invitation letters provided women with details of how they could get in contact if they were interested in participating, and enclosed a copy of the participant information sheet. In total, 46 participants were invited to interview across four waves, with 9 participants consenting to take part (Fig 1).

Data collection methods

All interviews were conducted by SO, who is female and has a background in health psychology and smoking in pregnancy. Written informed consent was obtained prior to interview. Interviews were carried out in participants’ homes, and lasted on average 40 minutes (range 10–60 minutes). All interviews were audio recorded and transcribed verbatim. Participants were offered an inconvenience allowance of a £20 shopping voucher as compensation for their time. Basic demographic details were collected via questionnaire.

Interview schedule

The interview schedule was developed using literature, discussion and reviewed by and piloted with a member of the public who was a current smoker and had smoked during two previous pregnancies. The interview schedule covered mother’s experiences of smoking during pregnancy, smoking relapse, smoking in their home and their attitudes towards child and infant SHS exposure. The schedule was designed to be semi-structured to allow flexibility and further exploration of areas of interest. [22]

Overview of findings

Mothers gave accounts of their smoking behaviour in pregnancy, and described how this changed as they progressed into the postpartum period. Mothers’ smoking intentions spanned across pregnancy and the postpartum period; however, these were adjusted over time reflecting their transient nature.

Desire to be a responsible mother

Being a ‘responsible mother’ was interpreted as important in women’s accounts of smoking in pregnancy, with protecting the health of their baby cited as a primary motivation for quitting. Mothers had some awareness that smoking posed a risk to their baby during pregnancy, and used this knowledge to help inform their decision to quit:

“I didn’t want to cause her [baby] any harm. I know the risk of smoking and I know obviously it can harm your baby. I’d wanted her for a long time, she was planned and I really wanted her so I wanted to make sure that obviously I gave her the best start.”

(Participant 3)

Mothers who had not been able to stay quit during pregnancy described smoking in a way that managed potential risks to their baby within a level that they personally found acceptable, for example, by only smoking half a cigarette or not smoking every day. These risk reduction strategies were a compromise which enabled them to reconcile their current smoking, or their cravings, with their intentions to be a responsible mother by quitting.

“I decided to quit smoking and then I kind of I did cut down, I didn’t smoke that much anyway in the first place, but I did really cut down. I think I stopped for a couple of months and then I’d have kind of the odd one.”

(Participant 5)

The desire to be perceived by others as a responsible mother was also important; some mothers wanted to be responsible but did not necessarily want to quit; however, they felt pressured by others to do so:

“I used to do it [smoke] behind his [partner] back sometimes! Which is wrong really because it’s only me that’s the bad one because I’m the one that’s carrying, you know, throughout the pregnancy sort of thing, so I’m only sort of, like, lying to myself really rather than lying to other people ‘oh no I’ve completely packed up’ but I hadn't, you know, I was having the odd one … I did feel bad but, you know, he’s [baby] turned out OK.”

(Participant 8)

Similar to the prenatal period, being a ‘responsible mother’ was dominant in mothers’ accounts of their baby’s SHS exposure in the postpartum period. Some mothers approached this idea when describing how they had relapsed after giving birth:

“When you become a mum you feel like you should be a lot more grown up … not just do it because everyone else is doing [it], not just because I was drunk—but I thought ‘she’s [baby] not even with me, I'm having my first night away’ so I was enjoying myself and it’s not like I’d come home—she’d come home to me tomorrow and I will [not] still be stinking of them because obviously I would have got a shower and everything by then.”

(Participant 3)

Postpartum smoking; reasons or justifications for returning to smoking

Differences were observed in mothers’ described smoking trajectories postpartum. Of the five mothers that quit for the duration of pregnancy, two relapsed to smoking within a couple of days after giving birth and reported returning to pre-pregnancy smoking levels or higher. Three mothers who quit for the duration of pregnancy reported relapsing between two and six months postpartum, often whilst out with friends or socialising, and tended to describe occasional smoking thereafter. All mothers in this sample had prospectively reported smoking at 3 months postpartum; differences in retrospective reporting of the timing of their return to smoking may be due to memory/recall biases, or reflect differences in when mother’s first had a cigarette postpartum and when mothers considered themselves to have returned to smoking. Of the four mothers who had not quit for the duration of their pregnancy, two smoked within a couple of days after giving birth, and two mothers returned to smoking within two months of giving birth. These mothers reported returning to pre-pregnancy smoking levels. Despite these differing smoking trajectories, similarities were observed in how mothers repositioned their smoking status and identity as a smoker and a new mother.

Stress was a common theme in mother’s narratives of relapse, particularly for those who relapsed in the immediate postpartum period:

“I had her on the Wednesday and she became quite poorly and I didn’t come out of hospital until the Sunday, and I was that upset in the hospital, I think I had one on the Saturday. I actually went outside the smoking centre entrance, which is disgusting, isn’t it? And I felt really, really bad, ‘cause my ankles were as big as anything, I still had my jelly belly, and then, like, to me, people probably looked—I was still pregnant. Do you know what I mean? Which I didn’t like. But that was, again, because I couldn’t cope with the stress of her not being very well.”

(Participant 7)

For those mothers who relapsed later in the postpartum period, being in a social situation with other smokers, or drinking alcohol, was commonly discussed as a trigger for relapsing:

“I didn’t want to start back up [smoking] but then I think he [her baby] was about 3 months old and I was able to go out and then just had the odd one [drink] and then started again.”

(Participant 8)

Some mothers attributed their relapse to habit, rather than addiction:

“It [relapsing] was habit, habit. Because I’m not addicted to smoking, I was never addicted to it.”

(Participant 1)

Postpartum, mothers described feeling ‘differently’ about smoking, with a subsequent change in risk perceptions. They were less concerned about the health implications for their baby as there was no risk of exposure in-utero:

“After you’ve given birth then it’s, I kind of felt a bit differently about it [smoking] because then it wasn’t you know, affecting them [the babies].”

(Participant 5)

Repositioning smoking identity

Since relapsing to smoking either during pregnancy or following the birth of their baby, many mothers repositioned their smoking behaviour and adopted a new identity of an ‘social’ or ‘occasional’ smoker. This was driven by a reduction in the number of cigarettes women smoked; mothers drew comparisons between their smoking prior to pregnancy and postpartum to emphasize the change, illustrating that their own perception of their smoking had essentially changed since having their baby:

“I was a full time proper smoker—like at work I’d go out for cigarette breaks and yeah—wake up in the morning—but now yes—and to go for none—but then I don’t ever fancy one, my boyfriend goes out for one and I don’t ever—I smell it on him but I don’t think ‘oh, I want one’.”

(Participant 3)

“I can go days with not having one and it’s only if I go out, you know, to socialise sort of thing that I decide to have one.”

(Participant 8)

Smoking was considered to be on a continuum, whereby occasional smoking was both distinct from, and more acceptable than, being a regular ‘proper’ smoker. What was important for mothers was that they employed strategies to protect their baby from SHS exposure, and it was this which differentiated them from other smoking parents, or from the negative social stereotype of parents who smoke.

Repositioning of smoking behaviour and identity was also observed among mothers who otherwise reported themselves to be daily smokers. Participant 7 reports daily smoking of between 5–10 cigarettes per day, however similarly discusses how since having her baby she feels less dependent on smoking, is able to abstain from smoking for longer periods of time during the day, and tends to only smoke half of a cigarette rather than a full cigarette.

“I can go all day without having one. So she’s changed me a lot for that … I don’t panic if I’ve not got any … if I can’t go out all day and get one, it doesn’t bother me.”

(Participant 7)

“If I go and have one, I’ll only smoke half of one, whereas before I used to smoke a full one.”

(Participant 7)

While this mother did not describe herself as a ‘social’ or ‘occasional’ smoker, she was keen to illustrate differences between her smoking behaviour prior to pregnancy and since having her baby.

Intentions

Mother’s smoking intentions appeared to be important in both the prenatal and postpartum period. All mothers described their intention to quit at least for the duration of their pregnancy, with those who relapsed before giving birth making further quit attempts as their pregnancy progressed:

“I was about 5 or 6 months when I would have the odd one [cigarette] and then when I got towards the end I was like oh no, you know, better stop this, but I shouldn't have started it anyway, you know.”

(Participant 8).

The majority of mothers described their intentions to quit smoking not only for the duration of their pregnancy, but also permanently:

“I thought what’s the point of going 9 months—or 8 months not having one and then starting again afterwards—that's just pointless.”

(Participant 3)

This intention was influenced by several perceived factors, including knowledge or awareness of the risks associated with smoking and SHS; their desire to be a responsible mother; their desire to be perceived by others to be a responsible mother, and internalised negative attitudes towards women who smoked during pregnancy or parents who smoked around their children. However, all interviewees had relapsed to smoking by three months after the birth of their baby, with mothers’ intentions transitioning as a result of unsuccessfully staying quit. The strategies outlined above, such as placing restrictions on where and when they smoked and repositioning their smoking identity, reflected mothers’ new intentions to balance smoking with being a responsible mother. Whilst some mothers were satisfied with using these balancing strategies and had no further intentions to quit, others reiterated their intention to stop smoking permanently:

“So that is my plan, is to stop [smoking] again. I can do it, I've got the willpower, just need to stop going out basically!”

(Participant 8)

Strengths and Limitations

This is the first study, as far as the authors are aware, which explores the experiences and beliefs of mothers who abstained from smoking for at least part of their pregnancy but subsequently relapsed in the early postpartum period. A strength was the utilisation of one-to-one interviews, which facilitated in-depth discussion of home smoking experiences, behaviours and beliefs among a target group of mothers. Furthermore, these interviews were conducted in mother’s homes, which enabled the researcher to gain insight into the home environment and how this may contribute to their home smoking behaviours. Although only nine participants were sampled from a small cohort of mothers and interviewed, this was appropriate for obtaining a detailed interpretative account from this specific group. The personal characteristics of SO positioned the interviewer as an ‘outsider-researcher’, [26] which may have been influential throughout both the data collection and analysis process; the assumptions made and subsequent interpretation of interviewee’s accounts may be different to those made by either an ‘insider-researcher’, or someone who does not have background knowledge about smoking in pregnancy or child SHS exposure.

Comparisons to previous literature

The reasons or circumstances mothers in this sample described around their return to smoking were similar to those reported in a recent qualitative synthesis [7] of experiences of postpartum relapse; stress, social influences and no longer needing to protect the baby from their smoking in utero were commonly cited when talking about their smoking relapse. The previous qualitative synthesis [7] of the evidence highlighted that research in this area was currently restricted to America and Canada, however, our findings illustrate that these issues are also pertinent within a UK sample.

The intention to be, or perceived by others to be, a ‘responsible mother’ dominated mothers’ narratives. Coxhead and Rhodes [27] similarly found smoking mothers of older children with respiratory illness were keen to portray themselves as ‘responsible smokers’ and ‘good mothers’, using emotive narratives and describing self-imposed smoking restrictions to demonstrate their good moral character. A strategy used by mothers in this sample was to draw on examples of other women or parents who smoked, demonstrating strong anti-smoking attitudes. Previous research has shown that individuals frequently reference either identifiable or generalised ‘others’ as part of forming moral tales and narrating experiences.[28] Comparisons to ‘others’ have been observed among smoking parents of older children (aged 0–19 years) to demonstrate who they identify themselves with, who they can make judgements of, and also to anticipate judgements of their own behaviour.[28,29] Mothers’ anti-smoking attitudes are likely to be influenced by ‘shared’ or ‘normative’ morals, [29,30] which predict both intentions and behaviour.[30] Moral tales of what is acceptable parental smoking behaviour are informed by community endorsements of smoking practices, and through comparisons to the worse smoking of ‘others’ help defend mothers’ own smoking behaviour.[29]

For some mothers in this sample, the desire to be a responsible mother, anti-smoking attitudes and normative morals towards smoking resulted in a sense of shame and disgust in their own smoking. As smoking rates continue to fall in the UK [31] those who do smoke are often in the minority, and report feeling a sense of stigma.[32] Many women who smoke during or soon after pregnancy will be from adverse sociodemographic backgrounds, [13,25,33,34] live with other smokers, [3,35] have greater interpersonal problems, [13] and may experience a lack of agency to change their smoking or the smoking of those around them. [36–41] A sense of shame and guilt among this group may further reduce self-efficacy to make positive changes to their smoking behaviour, or smoking in their homes. Future interventions need to be sensitive to the issues these mothers face, and avoid alienating this potentially vulnerable group by increasing their sense of shame and disgust about their smoking.

As found in previous research among older children [29,42] of smoking parents, mothers used harm reduction strategies to reduce or prevent SHS exposure for their baby. The most common of these was to make the home smoke-free, described by all but one in the current sample. This is in contrast to previous research, where mothers who relapse to smoking postpartum were vigilant in reducing their baby’s SHS exposure; [10,11] however, did not necessarily describe making their homes smoke-free.[11,43] Enforcing smoke-free rules often means negotiating with other smokers to implement restrictions, which can be challenging as it may be dependent upon equity in relationships with partners, family members or friends.[36–41] Similar to this previous research, [36–41] some mothers discussed a lack of agency, giving examples of sacrificing relationships where smoking restrictions could not be controlled in the homes of others. Some mothers in the current sample, however, were interpreted as having the agency to implement these restrictions in their own homes and the homes of others, such as family members, which may reflect greater community endorsement of protecting babies and infants from SHS exposure. A further issue described by mothers in the present study was the difficulty of balancing smoking with caring for a newborn baby, with some mothers describing their concerns of feeling they should leave a certain amount of time between smoking and being in close proximity with their baby. Future research is needed to explore this further, and any implications this may have for bonding with the baby and potential impacts on breastfeeding.

The repositioning of smoking identity in the postpartum period from being a ‘smoker’ to an ‘social’ or ‘occasional’ smoker interpreted in this sample has not, to the authors’ knowledge, previously been observed. A recent survey [44] of adults in California, USA, explored a new emerging category of smokers, labelled as ‘non-identifying smokers’, who report having smoked at least once in the previous 30 days but do not consider themselves to be a smoker. This group was estimated to comprise around 12.3% of all smokers in California. Non-identifying smokers were associated with having been a prior daily smoker, and having greater perceived control over their smoking behaviour. The authors argued that future tobacco control interventions should target this emerging smoking behaviour pattern, particularly within groups where smoking is stigmatised, and enforce the message that there is no safe level of smoking.[44] Robinson and Holdsworth [45] have previously discussed the limitations of the tendency to label adults as either ‘smokers’ or ‘non-smokers’. These one-dimensional categories are argued to not fully encompass the complexity of smoking and how smoking fits into people’s lives.[45] In this sample, transitioning from a ‘smoker’ to ‘social’ or ‘occasional’ smoker helped mothers to distance themselves from the perceived negative stereotype of being a smoking parent, and identify with the more positive label of ‘non-smoker’ which was better aligned with their desire to be a ‘responsible mother’. The distancing suggests that these women may be more receptive to messages around cessation or behaviour changes, such as implementing smoking restrictions in their homes, and maintaining these over the longer term. However, this also has implications for future interventions, which need to be designed to take mother’s self-perceptions of their smoking identity into consideration.

Implications

These findings can inform the development of future interventions to prevent or reduce infant and child SHS exposure in the home. These should incorporate mothers’ smoking self-identity; as mothers who relapse principally view themselves as ‘social’ or ‘occasional’ smokers, interventions that are highlighted as relevant for women with these types of smoking patterns are more likely to be responded to, and, ultimately, be effective. This may involve widening the criteria used to identify smokers to be more inclusive of occasional or social smoking behaviour patterns, and raising awareness that there is no safe level of smoking and even occasional smoking is harmful.[44,46] Anti-smoking attitudes and normative morals towards parents who smoke were influential in mothers’ accounts of their smoking behaviour, and their perception of being a responsible mother. Interventions that focus on strengthening a community’s normative morals to protect infants and young children from SHS exposure, for example, by increasing awareness about the dangers of exposing infants and children to SHS, are therefore also likely to be helpful. There is evidence that this can be achieved through person-to-person spread of changing smoking behaviour, which cascade to others within larger social networks.[47] However, such approaches should be sensitive to avoid exacerbating a sense of shame in smoking behaviour, as observed in the current sample. Finally, interventions should suggest actions that parents and families can take to reduce or prevent their child’s SHS exposure. These may build on existing strategies that families have already implemented, for example, increasing the length of time between smoking and interacting with their child, or help parents acquire new skills or strategies, for example negotiation skills to ensure family and friends conform to home smoking rules.